1. The Role of Accreditation Intent in LHDs’ Decision to collaborate with Hospitals around the Community Health Assessment Simone R. Singh 1 and Erik L. Carlton 2 1 University of Michigan Department of Health Management and Policy 2 University of Memphis Division of Health Systems Management and Policy

2. Context ACA requires tax-exempt hospitals to conduct community health needs assessments (CHNAs) every three years. In doing so, hospitals are encouraged to consult with public health experts. Community health assessments (CHAs) are a core activity of LHDs. CHA completing is also a prerequisite for PHAB accreditation.

3. Research Aims Opportunities exist for LHDs to partner with hospitals, yet it remains unclear whether interest in PHAB accreditation motivates LHDs to engage in collaboration, or vice versa. Research questions 1.What characterizes LHDs involved in collaborations with hospitals around the CHA? 2.What is the relationship between LHDs’ level of engagement with accreditation activities, in particular completion of a CHA, and their involvement in collaborations with hospitals?

4. Data and Sample Data sources – 2013 NACCHO Profile Survey – 2013/2014 Area Health Resource File Sample derivation – 2,000 LHDs completed 2013 NACCHO Profile – 1,958 LHDs (97.9%) provided information on collaboration with hospitals around the CHA – 1,332 LHDs (66.6%) provided complete information

5. Status of LHD-Hospital Collaboration around CHAs n=1,332

6. Characteristics of LHDs by Status of CHA Collaboration Currently collaborating (n=747) Discussing collaboration (n=168) Not discussing or collaborating (n=365) Don’t know (n=52) Population served55,58452,95925,27121,637 Geographic jurisdiction served City3.2%8.9%13.4%17.3% County84.1%78.6%78.9%76.92% Governance of LHD Local80.5%78.0%63.6%67.3% State10.1% 25.2%25.0% Has LBH78.6%74.4%64.4%61.5% Total expenditures (most recent FY) $2,673,597$2,163,044$940,166$679,978

7. Completion of Accreditation Prerequisites by Status of CHA Collaboration Currently collaborating (n=747) Discussing collaboration (n=168) Not discussing or collaborating (n=365) Don’t know (n=52) Completion of CHA Within past 3 years*71.9%52.4%44.9%50.0% Within past 3-5 years12.7%13.1%11.5%13.5% Planned for next year*9.0%20.2%8.2%1.9% Completion of CHIP Within past 3 years*58.8%42.3%33.7%30.8% Within past 3-5 years9.8%8.3%8.0%11.5% Completion of Strategic Plan Within past 3 years*43.4%36.9%26.3%21.2% Within past 3-5 years8.0%6.6%5.2%3.9% Note: *Kruskal-Wallis tests showed that differences in means were significant at the 5% level.

8. Multivariate Model LHD-Hospital collaboration around CHA = f (LHD accreditation intent, LHD characteristics, community characteristics) Logit regression model using cross-sectional data for 2013 Separate models for three dependent variables LHDs collaborating vs. not collaborating (n=1,332) LHDs collaborating or discussing collaboration vs. not collaborating or discussing collaboration (n=1,332) LHDs discussing collaboration vs. not collaborating or discussing collaboration (n=533) Separate models for three independent variables Completion of CHA within past 3 years Completion of a CHA within past 3-5 years Completion of CHA planned for next year

9. Multivariate Findings: CHA within past 3 Years Collaborating Collaborating or discussing collaboration Discussing collaboration CHA within past 3 years2.49**2.10**1.08 Jurisdiction served: County0.33**0.21**0.28** Jurisdiction served: City0.04**0.01**0.04** Governance: State0.45**0.39**0.39* Governance: Local1.62*1.95**1.67 Expenditures per capita1.00**1.01** Population size (log)1.48**1.60**1.49** Notes: Table shows odds ratios. Standard errors are in parentheses. * indicates p<0.05; ** indicates p<0.01. All regression models control for a set of LHD and community characteristics, including jurisdiction served by LHD, governance of LHD, per capita expenditures, population size, population density, racial/ethnic composition of the population, % non-English speaking, % 65+ years old, median household income, number of hospitals and physicians in the community.

10. Multivariate Findings: CHA within past 3-5 Years Collaborating Collaborating or discussing collaboration Discussing collaboration CHA within past 3 years0.840.851.03 Jurisdiction served: County0.36**0.23**0.28** Jurisdiction served: City0.03**0.01**0.04** Governance: State0.37**0.33**0.39* Governance: Local1.54*1.89**1.68 Expenditures per capita1.00**1.01** Population size (log)1.52**1.64**1.49** Notes: Table shows odds ratios. Standard errors are in parentheses. * indicates p<0.05; ** indicates p<0.01. All regression models control for a set of LHD and community characteristics, including jurisdiction served by LHD, governance of LHD, per capita expenditures, population size, population density, racial/ethnic composition of the population, % non-English speaking, % 65+ years old, median household income, number of hospitals and physicians in the community.

11. Multivariate Findings: CHA planned for next Year Collaborating Collaborating or discussing collaboration Discussing collaboration CHA within past 3 years0.761.76*2.87** Jurisdiction served: County0.35**0.24**0.31** Jurisdiction served: City0.03**0.01**0.04** Governance: State0.38**0.32**0.36* Governance: Local1.52*1.86**1.79 Expenditures per capita1.00**1.01** Population size (log)1.52**1.65**1.52** Notes: Table shows odds ratios. Standard errors are in parentheses. * indicates p<0.05; ** indicates p<0.01. All regression models control for a set of LHD and community characteristics, including jurisdiction served by LHD, governance of LHD, per capita expenditures, population size, population density, racial/ethnic composition of the population, % non-English speaking, % 65+ years old, median household income, number of hospitals and physicians in the community.

12. Key Findings Having completed a CHA in the recent past significantly increases the odds of LHDs to collaborate with hospitals. For some LHDs, accreditation intent, in particular CHA completion, appears to provide incentives to collaborate. Having completed a CHA in the recent past was not associated with greater likelihood of LHDs engaging in discussions with hospitals. However, planning to complete a CHA next year significantly increased the odds of a LHD to begin discussions. For some LHDs, decisions about collaboration and CHA completion appear to occur simultaneously.

13. PHAB accreditation prerequisites together with IRS requirements for hospitals foster collaboration, creating win-win situations for LHDs and hospitals. Public health practitioners who are discussing collaboration with hospitals should focus on CHAs as a mutually-beneficial collaborative activity. Public health policymakers may be able to encourage greater collaboration between LHDs and hospitals by incentivizing voluntary accreditation among LHDs. Implications for Policy and Practice

14. Limitations Analysis was cross-sectional and comprised data for only one year; direction of relationship remains unclear. Data did not include information on the types of hospitals engaged in collaborations, so information on hospitals was excluded from analysis. Missing data reduced sample size by one third; sample LHDs were somewhat larger, more likely to serve counties, and have a local board of health.

15. Thank You! Contact information: Simone R. Singh, PhD singhsim@umich.edu (734) 936-1194