Hospitals and Schools As Hubs for Building Healthy Communities

Hospitals and Schools as Hubs for Building Healthy Communities

Stuart Butler Carmen Diaz

Economic Studies at BROOKINGS 01 n o v e m b e r 2 0 1 6

Stuart Butler is a Senior Fellow in the Economic Studies Department at the Brookings Institution.

Carmen Diaz co-authored this report while a Research Assistant at the Brookings Institution. She is currently the Innovation Project Manager at Sibley Memorial Hospital in Washington, DC. This report does not represent the views of Sibley Memorial Hospital or the Johns Hopkins Medical Center.

The Brookings Institution is a nonprofit organization devoted to independent research and policy solu- tions. Its mission is to conduct high-quality, independent research and, based on that research, to provide innovative, practical recommendations for policymakers and the public. The conclusions and recommendations of any Brookings publication are solely those of its authors, and do not reflect the views of the Institution, its management, or its other scholars.

Support for this publication was generously provided by the Robert Wood Johnson Foundation.

Brookings recognizes that the value it provides is in its absolute commitment to quality, independence, and impact. Activities supported by its donors reflect this commitment. Contents

Introduction...... 1

Challenges for Hospitals and Schools as Hubs...... 4 Data Collection and Value Measurement...... 4 Budget and Payment Problems ...... 5 Inflexible Business Plans ...... 6

Recommendations ...... 9 Improve Data Collection and Sharing...... 9 Rethink Business Models...... 13 Increase Budget Flexibility ...... 27

Appendix: Advisory Group Members ...... 30

References...... 31 Introduction

ractitioners and policymakers have become Thus it is important to find ways for different sec- Pincreasingly aware in recent years that tors—such as housing, education, and health—to achieving good health and economic vitality in collaborate more effectively, to be more flexible neighborhoods requires the close collaboration in the sharing of resources, and to achieve the of a variety of sectors. The growing focus on so- broad goals of each sector. Collaboration does cial determinants of health, for instance, stems not occur in a vacuum; it is much more of an or- from the understanding that there are many ganic process. In communities and particularly in “upstream” factors that influence health, from lower-income communities, institutions often pro- housing conditions to poverty and education, vide a crucial focus for collaboration and are ac- and that community development in lower-in- tive agents in the process. We can describe this come communities can help improve residents’ function as carrying out the role of a “hub.” health.1 On the other side of the same coin, we know that a person’s health condition can be an A hub in this sense means an organization or in- important factor in their success at school and in stitution that is a focal point in a community and the workplace, influencing their ability to move helps blend together a range of stakeholders and up the economic ladder. An analysis of spending services that improve the health and economic patterns across countries shows that the United mobility of residents. It does not necessarily lead States is an outlier in spending on medical care activities or function as the sole focal point—often compared with social services, yet with little or no it is a partner with other institutions. But through advantage seen in health outcomes.2 This sug- partnerships and its own services it enables orga- gests that improvements in general health may nizations and people with particular skills, assets, be achieved more effectively by spending outside and connections to work more effectively togeth- the medical sector. Research on the balance of er to improve the neighborhood. A hub might be a health and social spending at the state level sug- school. It could be a hospital, church, or housing gests the same conclusion.3 project. It could be a community-based organiza-

1 Health Affairs, “Culture of Health.” Center on Social Disparities in Health et al., “Making the Case for Linking Community Development and Health.” 2 Squires and Anderson, “U.S. Health Care from a Global Perspective.” 3 Bradley et al., “Variation in Health Outcomes.”

Economic Studies at BROOKINGS 1 tion. In a particular neighborhood, there are like- strengthen core health and social services.4 Many ly to be multiple hubs with different characteris- engage in economic development and health im- tics that partner with each other, such as a clinic provement projects in their communities, often linked with a school. with other important hubs such as community development corporations and community-based In this report we feature two such institutions that organizations. A hospital, for example, might pro- potentially can play a major role in helping to en- vide mental health services and cooperate with a hance health and long-term economic mobility in housing authority to reduce emergency room vis- a community: hospitals and schools. We make its; it might partner with schools to help address six broad recommendations involving a number asthma and improve school attendance. Hospi- of steps. These are addressed to federal, state tals also have sophisticated data systems that and local governments, as well as hubs and their might be used as a “data warehouse” for storing partners. The focus of the report is not on the pri- and processing nonhealth data for partners in a mary mission of each institution—treating illness community. Thus, hospitals potentially have the and educating children—but rather how they can resources to make a significant difference, not play a collaborative role as a hub for a range of just directly by providing health services, but also, services. The purpose of the report is to suggest as many now do, through a variety of nonmedical ways to create the best policy environment for ventures that can improve health through such these hubs to fulfill their enormous potential. activities as housing development and improvement.5 Why did we pick these two particular institutions? It is not that others are unimportant, but that we Hospitals are, of course, only one part of the believe that with an improved policy environment health system servicing a community. More- hospitals and schools could play a much larger over, other parts of the health system tend to be role in improving the health and economic mobil- closely connected with the chronically ill and with ity of many communities. others in the community, such as school nurses, local clinics, and accountable care organizations Hospitals. We focus on hospitals, together with (ACOs). It’s also true that, in general, hospitals schools, because—with appropriate public policy have not developed the infrastructure and exter- changes and other steps—many hospitals have nal networks that would constitute a hub function. the potential to become backbone hub organi- But there are many exceptions. Some hospital zations in their communities. There are many systems, such as Montefiore in New York City reasons to look at hospitals in this way. For one and several Catholic systems including Trinity thing, the scale of operations and economic im- Health, and Dignity Health, have developed elab- pact of a typical hospital make it a prominent an- orate programs to work closely with community chor institution, with the capacity to improve local organizations, housing, and social services. conditions beyond health. Hospitals are large employers and purchasers, for instance, so in Hospitals today also have incentives that encour- partnership with other institutions they can help age them to look outside their walls and pay great-

4 See Norris and Howard, “Can Hospitals Heal America’s Communities?” 5 See Trust for America’s Health and Robert Wood Johnson Foundation, “National Forum on Hospitals.”

2 Hospitals and Schools as Hubs for Building Healthy Communities er attention to community health services and the address a variety of local needs. These include social factors that affect health.6 Most are subject health care: most schools can provide some to Medicare readmission penalties, for example, health services directly, such as through school and nonprofit hospitals are now required to cata- nurses or school-based health centers (SBHCs). log local health conditions and develop plans of Community schools7 and some other schools al- action to address them. ready organize teams to function as case managers for a range of factors that might be called “so- Thus, hospitals in the future could play a much cial determinants of education.” Such teams work greater role in improving health and economic with families and other organizations to address conditions in communities. This report examines a range of issues, including housing and family both the potential and the challenges for realizing problems as well as encounters with the criminal this greater role in the future and the actions that justice system. Meanwhile, organizations such could enhance the activities of hospitals as part- as the Health Schools Campaign8 provide train- ners and hubs. ing and support to parents who develop school wellness teams focusing on school policy and Schools. In contrast to hospitals, schools have practice to promote healthy eating and physical traditionally been a central institution in most activity. Indeed, schools are increasingly seen as neighborhoods, linking children and their parents critical institutions for improving children’s health.9 together and playing a key social role. In principle Some schools, such as Briya Public Charter they are well placed to help address a range of School in Washington, DC, pursue a two-gener- needs. For instance, teachers and school nurses ation approach, focusing on the needs of parents will likely see the effects of problems related to as well as children, by providing in-house social challenges at home; families generally trust these and educational services during the school day, professionals, and they may be the first respond- such as parenting classes and literacy programs, ers available to tackle them—if they have the ap- and sometimes partnering with clinics for health propriate time and resources. services.10

As existing, trusted, and familiar institutions in Like hospitals, however, schools face a number communities, schools can be an ideal location of limitations and challenges in fulfilling their full for organizing and assembling partnerships to potential as community hubs.

6 For example, see Butler, “Hospitals as Hubs to Create Healthy Communities.” 7 Jacobson, “Community Schools.” 8 Health Schools Campaign, website. 9 Robert Wood Johnson Foundation, “Achieving Healthy Schools for All Kids in America.” 10 Butler et al., “Using Schools and Clinics as Hubs to Create Healthy Communities.”

Economic Studies at BROOKINGS 3 Challenges for Hospitals and Schools as Hubs

s part of a Brookings Institution project sup- ing assistance. Organizations need to share data A ported by the Robert Wood Johnson Foun- if they are to be effective in tackling the multiple dation, we interviewed a range of individuals en- needs of a community. And third, it is essential gaged in efforts to improve collaboration across for evaluation, which is necessary to ensure re- sectors, and we have studied several institutions. sources are used efficiently and to make possible In a series of meetings, we also brought togeth- continuous improvement. To measure success, it er experts and practitioners to explore the role of is important to be able to identify the impact on hospitals and schools as hubs, the challenges other sectors of initiatives in any one sector, and they face, and policy steps that could help im- so calculate a true return on investment (ROI). prove their effectiveness. Regrettably, pervasive shortcomings and bar- In the discussions of challenges, we found three riers can interrupt the collection and sharing of broad areas of concern for both hospitals and important information. For instance, in the health schools. sector, social and other risk factors are often not included in personal health records, making comprehensive epidemiology difficult. The National Data Collection and Value Academy of Medicine and other organizations Measurement concerned with social determinants of health have called for incorporating broader background Collecting good data and sharing it between orga- questions in electronic health records.11 nizations are crucial to effective collaboration for three reasons. The first is epidemiology: data are Data are also often not collected by government needed to define and understand a population’s agencies or private organizations in a standard- needs and risk factors. Second, data are needed ized way that makes sharing easy, and agencies to develop the evidence base to select appropri- and organizations are often reluctant to share ate interventions that are likely to succeed. As- data. With health and education data, this reluc- sembling good information on the health, hous- tance can be due in part to concerns about priva- ing, education, and other conditions of a person cy requirements emanating from the Health Insur- or household or group is essential for coordinat- ance Portability and Accountability Act (HIPAA)

11 For instance, see Institute of Medicine of the National Academies, “Capturing Social & Behavioral Domains.”

4 Hospitals and Schools as Hubs for Building Healthy Communities and the Family Educational Rights and Privacy body of research analyzing the impact on health Act (FERPA). Many experts argue that, especial- quality and costs of efforts to address health-re- ly with HIPAA, there are ways to share informa- lated housing issues (for example, reducing falls tion that maintain appropriate privacy. But uncer- or eliminating mold),12 but that captures only part tainty about the law and regulations often inhibits of the value of intersector activities and initiatives. sharing, especially by smaller organizations and For instance, if a hospital engages in an initiative institutions. In addition, despite data system im- to reduce obesity among schoolchildren or men- provements in the health system, data continue tal illness among the homeless, the ripple effect to be entered in different ways—sometimes elec- can be very wide, including higher graduation tronically, sometimes on paper. Requirements for rates and better future earnings, reduced use of data to be collected differ, and what one facility social services, and better results from job train- or agency considers important data may not be ing for the homeless. important to another, often making it difficult to acquire data from different systems or to calcu- But these broad impacts are not usually fully cal- late the full ROI. culated to assess the full ROI of the hospital initiative. Moreover, a hospital’s accounting system Data collection itself can be problematic. Building does not capture the full value that the hospital and maintaining the capacity to collect data are activities generate in the community unless there a normal part of a hospital’s activities and those is a direct positive benefit to the hospital. Indeed, of larger schools. But it can be a challenge for a hospital’s accounting system measures only the smaller institutions; collecting and analyzing data cost associated with activities that generate medi- can be costly and require skills that are not read- cal benefits. The same is true of schools. A school ily available. This can make it difficult for a larger nurse or social worker may have a long-term pos- hub to have an effective partnership with a small itive impact on the family of a student, but that im- organization in the community. pact is typically not measured. There are many impacts that could be measured, such as reductions When data are difficult to collect and share, it in school absenteeism, greater family stability, and makes it hard, for example, to coordinate support improved economic mobility. But as we note in this for a young student because accessible data nor- report, there are troubling deficiencies in our ability mally do not make it easy to “follow the child,” to measure the full ROI, ranging from inadequate such as when they change schools or have an data to the costs faced by cutting-edge organiza- encounter with a health care facility or the juve- tions in conducting such analysis. nile justice system.

On the larger scale, there are considerable lim- Budget and Payment Problems itations in our ability to measure the true ROI of a hub or partnership because it is rare for adequate Deficiencies in measuring ROI exacerbate the research to be conducted to show the broad im- underlying “wrong pocket” problem commonly pact—or “value-added”—of an initiative in one associated with intersector collaboration—the sit- sector. In the health sector, there is a growing uation in which one institution or sector incurs the

12 See, for example, Green & Health Homes Initiative, website; and National Center for Healthy Housing, “Research.”

Economic Studies at BROOKINGS 5 cost of an activity but a significant benefit accrues may be well placed to work with local households to another institution or sector. This problem is to address social and health problems that limit a accentuated by different agencies considering family’s ability to move up the economic ladder, their problems, costs, and measures of value school budgets rarely cover the cost. to be unique to their sector. Not adequately rec- ognizing and measuring these broader benefits To be sure, there is some progress in addressing makes it difficult for a level of government to bud- this general problem, in the form of waivers and get efficiently by investing adequately in one sec- pilot programs used by federal and state govern- tor or institution to generate benefits elsewhere. ments, but much more needs to be done to deal With little ability to measure ROI for community with rigid budgets that inhibit collaboration and activities, institutions have trouble establishing the work of hubs. and justifying budgets for this work. The result is a suboptimal pattern of investment in hubs that incur costs in organizing services or partnerships Inflexible Business Plans that benefit the broader community. The ability of potential hubs such as hospitals and Siloed program budgets and payment systems schools to fulfill their potential is also limited by add to this problem. Public budgets are gener- the perceived functions of the institutions them- ally designed within agencies and committees selves. Hospitals and schools do have “business of jurisdiction that focus on specific policy areas. plans,” even if a school would not typically use Thus, the rules governing payments and the use that term. In part, this limited vision of the busi- of money by recipients are normally focused on ness plan simply reflects the budget and pay- that area. It is usually very difficult for a school ment system. Even if the leadership of a hospital or hospital functioning as a hub to obtain permis- or school envisions a community role beyond the sion to use funds for services outside their core traditional core functions of the institution, the activities or to incur overhead costs associated chief financial officer is likely to resist proposals with partnerships that benefit the broader com- seen as “mission creep” for which there is no rev- munity. Payment streams to hospitals do not enue stream. Even hospitals that have a religious typically cover a hospital’s nonmedical activities mission and an explicit commitment to the broad- or personnel costs that create value in the com- er economic and social health of their community munity by acting as a hub and improving social typically justify expenditures as the philanthropic determinants of community health—although this part of their business plan rather than a true busi- is beginning to change with the advantage of val- ness investment. ue-based care and associated delivery models, such as ACOs. Such payment problems arise in Envisioning hospitals and schools as hubs does examples such as hospitals working with local require institutions to view their business mod- housing associations to stabilize homeless peo- el differently and to explore different revenue ple with mental illness or employing social work- streams. For hospitals, among other things, it is ers to help patients obtain social welfare benefits important to continue the evolution from a culture that might contribute to their long-term health. of billing to a culture of value and return on in- Similarly, in the case of schools, even though vestment. If we think of a hospital not as a place teachers, school nurses, and other school staff that is paid to treat people when they are sick,

6 Hospitals and Schools as Hubs for Building Healthy Communities but as an institution that improves community development, to organize a range of support ser- health (and so reduce hospital admissions) by vices for discharged patients.14 promoting health in tandem with other services to enhance economic stability and mobility, then Hubs also need to be sensitive to their role in the we must think differently about the functions and community and how they are viewed. Schools revenue streams of hospitals. That’s very difficult are typically viewed as “of” the neighborhood, if the current business model is based on fee-for- potentially making it more likely they would be service payments for strictly medical services. trusted with a leadership role. That is less true Managed care institutions, where payment is re- of most hospitals, where the families served typ- lated to maintaining overall health rather than de- ically come from a wider area, so that their role livering specific services, have more incentive to may usually be best seen as a participant or part- explore a variety of social determinants as part of ner hub rather than a leader. In addition, aligning the business plan. But even capitated managed corporate headquarters’ strategies with the com- care institutions need a modified plan and oth- munity knowledge and goals of a local institution er sources of revenue if they are to have the in- can be difficult in this era of consolidating health centive to help organize a variety of services and systems. partnerships to achieve nonhealth improvements in the community. Creating a different business model and corporate culture in these sectors also requires a Fashioning new business models and partner- change in the vision and culture of government ships is difficult. Often the staff’s current skill sets agencies, which establish operational and bud- are not well aligned with a new role as a hub. get rules that essentially determine the business That is why it can make sense to turn to inter- models of many community institutions, including mediaries to supplement those of the institution, schools and hospitals. Thus, government at sev- at least for transition.13 In some cases these can eral levels needs to reassess its vision of commu- be “embedded” intermediaries that operate within nity improvement and its attitude toward the po- the institution. An example of this in the hospital tential of schools, hospitals, and other institutions sector is Boston-based Health Leads, which has in achieving that goal. If it does so, government embedded medical student volunteers working has important tools to encourage the adoption of with patients and their hospital physicians to re- different business models. In their use of pilots fer discharged patients to social services. Com- and waivers, for instance, government agencies munities In Schools creates a team in a school have been taking some important steps to en- to work with school administrators to develop a courage hospitals and schools to explore new plan to support students. In other cases, inter- business models and payment arrangements. mediaries can supplement in-house skills. For Sometimes these are sticks rather than carrots. instance, Washington Adventist Hospital in sub- Readmission penalties in the Medicare program, urban Washington, DC, partners with Seedco, a for instance, have triggered many hospitals to nonprofit organization specializing in economic undertake partnerships and hire staff with social

13 Singh and Butler, “Intermediaries in Integrated Approaches to Health and Economic Mobility.” See also Singh, Dying and Living in the Neighborhood. 14 Butler et al., “Hospitals as Hubs to Create Healthy Communities.”

Economic Studies at BROOKINGS 7 service skills to address housing, transportation, hospitals and schools could play a much great- and other problems that can contribute to read- er role as hubs in communities. In addition, we missions—and so avoid a reduction in payments. asked advisory group members to comment on Meanwhile community benefit requirements (for drafts of the report. nonprofit hospitals), including those of the Com- munity Health Needs Assessment (CHNA), are While the recommendations reflect suggestions pushing hospitals to address the general health raised in the conversations, they are not a con- of their communities and to develop or explore sensus of the advisory group, and the recom- partnerships with community organizations. So mendations do not necessarily reflect the individ- far, there are fewer pressures on schools to ex- ual or institutional opinions of any advisory group plore their broader community role. participant.

****************************** The authors of this Brookings report, not advisory group members, are responsible for the recom- For this project, we assembled an advisory group mendations. of researchers, policy experts, and practitioners to suggest policy steps and other actions that See the Appendix for a list of the advisory group would create an improved environment in which members.

8 Hospitals and Schools as Hubs for Building Healthy Communities Recommendations

fter discussions within the working groups Recommendation 5. Make greater use of Aand with other experts, we have arranged waivers, demonstrations, and other steps to our recommendations into three categories, re- foster hubs and other partnerships. flecting the opportunities and challenges facing hospitals and schools that could be effective Increase Budget Flexibility hubs: improving the collection, sharing, and use of data; adapting the business models of schools Recommendation 6: Take steps to facilitate and hospitals; and addressing budgetary and the braiding and blending of public and private payment issues. We make six broad recommen- resources from multiple sectors and sources. dations, each with multiple specific actions.

Improve Data Collection and Sharing Improve Data Collection and Sharing Recommendation 1: Improve the collection, use, and sharing of data among sectors to fa- Recommendation 1: Improve the collec- cilitate partnerships. tion, use, and sharing of data among sectors to facilitate partnerships. Rethink Business Models Institutions and hubs are often hampered by inad- Recommendation 2: Make greater use of in- equate data and the limited ability to share infor- termediaries. mation because of privacy regulations, a lack of channels to share data, and other obstacles. Sev- Recommendation 3: Widen the skill sets of eral steps could be taken to improve this situation. school and hospital leaders and key staff.

Recommendation 4: Make use of the com- • The federal government, states, counties, munity obligations of nonprofit hospitals and and cities should accelerate steps to estab- financial institutions, as well as the communi- lish “data warehouses,” health information ty focus of the new education statute, to help exchanges (HIE),15 and other forms of inte- launch creative, coordinated partnerships. grated data systems. Hospitals should ex-

15 See HealthIT.gov, “Health Information Exchange (HIE).”

Economic Studies at BROOKINGS 9 plore their potential to be data warehouses panding their data role (see discussion below for a range of data needs in a community. of business models and budgeting).

Some cities are making good progress in cre- • The federal government, states, counties, ating vehicles to collect information from sev- and cities should address governance eral sectors and to make it available to orga- and interoperability issues to improve the nizations seeking to coordinate services. An safe flow of data with personal informa- example is Dallas through its use of the In- tion among government agencies and be- formation Exchange Portal.16 HIEs were cre- tween government and the private sector. ated to allow a more seamless transmission of patient information between providers and In addition to the technical and privacy is- patients, replacing the error-prone method of sues associated with data sharing between faxing and manually delivering patient forms. agencies and nongovernment organizations, HIEs allow providers to exchange information government agencies at all levels need to on patients through a safe electronic system, address often complicated governance ques- through which they can standardize patient tions concerning the sharing of information data and improve efforts to coordinate care. among government agencies.2 Several states in conjunction with the Office of the National Many hospitals are part of HIEs, as are many Coordinator for Health Information Technolo- federally qualified health centers (FQHCs) for gy (ONC) are taking steps to address these underserved populations. Indeed, hospitals issues, as are some counties such as Allegh- are good candidates to play an information eny County (Pittsburgh) in Pennsylvania. warehouse role for other institutions dealing with education, juvenile justice, social ser- Several organizations and branches of gov- vices, and other sectors: they have the capac- ernment are focused on this issue. Examples ity and the analytical skills, and they are used include Medicaid Information Technology Ar- to handling sensitive personal information. chitecture of the U.S. Department of Health When data systems are used to identify and and Human Services (HHS)18 and the Ad- address community health needs, a nonprofit ministration for Children and Families’ work hospital’s financial contribution is considered on interoperability.19 In addition, the federal a community benefit for the purposes of meet- government has been developing and im- ing Internal Revenue Service (IRS) require- plementing a national information exchange ments. Taking full advantage of that opportu- model (NIEM),20 designed to be a community, however, requires both a more expansive nity-driven, standards-based platform to ex- vision of the business model of a hospital and change information within states and federal steps to align payments to hospitals with ex- agencies. Harvard’s Strategic Data Project21

16 PCCI, “The Dallas Information Exchange Portal.” 17 Kingsley, “Multi-Agency Integrated Data Systems (IDS).” 18 Centers for Medicare and Medicaid Services, “Medicaid Information Technology Architecture (MITA).” 19 U.S. Department of Health and Human Services, “Interoperability.” 20 National Information Exchange Model, website. 21 Harvard University, “Strategic Data Project.”

10 Hospitals and Schools as Hubs for Building Healthy Communities and the University of Pennsylvania’s Action- under new federal state and local “report able Intelligence for Social Policy22 project cards,”26 under the new Every Student Suc- are examples of efforts outside government ceeds Act (see below), which are design to to address governance and interoperability achieve greater equity and to address barri- issues. The Data Quality Campaign23 is also ers to student success. providing assistance to organizations on the sharing of personal information. • To help address the information gaps associated with the “wrong pocket” problem, • Jurisdictions and communities should states, counties, and cities should develop also make greater use of improved sys- better techniques to measure the multisec- tems for data, to allow communities, tor community “social return on invest- schools, and hospitals easier access to ment” (SROI) of health and other commu- cumulative neighborhood data to gain a nity initiatives. This work could perhaps be better understanding of community needs conducted in cooperation with local uni- and opportunities. versities and other research institutions.

In addition to collecting and sharing infor- The general lack of research on the intersec- mation to organize customized services for tor impacts of community initiatives is a major individuals, hubs and partner organizations impediment to calculating the true ROI from an also need detailed demographic, health, and initiative. Without these broader impact mea- other information to build a picture of the sures, such as the effect of improved health on community and design strategies to address high school and college graduation rates and issues and take advantage of opportunities. workplace earnings, it is impossible to know Such data does not include personal identi- the true return associated with an investment fiers, and thus does not raise privacy issues. in community health. Improving ROI measure- Projects such as the National Neighborhood ment would help determine the potential results Indicators Partnership,24 based at the Urban of coordinating services through a hub. Institute, and the KIDS COUNT25 data center are making such data more available. Armed There is a growing recognition of the need with such data, hospitals, schools, and oth- to calculate the “social return on investment,” er institutions can be a more effective hub and the American Public Health Services and partner. Moreover, these data can help Association, among others, has helped pro- nonprofit hospitals advance their community mote the importance and the methodology of benefit strategies. Such community informa- SROI.27 Other countries, such as the United tion would also make it easier for states and Kingdom, are building SROI methodology school districts to carry out their obligations into their analysis of a range of public in-

22 University of Pennsylvania, “Actionable Intelligence for Social Policy.” 23 Data Quality Campaign, website. 24 National Neighborhood Indicators Partnership, website. 25 See Butler and Grabinsky, “Building a More Data-Literate City.” 26 See Education Trust, “The Every Student Succeeds Act.” 27 See American Public Human Services Association, “Social Return on Investment.”

Economic Studies at BROOKINGS 11 vestments.28 In United States, some govern- sophisticated data capacity. Yet weaknesses ment-connected organizations are beginning in data capacity hamper efficiency and limit to carry out this kind of analysis, such as the the activities of organizations. These weak- Washington State Institute for Public Poli- nesses also reduce the organizations’ ability cy29 and EPISCenter30 in Pennsylvania, and to demonstrate their effectiveness in order to many in the health sector now recognize the justify support, as well as makes it more dif- importance of using SROI to make a better ficult for them to be effective partners in ven- business case for investing in health initia- tures organized by a hub. tives that have multisector impacts.31 Greater public and private support is needed Nevertheless, this broader impact analysis for this important infrastructure. Providing sup- is still in its infancy, and the data needed to port directly to an organization may be the best address the wrong pocket problem is insuf- approach. But funding hubs and other inter- ficient, making the case for budget reforms mediaries to provide data services to smaller more difficult. Thus, much more work needs organizations may sometimes be a better al- to be undertaken by research institutions, in ternative since that can achieve economies conjuction with governmental jurisdictions, of scale and increase the available technical hospitals and schools and a range of other expertise. Some intermediaries, such as the community organizations and hubs. Family League of Baltimore,34 are already beginning to provide data support for local • Private philanthropy and federal and state organizations they fund or assist. Thus, if a agencies should provide sufficient sup- hospital or school undertakes data warehouse port for community-based organizations functions, it may make sense for these hubs to and hubs to develop the data collection take on part or all of the data functions for local and analytics capability needed to (a) im- community organizations in some instances by prove operations and the ability of organi- embedding staff in the organization. In these zations to partner with schools or hospi- cases, public and private funders may need to tals and (b) prepare for evaluation. reassess how they define “overhead” in grants and payments to hubs, as noted below in the Developing the capacity to collect and ana- discussion of aligning budgets and payments. lyze data is a significant problem for many innovative community-based organizations.32 • Congress should review HIPAA (health Although there are exceptions such as the care) and, especially, FERPA (education) federal government’s Beacon Community statutes and guidance to improve the Program,33 funders are generally more in- ability of appropriate intermediaries and clined to support direct services than build a hospital- or school-led community part-

28 For instance, see Social Value UK, “The SROI Guide.” 29 Washington State Institute for Public Policy, website. 30 Pennsylvania State University, website. 31 See Trust for America’s Health and Robert Wood Johnson Foundation, “National Forum on Hospitals.” 32 Butler et al., “Using Schools and Clinics as Hubs.” 33 HealthIT.gov, “Beacon Community Program.” 34 Family League of Baltimore, website.

12 Hospitals and Schools as Hubs for Building Healthy Communities nerships to share information. States also States also need to review their privacy rules need to review their privacy laws. Govern- and help organizations navigate them. In the ment agencies should also help organiza- case of HIPAA, the federal statutes are a tions to better understand how informa- “floor” and so some states have more strin- tion can be appropriately shared. gent requirements.

Privacy rules can be important protections. In addition, hospital-community and school- But these rules also inhibit data sharing, in- based partnerships should design simpler pa- cluding health and especially student infor- tient and family consent forms, including opt- mation, and so can make coordinated action out default consent, to enable more patient more difficult. The major statutes governing information to be appropriately shared, as is privacy in these areas should be reviewed. being done in Maryland among hospitals using But, that said, often the law is not as restric- the state-wide health information exchange, tive as many organizations believe, so much known as the Chesapeake Regional Informa- can be done to address privacy-related ob- tion System for our Patients, or CRISP.38 Hos- stacles to sharing by training and better edu- pitals and school districts can also help train cation. Thus, the federal government should individuals in partnering organizations on how provide improved training procedures for to assure privacy in the use of data. the use of privacy-protected information by appropriately designated individuals in partnering organizations, including making great- Rethink Business Models er use of the Privacy Technical Assistance Center35 and the Department of Education’s As noted earlier, the traditional business mod- data-sharing toolkit for communities.36 The els of hospitals and schools, and their funding federal government’s Office of National Co- streams, do not readily accommodate an inter- ordinator (ONC)37 should continue to provide sector hub role. The general lack of good data on guidance to educate stakeholders on com- the broad value-added created by a hospital or pliance and legal risk. The ONC should also school functioning as a hub—in particular the typ- help design safe harbors and better consent ical absence of good SROI calculations—makes requirements as part of “yes, unless” cul- it very difficult to establish the true ROI. This in ture-specific forms to help foster partnerships turn makes it harder to make the case for the bud- involving patient information that will avoid get and payment changes needed to support new compliant problems and legal risk. Using the functions that will increase total value-added. best available advice on governance, states should structure strong data-sharing agree- This general problem manifests itself somewhat ments that preserve important privacy princi- differently for hospitals and for schools. In alter- ples while making it easier for agencies and ing the business model of a hospital to enable it organizations to share information. to function as a hub, the issue is generally one of

35 Privacy Technical Assistance Center, website. 36 U.S. Department of Education, “Data-Sharing Tool Kit for Communities.” 37 HealthIT.gov, “About ONC.” 38 CRISP, website.

Economic Studies at BROOKINGS 13 altering the range of services provided by a hos- stitutions by “importing” skills from intermediaries. pital to achieve the overall goal of better health. Envisioning an expanded hub role also requires Based on the evidence on social determinants of schools, and particularly hospitals, to be sensi- health and on the health benefits of social pro- tive to the need to build trust in the community. grams, this suggests that improving overall health Hospitals, for instance, are often seen by many would require moving some resources from tradi- community organizations as remote yet powerful tional medical care activities into other sectors, institutions, and a lack of trust arising from little such as housing and social services. But rather or no history of partnerships often hampers new than arguing that hospitals should simply accept partnerships and the acceptance of hospitals as reduced revenue and the diversion of their re- benign partners. So progress will often require sources to nonmedical organizations—unlikely to many trust-building steps to develop successful be popular in the hospital sector—the hub model new partnerships and business models. allows a hospital to imagine a more diversified set of activities and revenue sources in the future. In Recommendation 2: Make greater use of this model, the hospital’s budget directly or indi- intermediaries. rectly finances the delivery of nonmedical as well as medical services that contribute to the health Intermediaries are organizations or individuals and well-being of the community. Seen in this that provide specialized skills or “connecting” func- way, altering the range of services organized and tions that facilitate partnerships, helping to smooth provided by hospitals could maintain total reve- collaboration and add skills that may be lacking nue by diversifying functions, even if payments in one of more of the partners. Intermediaries infor traditional medical services are reduced. clude such connectors as parish nurses, school nurses, and community health workers. It can be For schools as hubs, the challenge is more one an organization providing specialized information of financing and providing non-instructional ser- services, such as data services, or enrolling dis- vices in addition to academics, and so expanding charged patients in social service programs. Or an the scope of the business model. intermediary can be a sophisticated organization that helps organize or link together a wide range of Thus, defining a business model is not just a services and activities, such as community devel- design or “culture” issue. Budget and payment opment financial institutions or integrated service reforms are essential to align funding with the organizations such as Family League of Baltimore potential of refined hospital and school business of the Harlem Children’s Zone.39 Intermediaries models that will improve the health and education are playing an increasing role in health care insti- and the economic vitality of neighborhoods, such tutions that are building community partnerships, budget reforms are discussed in the next section. and in schools that are tackling health, social wel- But many education and health care leaders also fare, and other problems that are holding back their need to consider new ways of thinking about the students.40 For an institution functioning as a hub, role of schools and hospitals, and how they might refining its business model to use intermediaries, develop more effective partnerships with other in- either as embedded staff or as connector organi-

39 Harlem Children’s Zone, website; and Singh and Butler, “Intermediaries in Integrated Approaches to Health and Economic Mobility.”

14 Hospitals and Schools as Hubs for Building Healthy Communities zations, can make the hub much more effective In other cases, the intermediary may be an as a focus for combining services in a community. external body operating under a contract with the hub. An example of this is the partner- • Hospital and school leaders should ex- ship between Washington Adventist Hospital, plore and use models of “embedded” and near Washington, DC, and Seedco,45 an or- “external” intermediaries. ganization that seeks to advance economic opportunity and provides Adventist with spe- Individuals with the skill sets associated with cialized social welfare and other services intermediaries can be part of the regular staff for some of its discharged patients. In some of an institution, as are many school nurses or cases—the Family League of Baltimore is an the multiskilled teams in community schools. example—the intermediary carries out critical In other cases, individuals from an intermedi- functions, such as data collection and report- ary institution may be embedded in a hospital ing, that otherwise would have to be covered or other hub, employed and funded by the in- by the school budget. termediary. Examples include Health Leads,41 Communities In Schools,42 and other organi- • Hospitals should make greater use of in- zations that provide nonmedical professionals, termediaries by taking greater advantage such as legal services workers and social ser- of waiver opportunities in federal pro- vice to hospitals or schools to link discharged grams that allow state-based innovations. patients or students with social services and The federal government should make other programs. Another example is Grand- many of these waivers permanent and Aides.43 These are nurse extenders who universal rules. make home visits to create a relationship with the patient and family and work to improve Taking full advantage of Medicaid’s Managed health and medical outcomes. Every visit by Care 1915(b)46 and 1915(c)47 Home and a Grand-Aide is supervised with a nurse avail- Community-Based service waivers, states able remotely on video, permitting interaction and health institutions should push forward of both the Grand-Aide and nurse with the pa- with making greater use of social workers tient/family. Grand-Aides have been found to and other professionals to provide services reduce unnecessary emergency department after discharge and to enable elderly and dis- visits for children in Medicaid by 74 percent.44 charged patients to avoid readmissions and A Grand-Aides school program might place remain in their communities. an aide in schools without a school nurse and have video supervision provided by a school Cities, counties, and states should work with nurse in a neighboring school. hospitals and schools to assure that such

40 Stuart et al., “Schools as Community Hubs.” 41 Health Leads, website. 42 Communities in Schools, “About.” 43 Grand-Aides, website. 44 Garson et al., “A New Corps of Trained Grand-Aides.” 45 Seedco, website. 46 Centers for Medicare and Medicaid Services, “1915(b) Managed Care Waivers.” 47 Centers for Medicare and Medicaid Services, “1915(c) Home & Community-Based Waivers.”

Economic Studies at BROOKINGS 15 partnerships are understood and can be excellent example of collaboration between launched easily, and help support and eval- schools and the health system in which the uate such partnerships as models for wider school functions as a hub. Yet SBHCs face use. Philanthropy has often helped launch challenges because there is often a misalign- and cover the cost of such embedded inter- ment of missions between health and educa- mediaries and could expand support. Medi- tional institutions involved, in addition to fund- care and Medicaid could also make the waiv- ing streams that often do not align with the er-based flexibility in their hospital discharge objective of collaboration. SISP positions are rules a permanent and universal feature. In part of structured partnerships between local addition, to simplify and promote the use of health institutions; schools face similar chal- such intermediaries, the federal government lenges in employing such professionals as and states should work with hospital systems they do with SBHCs. For instance, when SISP to explore a common standard for access are employed directly by districts, they are and address liability issues. often the first personnel to be cut from public schools since they do not provide (exclusively) Jurisdictions should also explore ways of academic or instructional services to students. modifying certification to foster innovative use of intermediaries when using waivers and in Several steps can be taken to strengthen the other situations. For instance, for paraprofes- role of SBHCs and thus the role of schools as sionals such as Grand-Aides and community community hubs.48 In addition, school part- health workers, states should provide certi- nerships with FQHCs, and even directly with fication for new services provided by these hospitals, should be encouraged—especially intermediaries, based on approved standard- since many SBHCs are already FQHCs. ized curricula and performance on tests. A particularly important step would be to el- • States and the federal government, as evate school-based health care as a CHNA well as local health and educational in- priority, with clear mentation strategy steps stitutions, should strengthen and sharply to ensure that resources are identified—both expand the system of school-based nurs- hospital-community benefit expenditures and es and SBHCs. They should also make other funds—to enable comprehensive and greater use of FQHCs to link students and sustained school clinic operations. It is also their families to health services in their crucial to clarify the use of hospital-community communities. Schools should also ex- partnerships under the CHNA. In some cas- pand access to specialized instructional es, for instance, a hospital-SBHC partnership support personnel (SISP), such as nurses might not qualify as a community benefit for and psychologists. tax purposes because the partnership might be considered a core business activity. Clari- SISP and SBHCs function as embedded in- fying this would encourage more hospitals to termediaries to provide crucial nonacadem- provide financial support, technical assistance, ic services within schools, and they are an and information services to these centers.

48 Price, “School-Centered Approaches to Improve Community Health.”

16 Hospitals and Schools as Hubs for Building Healthy Communities Steps discussed earlier to facilitate informa- sity of Virginia, for instance, has a youth and tion sharing would be very valuable to these social innovation major,49 designed to equip intermediaries. In addition, local universities graduates with a broad knowledge of social, and businesses could help by providing data health, and other factors affecting youth. In technology and other assistance to facilitate addition, the Kaiser Permanente medical collaboration. Furthermore, these centers, as school,50 opening in 2019, is planning to in- well as the network of school nurses, would be clude a training focus that forges closer re- assisted considerably by the steps discussed lationships between physicians and health earlier to make it easier for schools and hos- systems, and the communities they serve. pitals to share health, education, and other relevant data with SBHCs and school nurses, Introducing such rotations and new degrees and by making full use of the recent change in or majors would allow students to obtain “lead- Medicaid’s free care rule (see discussion be- ership” professional credentials in areas that low in Aligning Budget and Payment Systems). supplement their primary field. Professional credentialing and licensing boards and college Recommendation 3: Widen the skill sets accreditation boards should adapt course re- of school and hospital leaders and key staff. quirements to allow such rotations—in many instances that will involve reducing the number Realizing the full potential of schools and hospi- of required courses to allow more electives in tals as hubs requires leaders in these institutions these other fields. Educational leaders need to to have a broad vision and set of skills, to manage be trained to use evidence-based approach- the delivery of less traditional services, and to work es involving different sectors so that they can with partners and intermediaries. But the training develop partnerships with broad benefits. It is of leaders is still narrow, and this holds back the also important to sensitize medical students potential for these institutions to function as hubs. to the dynamics of community organizations through internships and other forms of direct • Medical schools, nursing schools, schools experience, such as Vanderbilt’s medical of public health, schools of education, and school partnership with the Siloam Family schools of social work should institute Health Center51 in Nashville. “rotations” for students to take classes across various schools in a university, and • Schools and school districts should train they should explore combined degrees. teachers and other school staff to become “spotters” of potential health and social Professional schools can help broaden the problems among their students and stu- skills of future leaders in one discipline by dent households. including classes in other disciplines. A few schools are currently adopting this approach. Some jurisdictions are using integrated data The Curry School of Education at the Univer- systems to help predict risk factors in poor

49 University of Maryland, “Youth & Social Innovation Major.” 50 Kaiser Permanente, “Educating the 21st Century Doctor.” 51 Ibid.

Economic Studies at BROOKINGS 17 health and other problems. For instance, Al- leaders who develop the skills and devote legheny County, Pennsylvania uses predictive time need to be appropriately compensated risk models to help child welfare workers iden- so they will stay in the school setting. They tify possible abuse and neglect. San Francis- also need to have the backup of appropriate co and other California jurisdictions use such professionals to deal with health and other models as early warning systems to identify conditions—they should not be required or patterns among young people that might lead held accountable for diagnosing, treating, or to dropping out of school or potential criminal managing care for the many challenges fac- activity so that professionals can intervene to ing children and their families. prevent problems. Similarly, the Urban Insti- tute–based National Neighborhood Indicators • School districts should explore using Partnership52 and local groups such as DC school buildings and land as mixed-use Kids Count53 use data to develop comprehen- facilities, especially in areas of declining sive pictures of neighborhoods that help iden- enrollment, allowing the buildings and tify general conditions that are associated with school grounds to be more effective hubs problems for families and individuals. in communities.

Schools are a good location to identify chil- The school building can provide a neutral dren who may be at risk, given neighborhood space in which to invite students, their fam- patterns and identifiable risk factors. And ilies, and other individuals to gather for ac- since they interact with students on a daily tivities that are not strictly related to academ- basis, teachers and some other staff are well ics. The creative use of school buildings and positioned with appropriate training to identi- grounds can help encourage family and com- fy possible health and other problems of stu- munity engagement and education, provide dents that require attention. But they need to access to clinical services, and address other be trained in how to discuss these issues with basic needs of the community members. parents. Expanding intersectoral networks would help support more “warm referrals” to Many schools have made innovative use of SISP or to other institutions that are better their facilities in this way. For example, the Hen- equipped to deal with nonacademic issues. derson-Hopkins charter school55 in Baltimore Some intermediaries, such as the Healthy designed its security and corridor system such Schools Campaign54 and the American Fed- that members of the community can access eration of Teachers, help teachers to be more exercise facilities and other services during aware of broader issues and patterns that re- school hours. In Washington, DC, one KIPP56 late to health and social problems, such as charter school included a dog-walking area as chronic absenteeism. But professionals and part of its playing field. The result is increased

52 National Neighborhood Indicators Partnership, website. See also Dews and Saxena, “See the Immigrant Demographics Presentation That Audrey Singer Gave to the White House.” 53 See Butler and Grabinsky, “Building a More Data-Literate City.” 54 Health Schools Campaign, website. 55 Henderson-Hopkins, website. 56 KIPP DC, website.

18 Hospitals and Schools as Hubs for Building Healthy Communities community activity that enhances safety around programs, contains provisions to encourage states the school and fosters social encounters that and schools to examine community conditions that help strengthen community bonds. Meanwhile contribute to problems in failing schools. In effect, Community in Schools57encourages its site co- ESSA encourages a greater focus on what might ordinators in schools all over the country to take be called social determinants of education. advantage of the school facilities to support their student population with programs, such as in- These requirements, separately and together, school food pantries, that contribute to student can help foster collaboration and strengthen hos- health and improve neighborhood connections. pitals and schools as hubs.

Recommendation 4: Make use of the com- • The IRS should provide guidance to hos- munity obligations of nonprofit hospitals and pitals on developing a wide range of com- financial institutions, as well as the communi- munity partnerships as a means by which ty focus of the new education statute, to help hospitals can implement their community launch creative, coordinated partnerships. benefit spending activities. It should do this by referring hospitals to information The Affordable Care Act (ACA) revised the condi- from the Centers for Disease Control and tions that nonprofit hospitals must satisfy to qual- Prevention (CDC), HHS, and other agen- ify for federal tax-exempt status. This extended cies familiar with how to foster and report the general community benefit obligations of community building. hospitals seeking to maintain their tax-exemption by requiring such hospitals to complete a CHNA Hospital community benefit spending activi- every three years. A CHNA means the hospital ties are undertaken in response to identified must review health conditions in its community community health needs. CHNAs play a key and develop a plan to address concerns.58 role in identifying community needs; under existing IRS policy, these needs also can be In addition to placing these requirements on non- identified through hospitals’ partnership activi- profit hospitals, the IRS applies requirements on ties. Many sources of information are relevant regulated financial institutions, as part of the 1977 in identifying the health needs of communi- Community Reinvestment Act (CRA). The CRA re- ties. Because partnerships with nonprofit and quires financial institutions to analyze and help ad- government entities can serve as the source dress the credit and economic development needs of such information, the IRS should help ex- of local communities, particularly lower-income plain to hospitals how such partnerships can communities. The CRA and the community benefit be developed and used as a source of infor- requirements on hospitals, such as the CHNA, ac- mation for identifying needs. tually have similar regulatory structures and goals.59 In developing such assistance and guidance, Meanwhile, the 2015 Every Student Succeeds Act the IRS should highlight certain types of part- (ESSA), the new statute governing federal K–12 nerships that can yield important information

57 Communities In Schools, website. 58 Rosenbaum, “Hospitals as Community Hubs.” 59 See NACEDA and Community Catalyst, CRA vs CB flyer.

Economic Studies at BROOKINGS 19 about community health needs, including Such guidance could encourage more hos- schools, economic development programs pitals to function as community health hubs, and agencies, public health agencies, pro- with an increase in activities aimed at im- grams focused on housing supports, early proving health on a community-wide basis. It childhood development, and food and nutri- would also help align IRS policy more closely tion. Further guidance on community partner- with policies governing financial institutions ships should emphasize their importance.60 under the Community Reinvestment Act IRS guidance should also emphasize the (CRA). appropriateness of using a broad definition of community health improvement that covers • The federal government should make nonclinical activities aimed at general com- use of the “report card” provisions of the munity health. ESSA to encourage school districts to examine social and health determinants of In developing additional guidance, the IRS student success. should draw on the information and experience of HHS and the CDC in developing pro- ESSA, which reauthorized federal school grams and services designed to address the programs, contains provisions requiring each social determinants of health. Indeed, a help- state and school district to publish report ful step would be to establish a working group cards on the performance of its schools. While from HHS and the Departments of Education, most of the required information centers on Housing and Urban Development, Treasury academic performance, the cards must also and other departments (See Recommenda- provide data on nonacademic indicators that tion 6) to collect research and case exam- could undermine effective schools, such as ples of successful inter-sector partnerships; chronic absenteeism, bullying, and crime on this would be a valuable resource for issuing school grounds—patterns well understood to guidance on community-based partnerships. be linked to health and social conditions in student homes and neighborhoods. In developing In addition, IRS guidance on community regulations and guidance on these provisions, health improvement partnerships should the federal government should encourage provide illustrations showing how hospital states and school districts to include data from community benefit spending might advance non-education agencies and nongovernment health needs identified through the CHNA sources to present a fuller picture of conditions process. The IRS should also consider revis- in school communities. This information could ing its current policy regarding “directly off- help trigger new partnerships to address fac- setting revenue” to permit hospitals to report tors influencing student performance and, in as community benefit expenditures the re- the future, perhaps lead to a school equivalent stricted grants they receive, in order to further of the CHNA—requiring schools to work with community health improvement activities. other institutions to address social and health factors school performance.

60 See Rosenbaum, Sara et al, “Improving Community Health through Hospital Community Benefit Spending: Charting a Path to Reform.”

20 Hospitals and Schools as Hubs for Building Healthy Communities • The federal government should encourage economic development role. For instance, the localities to develop partnerships and fos- Dignity Health system is an important inves- ter coordination by organizations and in- tor in housing and community development. stitutions covered by the CRA, CHNA, and Dignity even provided financial assistance to ESSA, such as by allowing “crossover” families to help them remain in their homes credits for institutions covered by these re- during the Great Recession when financial quirements. institutions were cutting back on loans and mortgages. Yet as a hospital, Dignity was un- As noted above, nonprofit hospitals can ob- able to claim and use CRA credits for this. tain credit from the IRS against their CHNA community benefit obligations by engaging The federal government should give greater in health-related investments and activities incentive for such crossover activities be- in the community. Meanwhile, financial in- tween sectors. Ideally the community objec- stitutions can gain IRS credits against CRA tives of the CRA, CHNA, and ESSA should obligations for economic investments. The be combined, and the activities of the best- U.S. Department of Education districts will placed institution supporting an objective now require states and school to explore should be recognized in federal require- ways in which they can address conditions ments, regardless of its sector. that lead to low-performing schools. Each of these requirements is designed to encourage One way to do this would be to widen the defini- creative activities to improve the health, eco- tions of activities that qualify under the IRS and nomic, and social conditions in a community. Department of Education rules. For instance, helping to prevent chronic absenteeism in But these efforts often lack coordination be- schools might be recognized as a CHNA activ- cause each institution is complying with sepa- ity. A more comprehensive approach would be rate rules governing its own sector. Moreover, for the federal government to encourage such there is little encouragement under these sep- coordination and crossover activities by allow- arate rules for institutions in one sector con- ing any of these institutions to meet its IRS or tributing to the community efforts of another. Department of Education obligations and apply For instance, it generally is difficult for hospi- that to its own sector requirements by an activ- tals to obtain CHNA credit for strictly economic ity that would qualify if it were in another sector. activities in a community or for financial insti- Thus, a nonprofit hospital might qualify for CRA tutions to obtain CRA credit for strictly health “credits” and use these against its own com- promotion and prevention activities, such as munity benefit obligations for activities that im- investing in a more walkable or bikable city. proved the financial well-being of the commu- It’s true that some financial institutions al- nity. Likewise, financial institutions could obtain ready fund community development financial CHNA credits for such things as supporting the institutions (CDFIs) that invest in FQHCs. operations of an SBHC and apply these credits CDFIs are private financial institutions that against CRA requirements. Thus, the credits provide credit and financial services to under- would be interchangeable for the purposes of served communities. Moreover, on some oc- complying with IRS community benefit obliga- casions, health systems have played a crucial tions and addressing ESSA obligations.

Economic Studies at BROOKINGS 21 • Hospitals should examine their role as a able development, has created the Hospitals leading economic anchor in the commu- Aligned for Healthy Communities toolkit se- nity and work with local government and ries,62 which outlines policy and practices that other institutions on plans to drive inclu- health systems have adopted as they move sive economic growth and, ultimately, im- in this direction. In addition, the National prove community health and well-being. Association of Chronic Disease Directors is helping state health departments and school Hospital systems are becoming increasing- districts to understand how schools and hos- ly aware of their significant economic role pital can utilize Medicaid, the CHNA require- in communities and the potential for them to ments, and other opportunities to develop affect social determinants of health by lever- school-hospital partnerships to help manage aging their hiring, purchasing, investing, and chronic health conditions.63 other operational assets more intentionally. For example, some health systems, such as Recommendation 5: Make greater use of Dignity Health, have allocated a portion of waivers, demonstrations, and other steps to their long-term investment and savings port- foster hubs and other partnerships. folios for community development loans— either directly or via financial intermediaries Federal agencies often have authority to grant like community development financial insti- waivers from the rules associated with a program tutions. Other institutions, such as University to provide more flexibility for states and localities to Hospitals in Cleveland, Ohio, have prioritized engage in innovative approaches that do not lead inclusive, local hiring and purchasing in order to additional budget costs to the federal govern- to create jobs and opportunities for surround- ment. In some programs, such as Medicaid, the ing low-income and minority neighborhoods. federal government has used its waiver authority extensively to encourage innovation and permit the Carrying out such an anchor mission, notes use of resources for some social welfare approach- Kaiser Permanente, “requires substantial es to improving health. In addition, the Office of culture change in corporate practices within Management and Budget has issued “uniform healthcare institutions.”61 Leadership com- guidance” that makes it administratively easier to mitment is crucial at all levels of a hospital obtain flexibility in the use of federal funds.64 system, as is a commitment to develop met- rics on the economic impact of hospitals. In Pilot projects launched by the federal government addition, incentives need to be developed or states also permit a number of ideas to be ex- that empower managers and mid-level staff plored and evaluated. A number of important pilot to prioritize this long-term work alignment programs have used waivers involving more than around purchasing, hiring, and investment. one cabinet department, such as cooperation be- The Democracy Collaborative, a nonprofit tween the Department of Housing and Urban De- focused on equitable, inclusive, and sustain- velopment (HUD) and HHS to coordinate housing

61 Norri and Howard, “Can Hospitals Heal America’s Communities?” 62 Democracy Collaborative, “Hospitals Aligned for Healthy Communities.” 63 National Association of Chronic Disease Directors, “Opportunities for School and Hospital Partnership.” 64 See Grants.gov, “Uniform Administrative Requirements, Cost Principles, and Audit Requirements.”

22 Hospitals and Schools as Hubs for Building Healthy Communities and medical services to promote the health of the and pilots to encourage greater collaboration elderly and the homeless. across programs administered by different departments and the use of professional staff However, many agencies are generally hesitant to with skills outside those traditionally reim- grant waivers that span more than one program. bursed. While Medicaid has become more Even in the health sector, the federal government open to reimbursing social services that con- has generally been reluctant to allow funds from tribute to health outcomes, as we learn more different programs to be grouped together in a about the social determinants of health, it is waiver in which budget neutrality applies to the important for the program’s administrators to cumulative effect. be even more open to reimbursing nonmedical staff for their services. Waivers and demonstration pilots are an important tool to test cross-sector collaboration, and The federal government should make the they should be used aggressively to encourage greatest possible use of waiver authority in the launch and evaluation of hubs and other part- statutes. It does not always do so. A recent nerships. example is the Obama Administration’s inter- pretation of Section 1332 waivers of the ACA, • The federal government should make which give states the power to apply for very the broadest possible use of its pilot and broad waivers to achieve the purposes of the waiver authority to encourage intersec- act in novel ways. The administration decid- toral collaboration and hubs. ed the federal budget neutrality requirement must apply to each health program area in- In general, the federal government has made volved, rather than to the combined impact wide use of its waiver authority under such of the state proposal; this has reduced state programs as Medicaid (in particular the 1115 interest in using the provision. The new ad- demonstrations65) and the provisions of the ministration should re-interpret Section 1332 ACA, such as the creation of the Center for to permit waivers that preserve budget neu- Medicare and Medicaid Services’ Innovation trality across health programs.66 Center (CMMI). Pilot programs have also helped test novel approaches, although sus- Where the legal authority to grant such waiv- tained funding for promising pilots is often a ers remains limited, Congress could enact challenge. legislation to permit broader budget-neutral waivers using nonhealth as well as health The federal government should in general programs to achieve improvements in com- make greater use of waivers, including waiv- munity health. For instance, Congress could ers that would encourage different agencies amend the ACA statute to apply the Section to work together to create the environment 1332 budget neutrality requirement in a pro- for community-based partnerships. For ex- posed state waiver to cover the combined ample, more could be done to use waivers budgets of health and nonhealth programs,

65 Centers for Medicare and Medicaid Services, “About Section 1115 Demonstrations.” 66 Bipartisan Policy Center, “Improving and Expanding Health Insurance Coverage Through State Flexibility.”

Economic Studies at BROOKINGS 23 such as housing and social services, if the tional and social progress of young people effect is to improve community health out- in neighborhoods, emulating the Harlem comes and insurance coverage. Children’s Zone. The secretary of education should make full use of Sections 4624 • CMMI should expand its efforts to encour- (Promise Neighborhoods) and 4625 (full-ser- age community-based strategies to advice community schools) of ESSA to fos- dress health. Other agencies should step ter school-community partnerships. Under up their efforts to foster cross-sector ap- ESSA, states can make more use of Title I proaches to improved economic mobility. funding to integrate community resources for at-risk children. In addition, there are grants CMMI has helped foster partnerships be- in Title IV for engaging with communities. tween health organizations and providers of community-based services, such as through Other federal departments should examine its recent initiative to launch the Accountable how they might create bodies similar to CMMI, Health Communities (AHC) model.67 The administratively or by proposing legislation, AHC initiative is an important step forward, to test innovative funding and organizational although in this early phase it is arguably too structures that could further the goals of the de- restrictive in the initiatives it permits. The AHC partment. CMMI was established by statute as can and should be used with other steps to part of the ACA, with significant funding to help increase hospital-community cooperation in finance pilots around the country. Still, short of the approved initiatives. These steps include legislation of that kind, departments might es- integrating social needs information into elec- tablish high-level divisions to work with each tronic medical records and making maximum other, including CMMI, on a variety of inter- use of the CHNA’s community partnerships. departmental efforts to encourage intersector Moreover, as some observers note, CMMI partnerships and hubs at the local level. could achieve much greater impact if it incor- porated social determinants more extensive- • States, school districts, and private ly in other innovation models.68 philanthropy should help initiate, sustain, and evaluate innovative models of Other agencies should expand their inno- schools and school districts partnering vation models and collaborate with CMMI in with medical systems, housing author- encouraging local efforts to reach health and ities, teacher unions, and other institu- economic mobility goals. A current example tions to address the social determinants is the Promise Neighborhoods69 initiative in of health and education success. the Department of Education, which provides grants to encourage a variety of community In some counties and cities, school systems organizations and educational institutions are working with a variety of agencies and to coordinate efforts to improve the educa- private organizations or nonprofit groups in

67 Centers for Medicare and Medicaid Services, “Accountable Health Communities Model.” 68 Perla and Onie, “Accountable Health Communities and Expanding Our Definition of Health Care.” 69 U.S. Department of Education, “Promise Neighborhoods.”

24 Hospitals and Schools as Hubs for Building Healthy Communities health, housing, and other sectors to address tionships. Nevertheless, initiatives like these social determinants of health and education. require creative initiatives and sustained sup- Examples include Oakland Unified School port. While philanthropy and short-term sup- District in California, the McDowell County port from the outside can achieve an effective initiative in West Virginia, and Vancouver, startup, states and localities need to explore Washington. Such examples illustrate both ways to use program funds creatively, such the potential of school-based strategies and as by braiding or blending money from differ- the barriers to implementation. ent programs (see next section).

In Vancouver, a community schools initiative • States and the federal government should was created to address the growing problem encourage experimentation with new of chronic absenteeism and intergenerational forms of funding, such as social impact poverty. The school district gave the housing bonds (SIBs). authority a seat at the table, which was an un- usual step for a school district. Vancouver’s Increased flexibility in service payment sys- initiative was successful in letting the school- tems is important for fostering new types of based group nominate families to receive partnership, but so is providing startup capital housing authority vouchers instead of leaving for hubs and other partnerships. Raising the it to the discretion of the housing authority. The capital required poses two types of challeng- experience in Vancouver underscored the im- es for jurisdictions. One is that the initial capi- portance of identifying which local community tal requirements—before services can flow— organizations are important potential partners compete with other budget priorities and thus and which ones should lead the effort. encounter resistance. The other is that new ventures are risky, making it politically difficult In another example, McDowell County ap- for a jurisdiction to authorize the use of funds. proached the American Federation of Teach- ers (AFT) to help address the long-term chal- Private philanthropy can help address these lenge of teacher recruitment and retention. challenges in some instances, and founda- The union found that local community condition-supported ventures are a common fea- tions were a major factor, such as intergen- ture of social policy experimentation in the erational drug use and poor access to health United States. But some jurisdictions are and social services. To tackle these issues, also turning to the private capital markets the AFT forged a series of union–community as an additional way to reduce the risk and business partnerships and focused on such the competition for public investment funds. things as improved housing. The research work of the Urban Institute and other institutions is encouraging states and States and private philanthropy can help local government to experiment with “pay for launch such efforts by supporting hub orga- success” contracts using private finance.70 nizations that seek to map the assets of part- These contracts involve SIBs, in which pri- nering groups, share data, and facilitate rela- vate investors finance a public-private part-

70 Urban Institute, “Pay for Success.”

Economic Studies at BROOKINGS 25 nership to undertake a new social project to of services provided, it appears that most achieve a defined outcome. The investors Medicaid agencies cannot identify SBHCs are reimbursed and receive a return from the in their claims data because they do not government only if the outcome is achieved. have an assigned place-of-service (POS) code. The Centers for Medicare and Medic- The experience with SIBs is still short and aid (CMS) should establish such a code for limited, and their potential is debated.71 But SBHCs. The current POS code for schools is they have been used for innovative ap- tied to school-based health services eligible proaches to such issues as reducing home- for Medicaid administrative claiming and gen- lessness, reducing prison recidivism, and erally not appropriate for SBHCs. testing home-based neonatal care for low-income mothers.72 The federal government In addition, SBHCs are often limited in the types should encourage further experimentation of services they can bill because Medicaid does with and evaluation of such novel forms of not recognize them as comprehensive primary capital. One way that the federal government care entities. Each state Medicaid agency has could help would be to set aside some funds the authority to assign a set of billable codes for to assist with feasibility studies and evalua- specific locations of service, but the mispercep- tion and to underwrite part of the repayment tion that SBHCs provide school-administered for interesting examples. There is legislation services required under the Individuals with before Congress—which passed the House Disabilities Education Act (IDEA) means some in 2016—that would do this.73 Medicaid agencies limit the types of services SBHCs can bill. CMS should issue guidance • HHS and state departments administering on a set of billable codes for SBHCs. Medicaid and the Children’s Health Insur- ance Program (CHIP) should review and Addressing services provided to students revise payment systems, reimbursement outside IDEA is particularly important. Until rules, and budgets to encourage and eval- recently, schools and school nurses faced uate school-based and other community limits on health services they could provide programs that improve health and reduce because of the “free care rule.” This rule direct medical costs. meant that Medicaid funds could not be used to pay for services that are made available Medicaid and CHIP are critical sources of without charge to everybody in the communi- revenue for SBHCs, yet barriers to reim- ty. For example, Medicaid could not be billed bursement remain and do not always align for hearing or eye tests for Medicaid recipi- with fully achieving the potential of the cen- ents unless all other students were billed for ters. For instance, while state Medicaid agen- that service. Fortunately, in late 2014, CMS cies are increasingly implementing innova- eliminated this rule. But there is still uncer- tive payment incentives tied to the location tainty in many states and school districts re-

71 Gustafsson-Wright et al., The Potential and Limitations of Impact Bonds. 72 See Chhabra, “Will 2016 Be a Social Impact Bond Growth Year?” 73 See Abello, “Congress Might Make Social Impact Bonds Easier on Cities”; and GovTrack, “H.R. 5170.”

26 Hospitals and Schools as Hubs for Building Healthy Communities garding this change for state Medicaid pro- nonmedical services that more effectively achieve grams and reimbursements to schools. For some aspects of community health. In other situa- instance, before districts can take advantage tions, the complexity and elaborate administrative of the increased flexibility in financing student steps make it difficult or impossible to use funds health services, many states will need to for- flexibly for innovative local approaches, such as mally integrate the federal policy change into hubs. A byproduct of the general “wrong pocket” statutes that modify the Medicaid state plans. problem is that government at all levels often does not invest funds efficiently to generate the highest The federal government needs to provide value-added across sectors. greater guidance for states and school districts to support school-based health ser- To tackle these problems, government needs to vices. It can also help in other ways. In experiment with some promising approaches. January 2016, for instance, HHS and the Education Department launched the Healthy Recommendation 6: Take steps to facili- Students, Promising Futures74 initiative to en- tate the braiding and blending of public and courage state education and health leaders private resources from multiple sectors and to collaborate more strategically to promote sources. student health. Many states and their technical assistance providers would benefit from An important strategy to align a variety of budgets comparative national data and more explicit with an agreed multisector goal is to create bodies guidance from HHS on complex topics, such or procedures that either coordinate the use of dif- as billing when risk factors, not medical ne- ferent budget streams (known as “braiding”) or com- cessity, are the basis for eligibility; billing for bine funds from multiple sources (known as “blend- interventions, such as behavioral and men- ing”). Doing this is no easy task. Braided or blended tal health, where groups of students are in- money still requires reports and evaluations to be volved; and joining with managed care enti- sent to each agency responsible for the funds. So ties under state contracts. to encourage the creation of hubs that can use program resources in creative partnerships, the government needs to experiment with procedures that Increase Budget Flexibility promote flexibility in the use of government funds, but in ways that preserve accountability and assure Funding is the lifeblood of service organizations, that the populations intended to be supported by and aligning funding streams with desired goals programs are still appropriately served. An effective is essential for collaboration and enabling hubs approach to this may combine procedures to co- to function as effective coordinators. Regrettably, ordinate agency spending with new bodies or new revenue streams are not aligned in this way. As procedures closer to communities. noted earlier, in some cases statutes or regulations restrict the use of money, preventing, for example, • Federal and state agencies should create organizations from spending health care dollars on bodies that link decision makers from mul-

74 U.S. Department of Education, “Healthy Students, Promising Futures.”

Economic Studies at BROOKINGS 27 tiple agencies to coordinate strategies and previously managed under several different budgets to help schools and hospitals be- funding streams and departments; the pool is come more effective hubs in the community. now managed by an interagency council.77

When collaboration at the local level involves The federal government could establish similar funds from multiple agencies, it is often im- bodies to coordinate agency strategy and bud- peded because the various agencies con- gets to support schools, hospitals, and other trolling funds, setting eligibility criteria, and es- institutions as hubs in communities. For exam- tablishing strategy literally do not talk to each ple, the federal government should appoint a other. To improve the environment for hubs to council comprised of senior officials from the function and to help partnerships across sec- Department of Education, HUD, HHS, and the tors to flourish, government agencies need Department of Justice to focus on supporting to better coordinate their activities to reach effective hospital and school-based partner- shared goals. That in turn requires leadership ships to improve health and social conditions, in government to establish procedures to fos- to reduce mental health–related and substance ter coordination and to signal to staff in each abuse–related interactions with the juvenile jus- agency that collaboration and joint planning tice system, and to achieve other community should be part of the agency culture. goals. State-level councils could mirror this coordination at the state and local levels, as they There are examples of good collaboration, have done with children’s cabinets. such as the HUD and HHS efforts to improve joint policies for the elderly. On a larger scale, • States should establish versions of Mary- the Reagan administration launched sev- land’s county-level Local Management eral “cabinet councils”75 designed to focus Boards78 that can braid together multiple multi-agency efforts on administration priori- public and private financial resources ties, such as economic recovery and national to support community-based health im- security; to reinforce the importance of these provement initiatives. councils, the president routinely chaired them. Other administrations have adopted some ver- The state of Maryland has created, by stat- sion of this approach in some areas. Some ute, bodies at the county level that are permit- states have established similar bodies, often ted to a degree to braid or blend state, feder- reporting directly to the governor. For instance, al (subject to federal rules and waivers), and many states have created “children’s cabi- even nongovernment funds and contract with nets”76 to bring together top officials to coordi- grantees at the local level to deliver health, ed- nate services for children across departments. ucation, family support, and other services for Virginia’s Children’s Services Act created a children and youth, using money from multiple pool of funds for high-risk children that were programs. These bodies, known as Local Man-

75 Smith, “Reagan Setting Up 6 Cabinet Councils to Shape Policy.” 76 See Rennie Center for Education Research and Policy, “Towards Interagency Collaboration.” 77 Clary and Riley, “Pooling and Braiding Funds for Health-Related Social Needs.” 78 Trust for America’s Health, “Blueprint for a Healthier America 2016.” Maryland’s Local Management Boards, “Making a Differ- ence for Children and Families, 1990–2010.”

28 Hospitals and Schools as Hubs for Building Healthy Communities agement Boards (LMBs), can be government The form of LMB would not necessarily need agencies or approved nonprofit organizations. to be a new institution. It could be an exist- The Family League of Baltimore is an example ing hub or other service provider that agrees of a nonprofit LMB. LMBs contract with com- to take on these additional responsibilities. munity-based organizations, which are local Some hospitals, in particular, might be well po- level grantees, to implement programs and sitioned to carry out these functions as part of strategies. The LMB is held accountable for the a revised business model, given their data and use of funds and for assuring appropriate re- reporting capacities, provided they are appro- porting and evaluation. The local level grantee priately compensated for these functions. has the advantage in that it can receive funds from multiple sources without shouldering the • Modeled on such Administration initia- full burden of applying and reporting to each tives as performance partnership pilots source. Similar bodies could be used for broad- (P3), federal departments should pilot er objectives, such as promoting education and hub-based initiatives that address social other social determinants of health. determinants of health and create other community value, such as increased sav- Adopting a version of an LMB would involve ings, reductions in violence, and econom- a number of considerations. Since the LMB ic improvement. has a crucial fiduciary role, it is essential to be sure that a chosen organization is certified Performance partnership pilots, created with as having the necessary capacity and internal a federal appropriation in 2014, gave author- controls and monitoring; DC Trust—an LMB in ity to the Departments of Labor, Health and the District of Columbia serving at-risk youth— Human Services, and Education, to estab- collapsed in bankruptcy due to mismanage- lish up to 10 pilots.80 These pilots will enable ment.79 If LMBs are to carry out data collection states, localities, and other jurisdictions to and reporting functions for local organizations, pool a portion of their discretionary funding the LMB is essentially shouldering additional to improve outcomes for disconnected youth, overhead that otherwise would be part of their blending money from several programs into grantees’ budgets. Thus, the funding for the a single stream of money with streamlined LMB itself needs to reflect this additional “back reporting and other requirements. office” function. The Family League of Balti- more, for instance, provides data, evaluation, HHS, with other federal agencies such as and reporting services to many of its grantees, HUD, should develop similar blended grant but often is not fully compensated for this. For programs to make financing more flexible for versions of LMBs to be appropriately financed, hospital or school partnerships that address their services on behalf of community grant- social determinants of health and create ees might need to be viewed as essentially a community value, such as improved school public good and appropriately financed by a attendance and reductions in homelessness. state or the federal government.

79 Davis, “Mismanagement Has Bankrupted a D.C. Nonprofit, Endangering Programs.” 80 See youth.gov, “P3 Fact Sheet.”

Economic Studies at BROOKINGS 29 Appendix: Advisory Group Members

For this project, we assembled this advisory group of researchers, policy experts, and practitioners to suggest policy steps and review drafts of this report.

While the recommendations reflect suggestions raised in the conversations, they are nota consensus of the advisory group, and the recommendations do not necessarily reflect the indi- vidual or institutional opinions of any advisory group participant.

The authors of this Brookings report, not advisory group members, are responsible for the recommendations.

Advisory Group Members Name Affiliation Laudan Y. Aron Urban Institute Katherine Barmer Adventist Health Care Caroline Battles Ascension Pablo Bravo Dignity Health Sana Chehimi Prevention Institute Bechera Choucair Trinity Health Anne De Biasi Trust for America’s Health Wendy Ellis Milken Institute School of Public Health, George Washington University Andrew R. Feldman Brookings Institution Arthur (Tim) Garson Health Policy Institute, Texas Medical Center Zachary Goodling Adventist Health Care Ashley Harding KIPP DC Reuben Jacobson Coalition for Community Schools Sallie Keller Virginia Bioinformatics Institute, Virginia Tech Chris Kingsley Better Measured Cindy Mann Manatt Health Alexandra Mays Healthy Schools Campaign Donna J. Mazyck National Association of School Nurses Stephanie Mintz Briya Public Charter School Debra Montanino Communities In Schools Anand Parekh Bipartisan Policy Center Chelsea Rae Prax Federation of American Teachers Olga Acosta Price Milken Institute School of Public Health, George Washington University Sara Rosenbaum Milken Institute School of Public Health, George Washington University John Schlitt School-Based Health Alliance Prabhjot Singh Arnhold Global Health Institute, Icahn School of Medicine at Mount Sinai Indu Spugnardi Catholic Health Association of the United States Julie Trocchio Catholic Health Association of the United States Sandra Wilkniss National Governors Association David Zuckerman Democracy Collaborative

30 Hospitals and Schools as Hubs for Building Healthy Communities References

American Public Human Services Association. “Social Butler, Stuart, Michael Horn, and Julia Freeland. “Schools Return on Investment.” May 2013, http:// as Community Hubs: Integrating Support www.aphsa.org/content/dam/aphsa/pdfs/ Services to Drive Educational Outcomes.” Innovation%20Center/2013-05-Social-Return- Brookings Institution, September 2015. https:// on-Investment-Brief.pdf. www.brookings.edu/research/schools-as- community-hubs-integrating-support-services-to- Abello, Oscar Perry. “Congress Might Make Social drive-educational-outcomes/. Impact Bonds Easier on Cities.” Next City, July 13, 2016. https://nextcity.org/daily/entry/ Center on Social Disparities in Health, Building congress-social-impact-bonds-bill. Healthy Places Network, and the Robert Wood Johnson Foundation. “Making the Case Bipartisan Policy Center. “Improving and Expanding for Linking Community Development and Health Insurance Coverage Through Health.” 2015. http://www.buildhealthyplaces. State Flexibility.” December 2015. org/content/uploads/2015/10/making_the_ http://bipartisanpolicy.org/wp-content/ case_090115.pdf. uploads/2015/11/BPC-Health-Improving- Expanding-Coverage.pdf. Centers for Medicare and Medicaid Services. “Medicaid Information Technology Architecture Bradley, Elizabeth H., Maureen Canavan, Erika (MITA).” https://www.medicaid.gov/medicaid/ Rogan, Kristina Talbert-Slagle, Chima data-and-systems/mita/index.html. Ndumele, Lauren Taylor, and Leslie A. Curry. “Variation in Health Outcomes: The Role of ———. “About Section 1115 Demonstrations.” https:// Spending on Social Services, Public Health, www.medicaid.gov/medicaid/section-1115- and Health Care, 2000–09.” Health Affairs 35, demo/about-1115/index.html. no. 5 (May 2016): 760–68. ———. “Accountable Health Communities Model.” Butler, Stuart M., and Jonathan Grabinsky. “Building a https://innovation.cms.gov/initiatives/ahcm/. More Data-Literate City: A Q&A with HyeSook Chung.” Brookings Institution, December 15, ———. “1915(b) Managed Care Waivers.” https:// 2015. https://www.brookings.edu/blog/up- www.medicaid.gov/Medicaid-CHIP-Program- front/2015/12/15/building-a-more-data-literate- Information/By-Topics/Waivers/Managed- city-a-qa-with-hyesook-chung/. Care-1915-b-Waivers.html.

Butler, Stuart M., Jonathan Grabinsky, and Domitilla ———. “1915(c) Home & Community-Based Waivers.” Masi. “Hospitals as Hubs to Create Healthy https://www.medicaid.gov/medicaid-chip- Communities: Lessons from Washington program-information/by-topics/waivers/home- Adventist Hospital.” Brookings Institution, and-community-based-1915-c-waivers.html. September 2015. https://www.brookings.edu/ research/hospitals-as-hubs-to-create-healthy- Chhabra, Esha. “Will 2016 Be a Social Impact Bond communities-lessons-from-washington- Growth Year?” Next City, March 3, 2016. adventist-hospital/. https://nextcity.org/daily/entry/new-social- impact-bonds-2016-denver-homelessness. ———. “Using Schools and Clinics as Hubs to Create Healthy Communities: The Example of Briya/ Clary, Amy, and Trish Riley. “Pooling and Braiding Mary’s Center,” Brookings Institution, July Funds for Health-Related Social Needs: 2015. https://www.brookings.edu/research/ Lessons from Virginia’s Children’s Services using-schools-and-clinics-as-hubs-to- Act,” National Academy for State Health Policy, create-healthy-communities-the-example-of- June 27, 2016. http://nashp.org/pooling-and- briyamarys-center/. braiding-funds-for-health-related-social-needs- lessons-from-virginias-childrens-services-act/.

Economic Studies at BROOKINGS 31 Communities In Schools. https://www. Grants.gov. “Uniform Administrative Requirements, communitiesinschools.org/. Cost Principles, and Audit Requirements for Federal Awards.” http://www.grants.gov/ ———. “About.” https://www.communitiesinschools. web/grants/learn-grants/grant-policies/omb- org/about/. uniform-guidance-2014.html.

CRISP, https://www.crisphealth.org/. Green & Health Homes Initiative. http://www. greenandhealthyhomes.org/. Data Quality Campaign. http://dataqualitycampaign.org/. Gustafsson-Wright, Emily, Sophie Gardiner, and Davis, Aaron. “Mismanagement Has Bankrupted Vidya Putcha. The Potential and Limitations a D.C. Nonprofit, Endangering Programs of Impact Bonds. Brookings Institution, July for At-Risk Youth, Board Members Say.” 2015. https://www.brookings.edu/wp-content/ Washington Post, April 26, 2016. https://www. uploads/2015/07/impact-bondsweb.pdf. washingtonpost.com/local/ dc-politics/mismanagement-has- Harlem Children’s Zone, website http://hcz.org/. bankrupted-a-dc-nonprofit-endangering- programs-for-at-risk-youth-board-members- Harvard University, Center for Education Policy say/2016/04/26/51f4a51c-0bb4-11e6-bfa1- Research. “Strategic Data Project.” http://sdp. 4efa856caf2a_story.html. cepr.harvard.edu/.

Democracy Collaborative. “Hospitals Aligned for Healthy Health Affairs. “Culture of Health.” Health Affairs 35, Communities.” http://hospitaltoolkits.org/. no.11 (November 2016): 1948-1949.

Dews, Fred, and Elina Saxena. “See the Immigrant Health Leads. https://healthleadsusa.org/. Demographics Presentation That Audrey Singer Gave to the White House.” Health Schools Campaign. https:// Brookings Institution, July 23, 2014. https:// healthyschoolscampaign.org/. www.brookings.edu/blog/brookings- now/2014/07/23/see-the-immigrant- HealthIT.gov. “About ONC.” May 12, 2016. https:// demographics-presentation-that-audrey- www.healthit.gov/newsroom/about-onc. singer-gave-to-the-white-house/. ———. “Beacon Community Program.” January Education Trust. “The Every Student Succeeds Act: 23, 2014. https://www.healthit.gov/policy- What’s in It? What Does It Mean for Equity?” researchers- January 2016. https://edtrust.org/wp-content/ implementers/beacon-community-program. uploads/2014/09/What-is-in-ESSA-Public- Reporting.pdf. ———. “Health Information Exchange (HIE).” https:// www.healthit.gov/HIE. Family League of Baltimore. http://familyleague.org/. Henderson-Hopkins. http://hendersonhopkins.org/. Garson, Arthur, Donna M. Green, Lia Rodriguez, Richard Beech, and Christopher Nye. “A Institute of Medicine of the National Academies. New Corps of Trained Grand-Aides Has the “Capturing Social & Behavioral Domains Potential to Extend Reach of Primary Care & Measures in Electronic Health Records: Workforce and Save Money.” Health Affairs Phase 2.” http://www.nationalacademies.org/ 31, no. 5 (May 2012): 1016–1021. hmd/~/media/Files/Report%20Files/2014/ EHR-phase-2/EHRfindingsrecs.pdf. GovTrack. “H.R. 5170: Social Impact Partnerships to Pay for Results Act.” https://www.govtrack.us/ Jacobson, Reuben. “Community Schools: A congress/bills/114/hr5170. Place-Based Approach to Education and Neighborhood Change.” Brookings Institution, Grand-Aides. http://www.grand-aides.com/. November 2016.

32 Hospitals and Schools as Hubs for Building Healthy Communities Kaiser Permanente, School of Medicine. Pennsylvania State University, EPISCenter. http:// “Educating the 21st Century Doctor.” www.episcenter.psu.edu/. http://info.kaiserpermanente.org/html/ schoolofmedicine/?kp_shortcut_referrer=kp. Perla, Rocco, and Rebecca Onie. “Accountable org/schoolofmedicine. Health Communities and Expanding Our Definition of Health Care.” Health Affairs Kingsley, Chris. “Multi-Agency Integrated Data Blog, March 2, 2016. http://Healthaffairs. Systems (IDS).” Working paper prepared for org/blog/2016/03/02/accountable-health- the Annie E. Casey Foundation, forthcoming. communities-and-expanding-our-definition-of- health-care/. KIPP DC. http://www.kippdc.org/. Price, Olga Acosta. “School-Centered Approaches to Maryland’s Local Management Boards. “Making a Improve Community Health: Lessons from Difference for Children and Families, 1990– School-Based Health Centers.” Brookings 2010.” 2011. http://communitypartnerships. Institution, July 13, 2016. https://www. info/wp-content/uploads/2014/05/MD_LMB_ brookings.edu/research/school-centered- Jan_2011.pdf. approaches-to-improve-community-health- lessons-from-school-based-health-centers/. NACEDA. See National Alliance of Community Economic Development Associations. Privacy Technical Assistance Center. http://ptac. ed.gov/. National Alliance of Community Economic Development Associations (NACEDA) and Rennie Center for Education Research and Policy. Community Catalyst. CRA vs CB flyer. 2016. “Towards Interagency Collaboration: The http://www.naceda.org/assets/CRA_vs_CB_ Role of Children’s Cabinets.” June 2009. Flyer_WEB.pdf. http://www.renniecenter.org/research/ TowardInteragencyCollab.pdf. National Association of Chronic Disease Directors. “Opportunities for School and Hospital Robert Wood Johnson Foundation. “Achieving Partnership in the Management of Chronic Healthy Schools for All Kids in America.” Health Conditions.” 2016 http://c.ymcdn. March 22–23, 2016. http://www.rwjf. com/sites/www.chronicdisease.org/resource/ org/content/dam/farm/meetings_and_ resmgr/school_health/NACDD_School_and_ conferences/proceedings/2016/rwjf431301. Hospital_Pa.pdf. Rosenbaum, Sara. “Hospitals as Community Hubs: National Center for Healthy Housing. “Research.” Integrating Community Benefit Spending, http://www.nchh.org/research.aspx. Community Health Needs Assessment, and Community Health Improvement.” National Information Exchange Model. https://www. Brookings Institution, March 9, 2016. niem.gov/Pages/default.aspx. https://www.brookings.edu/research/ hospitals-as-community-hubs-integrating- National Neighborhood Indicators Partnership. http:// community-benefit-spending-community- www.neighborhoodindicators.org/. health-needs-assessment-and-community- health-improvement/. Norris, Tyler, and Ted Howard. “Can Hospitals Heal America’s Communities?” Democracy Rosenbaum, Sara, et al. “Improving Community Collaborative, December 2015. http:// Health Through Hospital Community Benefit democracycollaborative.org/content/can- Spending: Charting a Path to Reform.” hospitals-heal-americas-communities. George Washington University, Milken Institute School of Public Health, December PCCI. “The Dallas Information Exchange Portal.” 2016. http://iep.pccipieces.org/. Seedco. http://www.seedco.org/.

Economic Studies at BROOKINGS 33 Singh, Prabhjot. Dying and Living in the University of Maryland, Curry School of Education. Neighborhood: A Street-Level View of “Youth & Social Innovation Major.” http://curry. America’s Health Care Promise. Baltimore: virginia.edu/academics/degrees/bachelor-of- Johns Hopkins University Press, 2016. science-in-education/youth-social-innovation.

Singh, Prabhjot, and Stuart M. Butler. “Intermediaries University of Pennsylvania. “Actionable Intelligence in Integrated Approaches to Health and for Social Policy.” http://www.aisp.upenn.edu/. Economic Mobility.” Brookings Institution, November 2015. https://www.brookings. Urban Institute. “Pay for Success.” http://www.urban. edu/research/intermediaries-in-integrated- org/research-area/pay-success. approaches-to-health-and-economic-mobility/. U.S. Department of Education. “Data-Sharing Tool Smith, Hedrick. “Reagan Setting Up 6 Cabinet Kit for Communities: How to Leverage Councils to Shape Policy.” New York Times, Community Relationships While Protecting February 15, 1981. http://www.nytimes. Student Privacy.” March 2016. http://www2. com/1981/02/15/us/reagan-setting-up-6- ed.gov/programs/promiseneighborhoods/ cabinet-councils-to-shape-policies.html. datasharingtool.pdf.

Social Value UK. “The SROI Guide.” http://www. ———. “Healthy Students, Promising Futures.” http:// socialvalueuk.org/resources/sroi-guide/. www2.ed.gov/admins/lead/safety/healthy- students/index.html. Squires, David, and Chloe Anderson. “U.S. Health Care from a Global Perspective.” ———. “Promise Neighborhoods.” September Commonwealth Fund, October 2015. http:// 16, 2016. http://www2.ed.gov/programs/ www.commonwealthfund.org/publications/ promiseneighborhoods/index.html. issue-briefs/2015/oct/us-health-care-from-a- global-perspective. U.S. Department of Health and Human Services, Administration for Children and Families. Trust for America’s Health. “Blueprint for a Healthier “Interoperability.” August 22, 2016. http://www. America 2016.” Trust for America’s Health, acf.hhs.gov/about/interoperability. 2016. http://healthyamericans.org/report/129/. Washington State Institute for Public Policy. http:// Trust for America’s Health and Robert Wood Johnson www.wsipp.wa.gov/. Foundation. “National Forum on Hospitals, Health Systems and Population Health.” youth.gov. “P3 Fact Sheet.” http://youth.gov/youth- Trust for America’s Health, 2016. http://www. topics/reconnecting-youth/performance- dialogue4health.org/resource-library/detail/ partnership-pilots/fact-sheet. summary-of-the-national-forum-on-hospitals- health-systems-and-population-he.

34 Hospitals and Schools as Hubs for Building Healthy Communities

The Brookings Institution 1775 Massachusetts Ave., NW Washington, D.C. 20036 brookings.edu