INTERVIEW WITH SAMUEL L. ROSS, MD: COMMUNITY ENGAGEMENT ADDRESSES HEALTH DISPARITIES Mary Ann Steiner

Interview with Samuel L. Ross, MD

Community Engagement Addresses Health Disparities

MARY ANN STEINER

Samuel L. Ross, MD, is the current chief community health officer for Bon Secours Mercy Health, one of the largest health care systems in the nation, with facilities that serve communities in Florida, Kentucky, Maryland, New York, Ohio, South Carolina and Virginia. He is responsible for a large network of community outreach initiatives that focus on housing, education, job skills, behavioral health, substance abuse and rehabilitation, all focused on reducing health disparities and improving access to care for the communities that Bon Secours Mercy serves.

Dr. Ross, you’re recognized across the counMore recently, the momentum has come from try as strong advocate for reducing health disthe heightened awareness and ongoing documenparities and increasing access to care. Where do tation of health disparities/inequities and social you see the momentum for that now and what justice issues due to years of structural racism in things do you see changing for the better, or African Americans as outcomes of the COVID maybe for the worse? pandemic and the death of George Floyd and

A lot of the momentum was coming from other persons of color. industry accelerators, most of that coming from The challenge to that momentum is still the revenue side around valuewhether this heightened awarebased purchasing. And as manness will lead to sustainable aged care — whether that’s Medichanges in intentional community care, Medicaid or a commercial engagement and investments. entity — they put more emphasis on social determinants, using A lot has happened in the last financial incentives, and someten years that affects racial and times penalties, to address screenethnic disparities: the ACA and ing and then referral of those Medicaid expansion; Black Lives attributed members to services in Matter; the immigration situathe community. These members tion. What can Catholic health usually make up a smaller subset care do to help move the needle of the broader community. on racial equity and health care

Another form of momentum Samuel L. Ross, MD, MS access? comes as organizations more If we are true to our mission, deeply embrace their mission and their role as if we are true to the principles of Catholic social anchors in their communities. That also serves as teaching, if we are true to our commitment to have an accelerator or reminder of institutional comprophetic voice, certainly in the form of advocacy, mitments made over the years. then we will intensify and be more intentional

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about our efforts in these areas. ational and regulatory parts fit well, and often

When we’re not, then we look no different than appears driven by the “tyranny of the urgent.” any other institution, nonprofits or for profits. I think our biggest risk is that people can’t distinHow can health organizations build trust in guish at times between what we say versus what communities where people’s trust in health care we do in our efforts to address racial equity and institutions isn’t very high? access to care. It’s about relationships. It starts with relation

In this intense period of mergers, acquisiWe often talk about community engagement, tions and divestitures in health care how do topbut we have to look at what is the actual practice ics of disparities and access come up in those around community engagement. Franklin Covey conversations? has published much about how things happen at

It probably does not come up enough. Even the “speed of trust.” If we don’t take the time to be when it does come up, you have to wonder about intentional about that, then it’s not going to hapthe depth and breadth of the discussion, because I would dare say that the amount of time spent on finanOftentimes the words of the mission cial analyses and economies of scale statements and vision statements around operations far exceeds the amount of time spent on discernand values are quite consistent, ments around culture and values that address disparities and access. and they’re easy enough to say. But

Oftentimes the words of the miswhat are the actual practices and sion statements and vision state ments and values are quite consis behaviors that go beyond the words? tent, and they’re easy enough to say. ships and ends with right relationship behaviors. But what are the actual practices and behaviors pen. We often use the phrase of meeting people that go beyond the words? Are they really being where they are, as opposed to where we want lived in a way that is truly consistent, are orgathem to be or expect them to be. The actual pracnizations truly, biblically, being “equally yoked” ticing of what we say is often a challenge, and it in these areas of focus? There is little evidence is what communities point to when our actions in published articles or case studies on mergdon’t match our words. Our behavior with comers/acquisitions that the same amount of time, munity should be a direct reflection of our stated energy and resources are placed on these aspects beliefs. of a merger that get placed on all the other factors There must be a trusted face of the organizagetting scrutinized by boards, rating agencies or tion and a consistent presence within communiregulatory bodies. ties. Those relationships must be built and earned and that doesn’t happen overnight. It’s a long

Do you think the right people are at the table term commitment. And regardless of changes in for those discussions? the organization, we must make sure that those

When you look at the governance structures of bonds with the community aren’t broken. It’s only our ministries, one would say the right people are in having those relationships and those bonds that at the table. But if someone were to measure the people give you good information about health or amount of time spent in discernment at the PJP their definition of health and their feedback about level and compare it to the time devoted to the how your organization is performing or not perfinancial/operational alignment level, one could forming, and whether they trust or don’t trust question if they would be equal, greater or would your organization. there be a significant discrepancy. If you really want to have that kind of relation

To most on the outside, “the deal” seems to ship with the community, then you must be much hinge primarily on whether the financial, opermore transparent and you have to have members

of the community consistently at the input and decision-making table around issues. “Diversity and inclusion” can’t just be words, there has to be evidence of actual practice.

The other thing we do a lot of is go out and hold community forums and community meetings, and we say we’re here to hear from you. Then we go away for a period of time, until the next time we come back and have our forums and community meetings to hear from them. It’s not really a twoway, mutually beneficial exchange of information and involvement in decision-making. We need to build trust.

Here’s an example: We are working with our community leaders in Baltimore, who requested that we convert an old library building that has been closed for over 20 years into a community resource center.

We started to look at challenges around projected capital costs and fundraising challenges. We could have made unilateral organizational decisions about facility changes to reduce costs, but that would violate community trust. Our community health leaders went back to what we call the “anchor group” members of the community, presented the challenges to them, and requested their input and feedback. They said come back to us when you’ve done more analyses and can present specific options and together we’ll figure out the best solution, even if it’s not what we all thought we would have from the beginning. There’s got to be that kind of mutuality where the people in the community respect and value your opinion and you truly respect and value theirs just as much. There is a phrase, “behavior equals beliefs.” If it doesn’t work that way, there isn’t real engagement or a real community partnership.

How do you lead community engagement in light of that? What programs and approaches work in getting that mutuality that you talked about?

You must have the right people and supports in place. In our markets, we have community health leaders. Depending on the size of the market, it might be a manager, a director or an executive director. Their primary role, in partnership with market leadership, is to lead community benefit tracking, community engagement and partnerships, driven by the community health needs assessment (CHNA), which guides the whole prioritization and implementation process.

In doing that we’re not just checking the box for the ACA or the IRS to say we have done the CHNA. We’re doing community engagement and prioritizing throughout the year so that there are effective partnerships with nonprofits, churches, schools, etc. We strive to make sure we’re not doing what we think is the priority but what they believe is the priority. If we’re doing that in the right way, we’re building relationships, building trust, building partnerships and bringing other stakeholders to the table, to optimize the likelihood that what we’re doing is sustainable. And it’s not just something Bon Secours Mercy is doing, but truly something that the community is embracing.

We often use the phrase that these things need to be “community-led and community-driven.” Because if that’s not the case, you’re not going to get the best outcome, you’re not going to get the collective wisdom. In the end, they’ll leave disappointed that once again somebody brought them to the table and promised them something, and it didn’t turn out to be what was originally agreed upon. It’s an ongoing process with principles from “Community Oriented Primary Care”: you identify and involve community; together, you diagnose what the issues and problems are; you implement solutions together, and then together you continue to evaluate whether or not it works and achieves desired outcomes.

Health care has never seemed more complex and complicated. If you could have just one thing move forward this year, what would it be?

For us, it would be the adoption at all levels — at the ministry level, at the board level, at our senior leadership level — of the framework created by the Healthcare Anchor Network, which is part of the Democracy Collaborative. Currently, there are about 45 health systems that have embraced the Healthcare Anchor Network framework for community engagement, economic development, and health improvement. And under that framework, tied to social determinants, tied to meeting community health needs assessment priorities, you focus on these three areas. 1. If you accept that you’re an anchor institution in your geographic community, you determine what your efforts are around local inclusive hiring. You look at what percentage of people you currently hire and then build on projections for the future about what that number needs to

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increase to and in what disciplines, because you to targeting 1% of the total investment income want to move beyond just entry-level positions to toward place-based investments that address positions where there is a living wage. We don’t social determinants of health. So, depending want to have employees living below the federal on the size of your organization, that number poverty level. would vary quite a bit. When you look at that 1% 2. The second area is local inclusive supply in aggregate across all those organizations, it’s a chain sourcing. Many of the systems have large total of about $700 million nationwide that would group purchasing activities, but we also have discretionary spend for purchasing. So how do we look at “Hope has two beautiful daughters; services — whether it’s electricians their names are Anger and Courage. or window washers or whatever it is among minority businesses — how Anger at the way things are, and can we increase contracts with them, such that they can grow and that they Courage to see that they do not too can become agents of hiring more remain at they are.” people from that anchor community. We can also use our expertise and — AUGUSTINE OF HIPPO resources to help community members start and grow businesses. There are great be committed to these community transforming examples in place by Healthcare Anchor Network initiatives. members in Cleveland and New Jersey. That’s our priority. That’s the baseline for mov3. The third area is investment, but you can ing us forward. Those are the key performance think of this in a couple of ways: indicators for all leaders throughout our system.

When we think about our community priEveryone at our organization knows that this is orities around social determinants like affordable what is important for us. Because, as I said before, housing, food insecurity, transportation and eduit starts with leadership, at the ministry level, at cation, we are looking to work with partners to the board level, at the C-suite level. This is what invest those dollars in programs and initiatives we do according to the principles of Catholic that address structural issues in our communities social teaching, and it is our commitment to really that can improve long-standing economic and make our communities healthier in all the ways health inequities. Our commitment has to do with we are called to do so. how do we, as a catalyst, convener and in some cases a funder, bring others to the table, whether Do you feel hopeful about that? that’s companies or politicians or others. That Leadership in Catholic healthcare is about kind of investment becomes more than a single hope and inspiration. transaction, but truly a way forward to transfor“Hope has two beautiful daughters; their mation in communities we serve. names are Anger and Courage. Anger at the way

There is also investment at a much greater things are, and Courage to see that they do not scale than just your own organization. Last fall, remain at they are.” (Augustine of Hippo) as members of the Healthcare Anchor Network, I am hopeful. It can’t be just a feeling. It has to each of the 15 health systems committed over time be put in action.