the health disparities podcast

191: The Community health needs assessment: An underappreciated tool

In today’s episode, we explore some big questions about community health — and how hospitals and health care workers can help promote equitable health outcomes in their communities.

The Community Health Needs Assessment, or CHNA, is a  powerful tool for promoting health equity, says Leslie Marshburn, Vice President of Strategy & Population Health at Grady Health System.

“We want to be hearing directly from the individuals that we serve — what they believe their community health needs are,” Marshburn says. The information is coupled with public data, “ideally at the most granular level, like the census track or zip code. And so those national data sets can help inform what the needs are, and then layering that with the community voice through your primary data collection and synthesizing all of that helps you identify your priorities.”

When it comes to improving health outcomes in communities, it’s also critical that health care providers understand health disparities, says Dr. Maura George, an associate professor in the Department of Medicine and an internist at Grady Memorial Hospital in Atlanta, where she also serves as Medical Director of Ethics.

 

“I think clinicians who don’t know how to recognize disparities are going to perpetuate them, and we can all do that unintentionally,” George says. “I think knowing our own internalized bias, implicit bias is important, because you have to realize how that can interact in the patient care space.”

Marshburn and George joined Movement Is Life’s summit as workshop panelists, and spoke with steering committee member Dr. Zachary Lum for this podcast episode.

Never miss an episode – be sure to subscribe to The Health Disparities podcast from Movement Is Life on Apple Podcasts, YouTube, or wherever you get your podcasts.

 

The transcript from today’s episode has been lightly edited for clarity.

 

Dr. Maura George: I think clinicians who don’t know how to recognize disparities are going to perpetuate them, and we can all do that unintentionally. I think knowing our own internalized bias, implicit bias is important, because you have to realize how that can interact in the patient care space. We talk with our students when they first come about who they are, we get to know them all. We have an increasingly diverse student body, which is great for the future of our physician workforce. But right now, our physician workforce doesn’t match the population, and as it gets increasingly so, that’ll be even better for really connecting the patients, but we all will need to be able to engage and connect with people that are very different from us and have different lived experiences.

 

Dr. Zachary Lum: You’re listening to the Health Disparities podcast – from Movement Is Life — being recorded live and in person at Movement is Life’s annual health equity summit. Our theme this year is “Health Equity: Solutions from Healthcare Leaders.”

 

I’m Dr. Zachary Lum, a member of the steering committee of Movement is Life and an orthopedic surgeon based in Sacramento. Today, we’re going to explore some big questions about community health and how hospitals and health care workers can help promote equitable health outcomes in their communities. I’m joined by two guests who are going to help us unpack all this. Dr. Maura George is an associate professor in the Department of Medicine and an internist at Grady Memorial Hospital in Atlanta, where she also serves as Medical Director of Ethics. And Leslie Marshburn is the Vice President of Strategy & Population Health at Grady Health System. Both of you – welcome to the Health Disparities podcast. Thanks for being here!

 

To start, Leslie, can you tell us a little bit about the communities served by the Grady health system?

 

Leslie Marshburn: Sure. So Grady is a level one trauma center and a safety net health system for Fulton and DeKalb counties, well the majority of residents in Fulton and DeKalb, we have about 2 million residents that we serve. It’s often a tale of two cities, because in the northern part of the counties, their communities with very high income, very high insurance rates, educational attainment, etc. And then in the south side of the city, many of those communities have lower household income rates, lower educational attainment, higher rates of disease. And Grady predominantly serves the southern part of that community, and many of our patients at Grady identify as Black or African American, almost 80% and so with our community health needs assessment work, we’re really looking at how we can identify disparities In health outcomes and help address the root causes of those.

 

Lum: Here at the Movement is Life Summit, you two led a workshop delving deep into often overlooked tools, specifically the health community needs assessment. Dr George, can you tell us a little bit about this assessment for those who may not be familiar with it?

 

George: The Community Health Needs Assessment isn’t new. It’s been done by public health for a long time, but it’s really a systemic, comprehensive look at the health things that are at risk for the community, that are putting the community’s health at risk, and the assets that the community has as well, to really find ways that we can help to improve communities and their health. And so the community health needs assessment, as outlined by the ACA, is required by all nonprofit hospitals now to show that they have benefit to the community that’s commensurate with their tax exempt status. And then the community health needs assessments that you do rely on a lot of qualitative and quantitative data that’s from either primary sources, like right in the community, or kind of higher level mortality, morbidity data that’s collected and all of that’s put together alongside the community voice to make a community health improvement plan or CHIP that allows your hospital to go forward and make changes.

 

Lum: Interesting. Great, great information. Leslie, how does a hospital system go about conducting a community health needs assessment? Are you looking at existing data, gathering new data? What does it involve? What is it? What are the details?

 

Marshburn: So this process happens once every three years. That’s the requirement from IRS, and it really takes almost a full year to conduct the Community Health Needs Assessment in a really robust way, as well as develop the community health improvement plan. So for the first step is really to design your process, identify both your internal and external. Stakeholders and evaluate your data collection processes. So as Maura mentioned, we have primary data collection which is really from the source. So we want to be hearing directly from the individuals that we serve what they believe their community health needs are in addition to identifying what the needs are, they can make recommendations for what would make an impact on their health and their communities. So that’s done in a lot of different ways, often new ways, as you mentioned, Dr. Lum, that’s community surveys, focus groups, summits, things like that, where you’re gathering a wide range of information.

 

Also paramount in that process is making sure specific voices are heard. You know, there are many in our community that are underrepresented in surveys and data, and we want to make sure those who are most vulnerable are included in this needs assessment process so that could be formerly incarcerated individuals, people experiencing homelessness, refugees, members of minority groups like the LGBTQ community, we really want To lift up their voice and hear what needs they have so that we can prioritize improvement activities in addition to the primary data, it’s important to look at the statistics. And you know for that, we typically go to the Census Bureau, to the CDC, many of those large publications that have data on mortality, mortality, morbidity, disease, prevalence, statistics on the population characteristics that include the social determinants of health, like the you know, income that I mentioned earlier, but even Things like the quality of housing in a particular community, access to transportation, because all of those factors influence health. So you’re really marrying data from public sources, ideally at the most granular level, like the census track or zip code. And so those national data sets can help inform kind of what the needs are, and then layering that with the community voice through your primary data collection and synthesizing all of that helps you identify your priorities.

 

Lum: No wonder why it takes a long time. That’s right. You know, it’s, and I think it’s, it’s really admirable that the resources that you used, speaking specifically from your workshop today, you know that making sure that you have good, transparent data that represents the communities that you serve, and that if that data, for whatever reason is has some inherent bias into it, that the information has to be retrieved again or the data has to be refined or redone in order to accurately represent the populations that you serve. So congratulations to that. Thank you so much. Dr. George, you work as a physician at Grady, a hospital that does community health needs assessments. What steps do you take to meet the identified needs playing out in your patient care?

 

George: It’s really been great to work at Grady. I’ve been there for my whole career, since residency, and I love getting to know Leslie, because I get to hear about all these innovative, cool things that she and her office are putting in place. So my patients have definitely benefited from a lot of the community health needs assessment work that Grady’s done. My clinic is right next door to this amazing food as medicine space that’s been created over 10 years. I’ve really seen this grow from what used to be a fast food restaurant into now a huge food is medicine, kitchen, teaching, kitchen, food bank. Where they’re we’re giving out healthy produce. And so a lot of my patients that have diabetes and high blood pressure and food insecurity are able to go and access this. And you know, no matter what I can do with my for my patients with medicine and with referrals or surgeries or whatever they need. Getting food is such a basic need to your health. And so I have a patient who’s an older patient of mine with diabetes, with heart failure, and she looked at me and said, this program is what’s keeping me alive right now. And it was just so striking and such a significant example of how social determinants and the work especially that’s being done with the Community Health Needs Assessment is impacting our patients.

 

Lum: That’s amazing and so impactful to hear that from a patient.

 

Marshburn: Can I mention one more thing about what Mara just mentioned? You know, the food is medicine program. It didn’t come out of nowhere. You know, it was born out of our 2016 CHNA work in identifying that food insecurity, as well as cardiometabolic syndromes, were top priorities for Grady, we looked around the community, found a willing partner who had expertise in food access and so worked with them over it was probably a three year period to get to the point where we could actually begin doing significant programming. And so the Atlanta Community Food Bank is our close partner in this. They provide all the food to our participants and engage with our patients. One other benefit that I’ll admittedly say was not part of our original plan is that our registered dietitian, who teaches the cooking classes, she also does educational sessions for our residents, and so it’s teaching culinary medicine. It’s this new emerging field about how food how can you use food to manage or treat your chronic disease? And so we’ve done great surveys with the med students and residents that participate in this, and they said, I didn’t know. You know, I diagnosed my patient with hypertension and obesity, but I didn’t know how to counsel them on eating healthy. I just put in a referral to nutrition. And because the physician and the patient have such a trusted relationship, it’s important to equip our providers with the information to help guide them. You know, telling people just to, you know, eat baked chicken is not going to work.

 

Lum: Totally, it’s, it’s so important when it comes from that established, trusted resource. So oftentimes, even me, as an orthopedic surgeon, counseling patients, they often will ask me things such as, what should I be eating from my recovery? What should I be eating to maybe lose weight or be healthy, et cetera. It just kind of is all baked into that food is medicine philosophy, which I definitely do believe in. In fact, actually, Mark Watkins is the CMO of Kroger health, and he was here last year, and he was describing, again, the same philosophy with the food is medicine. So I think that’s definitely something that is very important and powerful going forward. Dr George, one of the things you discussed in the Workshop here at the movement is Life Summit, is the interplay of health literacy and social determinants of health and the community health needs assessment. Can you unpack that idea for us?

 

George: I’ll start with health literacy. I think anything we do in medicine and healthcare needs to be centered around health literacy, in my opinion, because it’s we used to think of health literacy as very individualized. So how is your health literacy? Are you able to read this? Are you able to understand what I’m saying really put it on the patient when really our systems are so complex now that it’s overwhelming for anyone, regardless of their personal health literacy. So a lot of definitions now, including Healthy People 2030 are expanding to not just focus on that personal health literacy, but also think about what’s our organizational health literacy, what’s the obligation that we have to make sure that the things that we’re doing are understandable? So how does the community access the health care system? How do we deliver that information? What kind of paperwork are we giving people? What type of health IT that’s a whole new area for health literacy to think about. So all of these things, because there’s so much community embedded in a good CHNA really focusing on health literacy, making sure that we’re doing, we’re creating spaces where the skills and abilities of the community and all of us meet the demands and complexities of these systems to create these health literate spaces, I think, is essential to the work that we’re doing, where social determinants of health, I almost see these chnas as an extension of the physician patient relationship.

 

You know, you have these individual things, and if you’re really tailoring your care, and you’re meeting the patient where they are, and you’re asking about things outside of the office visit that are really impacting their health, that’s kind of what we’re doing at a much larger level with these CHNAs And inevitably, things are going to come up that are not, oh, I just need more medicine, sure, right? So, you know, I mean, there’s, you cannot be a good bedside clinician and just ignore everything that’s not technically medical. No, you know, I, I’ll give you one example. I had a patient who I was doing inpatient medicine at the time, she had bad COPD or lung disease. She kept coming into the emergency room, and she would almost get intubated. She was in bad respiratory distress. And they put her on a BiPAP machine and gave her medicine. So a BiPAP machine just is a has a mask that goes on and pushes arien, but it’s not the tube down your throat. And gave her some. Medicine, and she reversed like that, put her on my team, we took care of her, we gave her medicines and antibiotics and sent her home. A few days later, she came right back, same thing. Almost got intubated. We ended up putting her on BiPAP, giving her medicines this time. We increased her steroids, we gave her a different antibiotic, sent her back out. The third time she came back in that month, everybody said, Well, she must just not be compliant. And we talked with her, she actually had a BiPAP machine at home, which is pretty impressive in a low resource area to have at home. It’s pretty expensive, but she had that, and we said, You must not be using your BiPAP. And she said, I am. It just doesn’t feel like yours.

 

So we had her machine serviced, and it was full of cockroaches. So no matter what we, I could have the best the most perfect diagnosis, the most perfect evidence based plan, but she was going home to breathe in cockroaches. So the actual intervention that she needed wasn’t more medicine or more things that we traditionally think about. It was really us advocating to her landlord to spray for the cockroaches and to get that machine serviced. And I think on a larger scale, again, we see these chips as being more meaningful when they’re actually targeting the things that are impacting our community’s health, like food insecurity, like transportation.

 

Lum: Absolutely, you had to treat the patient as a whole, take care of the whole patient and being able to address the main barriers that are preventing them from having a healthy outcome and leading a healthy life. So Dr George, I understand that one of the courses you teach for medical students is about importance of a connection to community and recognizing bias, privilege and health disparities. Why do you think these things are important to instill in up and coming physicians?

 

George: I think clinicians who don’t know how to recognize disparities are going to perpetuate them, and we can all do that unintentionally. I think knowing our own internalized bias, implicit bias is important, because you have to realize how that can interact in the in the patient care space. We talk with our students when they first come about who they are, we get to know them all. We have an increasingly diverse student body, which is great for the future of our physician workforce. But right now, our physician workforce doesn’t match the population, and as it gets increasingly so, that’ll be even better for really connecting the patients, but we all will need to be able to engage and connect with people that are very different from us and have different lived experiences. And so I think really being able to have a conversation with someone who’s very different than you, being able to recognize go in with a lot of cultural humility and recognize what we don’t know, as physicians or clinicians in general, to meet people where they are is very important and really essential.

 

Lum: Yeah, I agree wholeheartedly. I mean, there is going to be some discordance between the physician and the patient, and I think it’s very important to try to understand where they came from, their experiences at the same time also understanding that there are discrepancies in the makeup of physicians, and we should do everything in our power to try to have a more diverse workforce, because those physicians, those individuals, are just going to have a little bit more of a shared experience with their patients, and we know that concordant relationships usually end in better outcomes, better compliance, and I think that it’s just, it’s overall, it’s a good thing for the community. So thank you for that.

 

Leslie: I’d like to share an example of what Maura does with her students, because I love it, and it’s such a great exercise, and would encourage you to seek it out in your communities. Our food partner, the Atlanta Community Food Bank, they host community food experience simulations, and I know you have your students do this and where you take on a persona, whether it’s a single mom, diabetes, no, no personal vehicle. And you have in the room the different you know this, the snap office, the church with the food the you know, the food bank over here. And you have on your persona, I get, you know, $25 is my budget for food for a week, and then you have to go and try and fill a nutritious plate with the resources you have access to. And it’s a simulated experience, couple hour experience, and and, you know, at the end of it, you really understand how challenging it is for people who are experiencing food insecurity to access one healthy food or even any food at all, given the landscape that we unfortunately present to them in this very complicated social services system. So that’s kind of that experiential learning. Is really important for any practitioner and just citizens in general, to understand what they may not have lived through themselves.

 

Lum: Absolutely I agree, 1,000%. Dr. George, med students may feel they’re in school to learn how to practice medicine, but I understand that you’re of the mindset that physicians also need to be equipped to do the work in transforming healthcare systems. Where does this conviction come from?

 

George: There’s a lot of talk of burnout in our profession, and a lot of sources of burnout. We asked our residents in internal medicine, what where they find a lot of burnout, and we were really surprised to see that a lot of it actually the highest rated thing was unmet social needs, like having patients in front of you that you can’t meet their social needs. So so much of what is done and what’s going to impact my patient’s health is already written in the stand by the time they walk in my door, because of health policy or because of things that are further upstream. I think, you know, we can really be change makers in this system. And you with burnout, I think you can only be pulling people out of the metaphorical river or suturing up literal gunshot wounds so often before you feel like you have to go upstream and do something about it. We had a great ear, nose and throat physician, Charles Moore, who was seeing so much end stage head and neck cancers and had to go upstream and started smoking intervention programs, and then eventually started a primary care clinic of his own as an ENT, because you just feel like you need to do something before this piece that’s right in front of you that just keeps churning otherwise, and I think that’s a good, a good way to decrease burnout.

 

You know, one of the things that I like to advocate for here in Georgia is Medicaid expansion, and it came because of the same cycle of people falling in the river. I had a patient that I went to see once he was coming out of the ICO and getting admitted to my team. So it’s the first time I was meeting him, 37 years old. He’d been admitted so many times with DKA or diabetic ketoacidosis, so he had very high blood sugars, ended up very sick and in the ICU, over and over again, never came to his appointments, never took his medicines. When I was meeting him, he was coming out of the ICU because he’d had to support the amputated. So I went, and I was geared up to give him a pep talk about coming to clinic and taking his medicines. And I sat down and introduced myself and started talking, and he said, Oh, I’m going to come to all my appointments and I’m going to take all my medicines. And he had big smile on his face. I said, Well, what changed? And he said, I got Medicaid. And so because our state is one of the 10 states that hasn’t expanded Medicaid, he did not have access to care, and he couldn’t afford his medicines. Couldn’t afford his appointments before that, and now he can, but we took a 37 year old father of three, and made him lose his foot before we would give him the cheap and effective care that we knew we had access to. So stories like that are just this churning frustration and source of burnout if you can’t do something about them. And being able to engage with community advocates and activists in Georgia and kind of move upstream on that issue has helped me in being both at the bed, the kind of that duality of being a physician and being at the bedside, but then also feeling like you have a larger role.

 

Lum: Yeah, and being it being a part of thank you for being a part of this, and also just being able to spread the word out and get the news and information out to others that these problems exist and they’re real world problems, and they affect many, many people. And so thank you for that. Couple more questions. Leslie, what role or responsibility do you feel hospitals, especially those with nonprofit status, have to improve health equity and outcomes for their communities?

 

Leslie: Yeah, I truly believe that nonprofit hospitals have an obligation to the community that they serve because of the benefit that they receive with their tax exempt status that was written into the ACA, and you know that is the focus. And if you do a ch and a right, you are looking for how you can lift up and support populations who experience health disparities in their health outcomes. So, you know, it’s not just oh, well, let’s have exercise classes, because behavior changes is hard and you know, but you want to look at what is the true need, and what does that population need to be healthier, so really making sure that you’re tailoring the interventions to the population with the greatest need, that way those individuals can have their best chance at optimal care. And you know what a physical activity intervention looks like for a senior in a suburban you know, high income community will look very different than what a physical activity intervention looks like in the inner city, in an unsafe neighborhood with a family that works multiple jobs, you know, to support their families, so really making sure that the health systems are being intentional with the and with the support that they invest in the community through the chip to get to the root cause of it, of the need and what’s really going to raise the bar.

 

Lum: Thank you. If community leaders feel like they identify a community health needs assessment that they feel that they could help address or find ways in which to partner with local hospitals or healthcare systems, how would they go about doing that?

 

Leslie: Well, first, reach out to your local health system with the requirements for the CHNA it is explicit that you’re supposed to get feedback from the community. And so generally, health systems have a way to contact them. If you search up a health system and community benefit, there will be a way to reach out. So reach out and say, you know, we have this need. We’d love to partner with you on this. You know, I love meeting people out in the community that identify, you know, oh, we’re doing this food pantry, or we’re doing this community garden, and so that helps the health systems direct their efforts to what’s already on the ground and in place, versus creating something out of scratch that you know doesn’t support the assets that are already in the communities. So definitely reach out, engage in the process and and help create that link.

 

Lum: Well, it’s very complex. It seems that social support and social workers are part of the front lines of the Community Health Needs Assessment. Is there some truth to that or and are there other allied health or non non allied health professionals that play a role in the CHNA?

 

Leslie: Yeah, certainly, the web of social service agencies that exist outside of the hospital are critical to be engaging and understanding what resources are available and what constraints they have in their system to be able to support the community with optimal health. And kind of thinking about the, you know, within the the health system, and the professionals that work in the health system, social workers, are like the lifeblood at Grady, and deserve a ton of respect. And there’s, and, you know, a new and upcoming profession called a community health worker, and these are individuals kind of similar to social workers, but don’t have the training that social workers receive. They’re people with lived experience, people who have a trusted relationship in the community, understand the healthcare system and help advocate for the patient, as well as assist them in navigating the healthcare system. Now, community health workers are a great gateway to getting to know the community, and so you know people who have that shared experience and are connecting on a regular basis, they’re a great resource within the health system to help tap into the community and open doors and and allow those conversations to occur in a genuine space so certainly, social services are very important.

 

Lum: I could see how that really builds trust in the community, especially when there’s sometimes a little bit of a discrepancy between the large healthcare institution and the community. So I see how that can definitely maybe disarm some guards that are up in place for when that happens. Leslie, what do you think about the direction we’re headed as a nation in terms of health equity, diversity in healthcare and addressing health disparities? What gives you hope?

 

Leslie: Now, I’m not sure about the future, but I can comment on the present, which is CMS is doing some really great things around social drivers of health effective 2024, January, 2024 CMS is requiring as a condition of participation in Medicare for every patient admitted to a hospital to be screened for social drivers of health on five domains, and we are required to report our screening rates as well as the positivity rates among our population on the ambulatory side of. They’ve also introduced reimbursement, well, very small. Every little bit helps for completing an SDOH assessment during a clinic visit that will help the provider tailor the care plan to the whole person needs that we were talking about earlier. There are also some new codes that reimburse physician practices for ancillary support through community health workers or peer support specialists, that are new and are how health systems can support patients with accessing resources to address their health related social needs. So, you know, I think that is incredible. We’re trying to take advantage of all of those opportunities. And you know, Medicare really has a great history of reducing racial disparities in health care. And you know, we did this great Juneteenth event at Grady, where we watched the documentary power to heal, and it talks about the history of Lyndon B Johnson. When he adopted the Medicare program, he required that anyone that any hospital that participates in Medicare, must adhere to the Civil Rights Act of 1964 and because of that, hospitals are now desegregated. I mean, that was the watershed moment that led to that, you know, reduction in racial disparities in the in the provision of health care, and that was in 1964 so we have a long way to go. I think, you know, Medicare has tremendous impact in how we provide care to our community, and you know, their focus and attention on social drivers of health, I feel like is, is another kind of turning the page on reducing disparities, and, you know, improving health equity.

 

Lum: Thank you. Yeah, I’m very hopeful that with time, and obviously it feels like it’s it can’t come soon enough, but there are some gradual changes that can can occur and will occur, and even in the future, I think in the next couple of years, they’re discussing potentially incentivizing to take care of people that are more underserved as well. So thank you for that. Is there anything else you two would like to add?

 

George: I guess I’ll just say, if you’re a clinician, whether you’re at the bedside or you’re doing something in the community further upstream, like community health needs assessments or other advocacy work. Really, the concept is the same. You want to listen and learn and approach it with humility and partner together to make a tailored plan that’s really going to be effective and tailored for that patient or that community.

 

Lum: Excellent. Well, I’d like to thank my guests today, Dr. Maura George and Leslie Marshburn, for being here with us. You can find links to more information about the work that our guests do at Grady Memorial Hospital and Health System at the link in our show notes. That brings us to the end of another episode of the health Disparities podcast from Movement Is Life. I’m Dr. Zachary Lum. Until next time, be safe and be well.