Plumas County Public Health Agency Summary
Collaboration in Action
A look at how three hospitals, one local health department, and a Tribal health clinic in this small, rural county are navigating past organizational mistrust, competing priorities, and strong intra-community identities to examine their community's health status and take action to improve health and well-being.
Set in the Sierra Nevada Mountains in Northern California, Plumas County, a community of approximately 20,000 people, including Maidu Tribe members, native inhabitants of this area, is busily working to translate its recently completed community health (needs) assessment (CHA) and community health improvement plan (CHIP) into action. This small, rural county, comprised of four distinct communities is served by a cadre of health care providers, including Greenville Rancheria, a Tribal health clinic; Eastern Plums Healthcare, Plumas District Hospital, and Seneca District Hospital, three district non-profit hospitals; and the Plumas County Public Health Agency, the local health department. Completing a collaborative CHA and CHIP that could identified and addressed the needs of the whole county, including the Tribal population, was successful and also had its fair share of challenges and lessons along the way that can be common to collaborative endeavors.
A few years ago, four hospitals provided services to the four distinct communities further supporting the distinction between them and their local focus. Then, a few years ago, one of those hospitals closed and competition between two of these remaining hospital systems for this community ensued, resulting in some mistrust, a common attribute among any business. This community is slowly working to pave a path to more collaboration and the CHA is one of their first steps to this. “I think there had been a history of a lack of trust; primarily between Eastern Plumas [Healthcare] and Plumas District Hospital. But, as we started talking we saw a commonality; something that we needed to get done. I think that between all of us we saw the greater vision that we really need to have something much better that would work much better for our citizens. Not just for meeting the requirement for the community health assessment, but for really doing something valuable…,” said Tom Hayes, CEO of Eastern Plumas Healthcare. He added, “[We could take advantage of] certain strengths within each organization and that’s where we could lend our support. Of course, that assumes that you’re not going to compete with each other, which is a whole different issue.”
“…It was actually Tom who came to one of our meetings and he brought the letter, I don’t know if it was from the IRS or the hospital association, but it was the letter talking about that element of the ACA [Affordable Care Act] specific to non-profit hospitals and he said, ‘What are the rest of you guys doing about this?’ A little light bulb went off in my head because assessments are what we [local health departments] do all the time, but we’d never had the opportunity to do one that was community-wide with partners; really important partners in the local health system, which was the health care community. So, that was how it started…we got all excited about how we could go down this road to do a community health assessment all together and benefit the hospitals and benefit us [local health department] as well,” explained Mimi Hall, Director of Plumas County Public Health Agency.
The mistrust between the hospitals was something that happened ahead of the tenure of many current hospital leaders, but these leaders and the organizations’ staff still face the challenge of forging a new path to collaboration. “The real core of the matter that has kept this process driving is that it is valuable to improve the health of the community and engage the partners you need, both at the health system level and the community level to do it”, reported Hall. Hall and Hayes both believe that leadership support, however, within each partnering agency is an important component and one that this group of partners thoughtfully and systematically considered. “I think one key piece of advice for other communities that might be thinking about this, especially small communities, although it’s applicable to everybody is [remembering] that we have experience failed relationships before and we examined why they didn’t work. A big piece of it was that you can be partnering with leaders of an organization or a department or unit within a hospital or organization and have great success and when those people leave you have to start from scratch,” said Hall. In attempt to address this, each of the three hospitals, the local health department, and the Tribal health clinic ensured that they had full board support and buy-in for the collaborative community health (needs) assessment. Hall described her motivation for seeking the formal approval of the health department’s governing board and said, “Part of our reasoning for doing that, from a public health perspective, was that regardless of whom our leadership was, regardless of what funding we had or didn’t have, that it was clear that this was a priority.” The hospital administrators also went to their boards and the Tribal health clinic partner worked with Tribal Council to achieve its support for this collaborative work. When it was deemed useful, they helped each other. For example, both Hall and the Director of the Sierra Institute accompanied each hospital administrator in seeking his/her respective boards’ support and both Hall and Hayes think that this was an important gesture. Hayes said, “I went to the [Eastern Plumas Healthcare] board and told them what the efforts were and I told them what they goals were. Then Mimi came to a meeting and talked about the whole thing and basically gave her viewpoint on what we should do and so on and so on. It lent credibility to the whole effort.” “I think that what we want to do is ensure that whatever we’re going to do together is going to have mutual benefit. [We want to] make sure that each organization understands that; that there is opportunity for mutual benefit and [although] we talked about this early on, it has since faded quite a bit,” added Hayes. “It’s just that you have to have trust in each other and you have to make sure that people understand that just because we get together doesn’t mean I am going to take this as an advantage to take your patients away.”
Hall and Hayes both think that overcoming competition or concerns about competition will be a long-term process. Hall explained, “There was always, and still is, some portion of the community as well as the hospital boards and maybe some folks within the other hospital organization that feel like some of this work is a front for consolidation or some other motive. There is really nothing we can do with that except to keep on task and keep moving forward. I think that’s another reason why it’s important to have the local health department as a driver of this project. We really don’t have any interests whatsoever in whether the hospitals consolidate or not, whether they combine to purchase materials, equipment, or share services; we have no skin in that game. I think that if we weren’t a key player and the hospitals had tried to do this on our own, that they wouldn’t have gotten very far.”The past issues and changes in hospital leadership over the last few years were cited as two potential reasons for the mistrust and feelings of competition between at least two of the hospitals. Yet, both recognize that change, specifically changes in leadership, can also be good for collaboration. Hall explained, “I am not sure we ever would have gotten the Rancheria on board as a partner if they didn’t have a new Tribal Council where the majority of members had recently changed seats and they also had a new…executive director, who was also the medical director…She had a feeling for what could help change both the Tribal population’s health and the Tribal population that was embedded in the most impoverished area of our county.” Hayes and Hall both think that collaborative partnerships, like maximizing the role of the local health department, and having an understanding of the bigger picture are ultimately what led them to successfully completing the CHA and CHIP collaboratively. Hayes explained, “If we only get a community health assessment project out of this discussion, we will have some value; the community health assessment piece will at least have been a success.”
Alignment of efforts in a myriad of ways is a key consideration in their work. For example, the team worked to align their community priorities with the Healthy People 2020 Indicators, National Prevention Strategy Indicators, and the California Department of Health Services Strategic Plan and Indicators. In addition, they reviewed the 2009 Greenville Rancheria Needs Assessment and worked with the Greenville Rancheria Executive Director to ensure that Indian health priorities and local Maidu family needs were included. Review of CHA findings along with these efforts resulted in the following CHIP priorities: improve access to health care, improve health behaviors, and to optimize current resources. With the CHA and the CHIP completed, the partnership has ended their formal collaborative efforts as a cohesive hospital-Tribal health clinic- health department group for now. Now moving forward in a more decentralized fashion, Plumas County Public Health Agency is currently conducting follow-up meetings with the administrators of the original group organizations to review the three main CHIP priorities to prime them to what the health department would like to see their organization pursue moving forward. “Throughout this whole [community health improvement] process it’s been a lot of work for everybody and our fear has always been scaring away our partners because there seems to be so much expectation on top of a lot of other competing priorities. So, we made it clear at each of those [administrator] meetings that our goal really is to take our health priorities that we all came up through a community engagement process together and identify areas that truly align with their own communities [i.e. districts] and their own organization’s strategic plan, operational goals, and quality improvement goals,” reported Hall. Hall’s team is also strategic in choosing which organization they meet with when given the competing priorities their partners face.
Both Hall and Hayes are encouraged and hopeful that although their original hopes for centralized, collaborative implementation re changed for now, that they will ultimately achieve their goals. “I am hopeful in the future that as we start getting into more specific analysis of issues within our respective areas [districts] is not just [focused on] what each of us can do, but how each of us can help each other if we can get past some of this past mistrust or competition issues,” explained Hayes. Hall added, “...What hasn’t been a challenge is that no one disagrees that improving the health of our entire county; the communities in our county, is a value that we all share. It’s important [to consider] when you’re thinking about partnerships and about who stays and who doesn’t. This project makes sense. It makes sense for the local health department. It makes sense for our hospitals. I think as we move forward and start addressing some of our health priorities, some of our priorities are going to make sense for our employer community and our educational community.”
For more information, please refer to the Q&A with Hall and Hayes.