Bringing It All Together: Convening on Health and Community Development Investments

Just Economy Conference – May 10, 2021

Each year brings new research and attention to the connection between economic security and physical health and 2020 certainly brought that and more. Local leaders are clear on their community’s needs and are actively combating disparities, yet the greatest impact comes from community investments made by anchor institutions such as banks and health care systems. Aligning resources can be a game-changer in the fight to reduce health and economic disparities as they typically reinforce each other. This session will highlight recent research from the Federal Reserve’s report Exploring Hospital Investments in Community Development, outlining opportunities that exist for collaboration between community development and hospitals and health systems. Subsequently, we’ll provide a presentation from Build Healthy Places Network on a framework and scan of policies that create a more conducive environment for collaboration across sectors and ways in which we can incentivize healthcare to consider community development organizations as important partners in shaping policy and investments in social determinants of health. This interactive session will culminate in an open discussion and breakout between community development leaders, hospitals and health system innovators, and other community stakeholders.

Speakers:

• Karen Kali, Senior Program Manager at NCRC
• Ranae Badruzzaman, Program Manager at Build Healthy Places Network
• Eileen Diviringi, Community Development Research Specialist on the federal Reserve board of Philadelphia
• Kevin Mahany, Director of the Community Health Investment at Providence Medical Center

Transcript

NCRC video transcripts are produced by a third-party transcription service and may contain errors. They are lightly edited for style and clarity.

Badruzzaman, 00:35 

Welcome everyone to the 2021 just economy sessions and welcome to this particular event, bringing it all together a convening on health and community development investments. I’m Karen Kali. I’m a Senior Program Manager here at ncrc. And my co host today for this convening is Renee Patrice men who build Healthy Places network.

Kali, 00:12 

Hello, everyone. Good morning. Good afternoon. My name is your neighbor Drew’s admin Program Manager at build Healthy Places network. Thank you to ncrc and Karen Collie for organizing this important conversation on health and commune development investments. I’m excited and privileged to be speaking on alongside Eileen and Kevin today. And we’re on we understand and know that from the both the commune development and the health care sectors, that zip code is more important than genetic code. So more than anything else, where you live, particularly where you’re born, and where you grew up, predicts your long term health. And people get sick because of where they live. And that equitable distribution of those social determinants of health resources creates the community conditions for people to be healthy and well and thrive. So for example, if people have if people where they live in the community, they have fresh healthy food available, affordable quality housing, good schools, clean water, air, accessible transportation, open spaces, parks, good paying jobs. All of that determines a person’s health and a community’s health. And those resources are distributed at a policies and systems level. So I’m really excited again for the conversation today. And thank you so much for joining us.

Kali, 02:04 

Thanks Renae, so today’s event is part presentation part discussion on the impacts that we can create when we align community investments and foster collaborations with hospitals and health systems and others to reduce health and economic disparities. We know that a good community development can be foundational to building wealth for many, as well as fostering healthy communities and reducing health disparities. So today, we’ll first have a presentation from Eileen Devaney. She’s a community development research specialist from the Federal Reserve Board of Philadelphia, around opportunities that exist for collaboration between community development and hospitals and health systems will then hear from Renee from build Healthy Places network on a scan of policies that enhance collaboration from across sectors and increased health care’s interest in community development investments in social determinants of health. And then lastly, we’ll hear from Kevin Mahany, director of the community health investment at Providence St. Mary Medical Center will provide his practical insights on improving Community Health from a local hospital system perspective. After our speakers will then move to a more interactive discussion and breakout rooms to dig a bit deeper on the topic and gain your perspective on the challenges and opportunities that propel significant Community Investment and make health equity happen.

Badruzzaman, 03:25

And our staff that build Healthy Places network and NCRC will help lead the breakout discussions, which will include both a discussion and participation on a digital whiteboard. We hope the breakout component to this session provides an opportunity to take a moment to pause and consider the ways in which we can leverage cross sector partnerships and financial investments that improve the social determinants of health, advanced health equity and racial equity. Our speakers, our speakers will be in the group out as group breakout groups as well. And with that, let’s get started with our first presentation for my lead. 

Diviringi, 04:06 

Thanks. Hello, thanks for having me as part of this really important conversation today. As Karen mentioned, I’m Linda Diviringi. I’m a community development research specialist from the Federal Reserve Bank of Philadelphia. The research that I’m going to share with you today looks at how much nonprofit hospitals report spending on community development related activities and pulls out some specific examples of the kinds of activities of that sort that they’re engaged in. We were hearing a lot from stakeholders in our district, they were really interested in partnering with healthcare, the healthcare sector on their programs, but they didn’t really have a good sense of, of how to start those conversations or what to expect. So our hope is that proved by providing some sort of kind of baseline information about their activities. That the this would help sort of move those conversations forward. And also, when we started this, the covid 19 pandemic was not on anyone’s radar, but it really has elevated and sort of highlighted the urgency of addressing critical social determinants like housing and financial stability, both for the public at large. And I think for a lot of healthcare sector organizations as well. So before I get started, I have to provide this brief disclaimer. So the views expressed in this presentation are mine and those of my co author, and do not necessarily represent the views of the Federal Reserve Bank of Philadelphia or the Federal Reserve System. So I’ll start with a really brief background on hospital community benefit report requirements and related reporting, both because it’s really important context for understanding our results, but also understanding sort of how the IRS defines hospitals responsibility with respect to these kinds of activities. So to maintain their tax exempt status, the IRS requires that hospital nonprofit hospitals, show that they’re providing some sort of kind of public service beyond just providing medical services and charging sort of the standard rates for those services. And for a long time, this was a really nebulous requirement. But in 2009, the IRS sort of implemented more comprehensive reporting requirements, and requiring hospitals to start filling out forms schedule H, where they had this sort of detail they’re spending in different categories. And there’s two categories of spending that were sort of particularly interested in for our purposes today. The first is spending that’s reported on part one of schedule H, which is referred to as community benefit spending encompasses a lot of what you think of would be kind of typical hospital services. And I’ll get into a little bit more detail on that in a moment. All hospital nonprofit hospitals are required to complete part one. And then the primary focus of the presentation and our research is actually expenditures reported on part two, which is referred to as community building activities. These are activities that are more focused on addressing sort of non medical determinants of health. And again, I’ll I’ll get into more specifics in a moment. Unlike part one, part two, recording reporting is not required from hospitals. So there’s a little bit of an imbalance in sort of how the two are viewed in terms of how hospitals are sort of assessed and meeting their public service mission. There’s actually no minimum amount that hospitals are required to spend in either of these categories. And it varies very dramatically across different hospitals. Let’s let’s take a quick look at some examples are met the subcategories under these two categories and sort of what types of things the hospitals would report on, on schedule h. So on the part one can be the benefit side, you can see that most of these categories are sort of related to patient care activities. There’s also research and health professions education, which you’ve mentioned, see it with the hospital that’s affiliated with a medical school. But the two that are most kind of interesting, for our purposes today, are community health improvement services, and cash and in kind contributions to community organizations, those have sort of the highest potential overlap with community development work, but at the same time, my understanding is that the bulk of those are still going to more sort of medically oriented services. So things like vaccination campaigns, pass through funding to community health centers, which are critically important but not necessarily in the scope of what we’re focused on. On the part two community building side, you can see there’s a lot more categories that much more directly aligned with community development work. So there’s things that are focused on non medical activities, some of them are placed based, some of them are focused on building capacity and supporting sort of advocacy. So as I’ve sort of alluded to, the data in this analysis primarily comes from hospitals, 990 tax filings, which were scraped and cleaned and made easy to use on this website called community benefits insight, which is very helpful. We use their API to pull the community benefits and community building expenditures data for all nonprofit hospitals in the US from 2012 to 2016, tax years 2012 2016, which was the most recent available at the time. And then we also compiled the narrative descriptions of hospitals, Community Development Committee or committee development related activities, so that we could look at specific examples of how hospitals were doing. And we did that for facilities that are in the Philadelphia offense region. So I’ll start with a quick look at our findings with respect to that part one community benefit spending, which again, isn’t necessarily the focus of our research, but is sort of an important piece of context. So in aggregate, hospitals spend an average of about $67.9 billion annually during this period on community benefits, which is a quite quite a significant amount of money. But as you can see from the chart, the vast majority of that spending goes towards sort of these patient care activities. So providing care to people who don’t have insurance or providing care that’s not reimbursed sort of at cost by Medicaid, as well as providing health services better have to be subsidized in order to be available in a certain community. By contrast, a little under 7% of the spending went towards the more kind of community oriented categories of community health improvement and cash and in kind contributions, it comes out to about $4.7 billion a year, so still a pretty substantial amount of money. So shifting focus to kind of the main focus of this research, we’re looking at sort of the community building expenditures reported on part two that are kind of more closely aligned with our community development activities. One thing that’s important to note upfront is that so all hospitals since they were required to fill out part one, virtually all hospitals reports, in part one community benefit spending. On the community building side, a little under 60% of hospitals report, community build expanding, which is notable in the sense that hospitals aren’t necessarily required to engage in this kind of activity, but many of them are sort of opting to anyways. And what we find is that on average, hospitals spend about $474 million per year on these activities. So that’s millions with an M, it’s a substantial amount of money, but not quite in the same ballpark is going to community benefits overall. And then, among hospitals that engaged in the spending per facility, they spend, on average, about $270,000 a year, we find that rural hospitals are a little bit less likely to report community building spending, which makes sense because many of them are smaller, kind of less well resourced hospitals. And interestingly, we find that hospitals in higher poverty counties are less likely to report community building spending. Though, when you look at the spending per facility and aggregate spending, it’s actually highest for hospitals that are in that second highest poverty quintile. And then by contrast, when you look at the highest poverty counties, the aggregate spending is lowest and in large part this is because many of those counties just don’t have hospitals. Or they have much smaller hospitals. So here’s a breakout of spending by category, you can see that they, these different activities, these different sub categories are funded, more or less frequently and at different levels. And one thing that jumps out is that about two thirds of aggregate spending is in the categories of community support, Workforce Development and Community Health Improvement advocacy. And by contrast, a little under a fifth goes to more place based categories like economic development, housing, and environmental improvements. So we’re also able to break out the spending geographically, and what we find is that there is a lot of variation in spending per capita by state, it ranges from about three cents per capita in Rhode Island, to over $8, per capita and Delaware. The geographic pattern here isn’t super clean, but you can see that the southeast generally has lower per capita spending, and New England generally has higher per capita spending. And of course, this is sort of a function of where there are hospitals and particularly where there are larger hospitals. So to give you a sense of kind of more specific examples of the types of community building activities that we we found in our research, I pulled together just a few examples in different categories of initiatives or programs that hospitals described being involved with from the narrative descriptions and their 990s. Again, these are from the Philadelphia Feds region, but it does include, I think, a good cross section of urban, suburban and rural communities. And as you can see, this sort of runs the gamut of different activities, from affordable housing, to human services, to youth employment. And all of these things are sort of well within the community development, wheelhouse. And there’s a lot more examples that are discussed in the report. So I encourage you to check that out. And then, to recap our main findings. During our study period, we found the hospitals spent about $474 million annually on community benefits activities, which are sort of the most directly related to community development. The spending was mostly in the categories of workforce development, community support and community health improvement advocacy. We saw a lot of variation across states. And we found that hospitals in the highest poverty counties and in rural areas were the least likely to report community building spending, sort of consistent with what we think of as the financial constraints for a lot of hospitals in those areas. And then lastly, just to sort of close out and highlight and move to kind of the next step in this conversation, you know, as the healthcare sector continues to sort of recover from the financial disruption with the pandemic, it’s clear that they that partnerships and collaboration and leveraging of resources are going to be really important moving forward. And with that, I will pass things back to Rene 

Badruzzaman, 15:02 

Great, thank you so much, Eileen. And go ahead and share my screen now. Can you all see my screen? 

Mahany, 15:26 

Yes.  

Badruzzaman, 15:29 

Great, thank you. All right, I am thrilled to introduce the healthy neighborhood investments policy scan and strategy map. And this project was done in partnership by build Healthy Places network and with shift health accelerator and supported by Blue Shield of California foundation. And the two goals I want to highlight today. Were to for this project were to identify policies that create a more conducive environment for collaboration across sectors and to incentivize healthcare to consider community development organizations as important partners in shaping policy investments in the social determinants of health. As we can hear from bylines previous research in conversation, that’s certainly an area where we want to continue to grow in partnership with so the healthy neighborhood investments project, the process included a review of hundreds of policies from across the country. And we we were advised by a 38 member Policy Council in that process, and Kevin MAHANEY with us today was a part of the policy council, as well. And what came out of that process was an identification of policy actions at the federal, state and local levels for advancing health equity and racial racial equity, through cross sector investments. And this creation of a resource or a tool for community owned priority setting that reduces inequities in revitalizes neighborhoods. A little bit about build Healthy Places network. We are a national organization with the mission to transform the way that organizations work across health, commune development and finance sectors to reduce poverty, advanced racial equity and improve health in neighborhoods across the US. Be healthy neighborhood investments policy scan and strategy map is really an acknowledgement that collaborations of community leaders, health and community development and local government are trying to clear the same policy hurdles, and in pursuit of aligned goals. And this slide here really is who the policy scan is for. Those policy hurdles have stood in the way of better health for all communities have known this right, especially our black indigenous people of color, and other marginalized in disinvested, low income communities. And now with today’s current climate, it is imperative that all of us advance anti racism within our laws and policies to create those community level conditions for everyone to thrive without exceptions. So I’ll give an example of a collective effort uplifted in the policy scan. The six cities and the county of Solano and California created a Community Action Partnership, joint powers authority to provide community services to residents to reduce poverty and homelessness with a focus on safety net services. In this was recognized as a valuable partner for improving health by a local nonprofit health plan called partnership health plan of California, who awarded the Community Action Partnership funding to develop housing projects. So that’s an example of the multisector partnerships for policy actions uplifted in the policy scan. So on this next slide, you’ll see the thriving together springboard framework, which was a fundamental framework for the policy scan. This was created by the well being trust and CDC foundation. And as I mentioned before, the policy scan really serves as a broad compendium of federal, state and local policies and the tools for multiple sectors to take action. So what we did in this kit is we essentially organize over 50 policy strategies or so an actions by these vital conditions. You see here that Being belonging in and civic muscle, thriving and natural world, basic needs for health and safety, humane housing, meaningful work and wealth, lifelong learning and reliable transportation. So we essentially operationalize this springboard framework specific to policy change, which really connects the framework to real people in real places. And the policy council helped us up lift some cross cutting themes across those vital conditions. And I want to underscore that these were themes as opposed to a top policy list, not because we weren’t asked for the top policy list, but because we, as the organizers heard from the policy council, that we should not be determining the priorities of local communities. There’s no one size fits all scenario to address health. And neighborhoods at the local level, are incredibly diverse culturally and have rich histories. So for those communities that have historically been marginalized or persistently marginalized. across the United States, there’s often a tale of oppression and trauma existing in those communities, as well as a tale of power and resistance. And those narratives, those stories are only the stories that folks who’ve been a part of the community can tell, and also a part of the solutions. So if you’re listening, whether you’re a healthcare administrator, a banker, a community member, or a local public official, these themes applied to help move the needle on racial and health equity across those vital conditions. So for example, we have learned that without civic muscle without belonging, and without community capacity or community power, to make informed decisions, we won’t be able to have trusting meetings, we won’t be able to have meaningful conversations, or honest dialogue needed for policy change, right. And policy is one lever to create change to promote social justice. And the way in which we engage with others to do that policy change can itself be a transformative process, it can be a healing process, if done with intentionality. The policy process can help build trust through commitment to relationships and transparency. It can be restorative, it can promote social connectedness, it can promote inclusion and it can promote belonging. And my presentation today will introduce the policy scan and strategy map as a tool to create policy action for good. So on this next slide, you’ll see a policy treasure map for racial and health equity. And really, this is a visual guide that describes the journey that multi sector Coalition’s can take to dig together to find policy solutions for their community needs in this policy scan. And I’m really excited to talk to all of you in the breakout session. So I encourage you all to read the policy scan. Thank you so much for listening. I’m looking forward to speaking with you soon. And with that, I will toss it to my to Kevin Mahany. 

Mahany, 23:52 

Renee, thank you and Eileen, thank you for your presentation as well. My name is Kevin MAHANEY, I’m Director of Community Health investment here at Providence health in San Bernardino County in Southern California. And it’s a pleasure for me to share with you the work that we are doing out in the community. St. Mary Medical Center where I’ve worked for the past 20 years, is a nonprofit, community hospital we’ve prided ourselves on not just providing health, to people who need it to communities who need it, but also to build community capacity and address quality of life issues. I’m really glad Eileen was able to first examine and share how hospitals have traditionally been investing. And lean is right her data is is showing that there is a large investment in wanting to make health systems better, especially out in the community. One of the interesting things we face in rural communities is the lack of physicians that can adequately serve the community. And so a tension that hospital systems will feel is a need to work on both the recruitment and the innovation that allows communities in community including communities of color, to more readily access health care. One of the interesting learnings coming out of the COVID pandemic, has been the use of telehealth in particularly connecting communities that we’re needing because of social isolation, access to mental health. We’re going to continue to see hospitals, look at community benefit and look at ways to innovate, how health care can be provided in communities through technology, artificial intelligence, and I should do want to add through policy change. I’m pleased to let you know that in San Bernardino County, our public health department has declared racism as a public health issue. Likewise, to neighborhoods in our service area, Victorville and Apple Valley have done the same. This has opened up conversations that we’ve not had before, about how do we examine what has been a status quo mis investment or under investment in communities where innovation and as Renee points out, policy change can help make communities more equitable. Eileen reported, how hospitals could do more in community building activities. And so I want to report out that Providence definitely is investing in the community building activities. We’ve had a long history doing it. And if I could, I want to touch a little bit on some of the policy opportunities that Renee mentions, Eileen mentioned earlier, and I believe Karen did as well, that geography where we live our zip code impacts health, it most definitely does. There are neighborhoods in our service area where you living them would mean you would pass away eight to 10 years earlier than other neighborhoods. And so this is this is causing us both locally, and at the county public health department to question How are we investing. And then how are other parties investing. And when I say other parties, I mean, workforce development, education, the ability to create economic development to bring jobs, the role of hospitals, oftentimes, as Eileen pointed out with advocacy, is to use our brand to bring different parties together to examine these issues, these inequities, and where, as Renee has pointed out, to try to create policy opportunities. I’m going to jump to one. We are working right now in our housing plan. And we’d like to see at least two policy changes by local governments that would expand the affordability of housing, that would make affordable housing more common. We’ve had a problem up here as much of California has, with just not being able to build enough affordable housing, we see a real opportunity with policy change. And locally, we have at least one city that’s very receptive to that. So fingers crossed with our public health department, we continue to work with them on the idea of implementing policy, policy that would make things more equitable, that would make investments more equitable. I’ll be honest with you, it’s going to take a little bit of time, other public health departments, being very familiar with local communities, is sometimes in such a very large community of ours difficult. I also want to share that research has been done. And the way Eileen and Renee pointed out that a county is not going to be able to do this themselves, that we are going to need to build public private relationships, such that we can pull in both state and federal resources to address the inequities that we’ve had perpetuated in our communities. Let me give you an example. Housing. We’ve had a status quo, where in at least our community, single family homes have been the predominant way that we’ve added housing. Local governments play a large part controlling that action at the state level is attempting to be a game changer to change the way in which zoning is done. The way in which housing is built. We hope allowing multifamily housing to be built on properties currently zoned as single family only. Please understand, there’s a tension there. Low governments that have had their local communities define how they want to create their quality of life, are going to be possibly giving up control. And as control goes to maybe a state mandate, a policy change, there can be a fear of giving up power to a state government in order to create and create more housing. And so local communities are very concerned, they point fingers, perhaps at a state and say, with housing, we need to do something. And then when the state wants to do something, there’s Wait a minute, wait a minute, you’re taking something away from me? I guess I’m bringing up a tension attention that is very real. hospitals have to look at how do we make investments that both improve the quality of care that people are getting, particularly communities where they’re rural, by zip code, we know they’re passing away earlier, that there is disparities by color, let me say maternal African American mental health issues long term, under investments in those health systems, coupled with the reality that the social determinants of health, such as access to housing, jobs, higher education, and food, played an incredible role, not just on how healthy we are, but on the opportunities that families have in raising their children, such that your children will have a quality of life equal to theirs, or maybe even better, or being able to afford the American dream. Eileen, Rene. Karen, I’m, it’s an honor for me to share with you the work that we’ve been doing here in Providence, St. Mary, and our embracement of policy, and public private partnerships in an effort to address what has been long standing under investments. And the reality that we have been a rural area that is economically developing into a suburban area, but bringing with us urban like problems of homelessness, the lack of available affordable housing, the ability to innovate, to try to create jobs that pay people more such that they can afford the higher cost of housing. It’s been, it’s an honor for me to share with you our workout here. And I appreciate doing so. 

Kali, 32:31 

Thank you, Kevin. Thank you, Eileen, and Renee as well. Hi, everyone, I’m assuming that everyone can hear me now, I hope that you enjoyed the presentations from our panel, big thank you to Renee, Eileen and Kevin for sharing their expertise and insight. So we’re actually going to this is a convenience, it’s a little bit different than some of the other sessions that you may have attended thus far. In a just economy conference, in that we’re going to do a breakout session in smaller groups. For the next I’d say maybe 20 minutes or so of the session or the time that we have the meaning of the session. But before I do that, I want to just see if there any questions that we may have, feel free to put them in the chat. There’s, you know, maybe one or two questions that we can take right now. We’d be happy to take them. While we’re while we’re doing that on the back end, I think Chloe will be putting us right now into into groups into into our breakout groups. And once you get into the groups, you’ll have the option of providing your comments and insight via digital whiteboard or orally if you prefer or both. Our speakers will be in the breakout groups for the discussion. And then we’ll come back to the main room and close out the can be for the last few minutes or so. Um, one last call for any questions. I’m not seeing any which is totally fine. Again, Big thanks to our speakers. And I think Chloe is going to move us into our groups right now and then we’ll see you back in the main room soon and I hope everyone will have a really great discussion. Thanks a lot all. 

Kali, 34:59 

Hi, everyone. Thanks for joining us back at this session, I was like, talking to myself for a long time. And then we all got back into the room, which is great. So anyway, I hope the discussions that you’ve had were fruitful, I’m sorry that we don’t have time for a report back. But we really wanted to make sure that folks had an opportunity to talk together. However, I do want to say to folks, and I’ll, you’ll see an invitation coming in here. But we, you know, we want to continue the discussion, I want to invite folks to participate in ncrc, healthy communities community of practice. And a couple of weeks, I’ll send out an invitation to all the participated today to join ncrc online platform, which will allow us to connect around the intersection of health and wealth and have, you know, these types of in depth conversations around new investment and health. The community practice, I think, is just a great space for networking, or can be a great space for networking, for sharing resources and information and much more. So please be on the lookout for that invitation in the next several weeks or so and, and with that, again, thank you to our presenters, thank you to the audience, especially those of you who stick around all the way to the end, for being part of the just economy session and conference. I hope that folks enjoy more of the sessions for the rest of the week, including a quick plug. But I want to make for a session that we’re having on Friday afternoon. policy options to community development for promoting long term health equity. This session will be more specifically focused on the more macro policy solutions for health equity, and I would love to have all of you join us for that session. So again, thank you all so much, and I hope you enjoy the rest of the conference.