Connecting with Community-Based Organizations (CBOs): Learning from Failure and Success

Learn from success and failure in connecting with Community-Based Organizations (CBOs) to address Health-Related Social Needs (HRSNs) in hospitals. Explore challenges, solutions, and tools for effective partnerships.

Building community ties

Prior to the pandemic, Center of Life (COL), a local Community Based Organization (CBO) in Pittsburgh, PA, partnered with Duquesne University’s Center of Integrative Health to address asthma complaints in the Hazelwood neighborhood. Hazelwood, like many other communities that previously housed steel mills, does not have great air quality, and as a result, has a high occurrence of residents who have asthma. Duquesne provided physicians to examine asthma patients who also attended COL’s after school program. They came and completed the appointments while the kids were already at programming. One of the leading pharmacists who worked as an instructor at Duquesne established this connection and eventually became a COL board member.

This pharmacist had another idea: find funding to hire Community Health Workers (CHWs) who would be placed at Center of Life but employed by Duquesne. They would work on the ground to help community members make and keep medical appointments; visit residents at their homes; bring them food if they were in need; maintain a closet of toiletries and clothing basics, etc. The CHWs would work with the social worker on staff at COL to address deeper, more challenging issues that residents faced, such as utility support, domestic violence, and imprisoned family members.

The funding for this program came through in 2020. One full-time and two part-time CHWs were hired. They had office space at Center of Life but were paid by Duquesne University. They were able to meet the established goals of the program and gain the trust of the Hazelwood community.

In May of 2023, the CHWs were told that their positions would end the following month. There was no warning, no alternative employment offered, and no reasoning behind the jobs ending, aside from a lack of funding. And just like that, the program was over. COL scrambled to absorb these positions into their organization which had become critical for the community they served.

Stories like this one play out thousands of times each year in CBOs across the country. The new SDOH mandate that requires all hospitals to survey hospital inpatients about their Health-Related Social Needs (HRSNs) has emphasized the need for them to work with Community-Based Organizations (CBOs). Unfortunately, we are also more keenly aware of the difficulties facing establishing these CBO/hospital relationships to help address the needs discovered by the HRSN survey. There are gaps in service, both geographically and capacity-wise.

Nonprofit Finance Fund (NFF) is an organization dedicated to advancing racial equity and community wealth and well-being by boosting the collective success and power of nonprofits. They work closely with various CBOs and have a wealth of experience helping them form connections (or attempt to form connections) with health systems to address HRSNs. We had the opportunity to chat with NFF consulting Directors Meadow Didier and Brian Kellaway about the problems CBOs and health systems face as they forge new relationships. We also got some tips for health systems in the process of establishing new relationships and provide some considerations to look out for.

The Major Challenges Facing CBOs

NEWER, SMALLER CBOs (LED BY PEOPLE OF COLOR) ARE OFTEN EXCLUDED

The first challenge NFF mentioned is tricky. CBOs that already have the infrastructure to support health systems tend to be those that are well-established and are most often led by people who are White. As a result, this may not leave space for smaller, newer CBOs that are led by People of Color to take advantage of collaboration opportunities.

In the same vein, safety net clinics or communities that have systematically been deprived of resources are the ones most likely to be denied grants to work with health systems (e.g., CBOs that are less established or operated by People of Color).

In this way, societal and cultural inequalities that already exist are being perpetuated, which take away from anyone getting the help that they need.

CBOs lack data and technology expertise

Due to how CBOs are funded, they don’t usually have much ability to invest in infrastructure. Additionally, they were started because they identified a community need – technology investment is secondary to meeting that need. Many CBOs lack a technical platform, infrastructure, and know-how to integrate data from different sources, such as EMRs, claims data, and HIEs.

Ideally in a CBO/hospital relationship, patient data could be exchanged bi-directionally so the CBO knows they’ve got a community member in need and the hospital knows when a patient is working with a CBO. But that seems unrealistic without substantive investments in technology and time-intensive systems development.

And we can’t forget about HIPAA

Health systems must follow HIPAA ordinances and laws, and they have IT structures in place to support these requirements. However, these items come with a price tag that is often too hefty for CBOs to invest in. As a result, they are maintaining classification for their referrals in more informal ways that may not adhere as strictly to privacy mandates as required by HIPAA.

A LACK OF FUNDING FOR INDIRECT costs mean tough choices for CBOs

CBOs largely run on grants, which often do not include sufficient monies for indirect costs, such as operating and administrative expenses. For example, a CBO staff member may be spending large amounts of time coordinating with a partnered health system or administering assessments to community members, but that staff member’s salary is unlikely to be included in the parameters of the grant.

Additionally, the time that a CBO staff member spends with community members or assessing or determining logistics with a health system partner could take them away from the opportunity to help support their community in ways that are ultimately more impactful to the community members. There is so much red tape tied to some funding requirements that simply trying to get efforts off the ground can monopolize the entirety of the grant.

Meadow gave an example of a CBO that kept getting stuck because the health system had recurring turnover. The CBO would complete one step and then suddenly the health system contact was no longer in a position to support them, and the new person in that role was not familiar with the necessary process or maybe didn’t have the context as to why it was even important.

They spent millions of dollars attempting to close the contract and being stymied by logistics. Meanwhile, that money could have benefited the community in concrete ways.

How to get started with a CBO

So, how can health systems turn these experiences into positive responses that will support community members who have identified that they have an HRSN?

It’s important for health systems to realize that, inevitably, there is already someone doing the work. It becomes a matter of identifying who that person or CBO is, and how to establish a partnership with them.

The first and possibly most vital component to establishing that partnership is trust. The health system must trust that the CBO will work with the patient to address the HRSN and the CBO must trust that the health system has the patient’s best interests at the forefront of their goals.

Communication is also important. If Duquesne University had communicated to Center of Life that there was a funding crisis, they could have worked together to find a path forward for the Community Health Workers. Instead, the trust between the two is damaged, and working together in the future will be a rockier path.

The Partnership Assessment Tool for Health (PATH)

Nonprofit Finance Fund has developed a tool to help establish and strengthen relationships between the two entities. Their Partnership Assessment Tool for Health (PATH) was created to help partnering organizations work together more effectively to maximize the impact of the partnership for both parties.

The PATH focuses on four areas:

1. Internal and External Relationships – identify a point person from each organization as well as who will be working with those point people and how communications will proceed.
2. Service Delivery and Workflow – who is receiving the referrals? How are they being shared? What specific services are being addressed?
3. Funding & Finance – the partners should walk through the costs of every piece. Who is paying? How? How long is funding secured for? What are those funds NOT to be used for?
4. Data & Outcomes – who is collecting data? How is it being collected? How is that data being used and shared? What HIPPAA considerations must be addressed?

Also, the PATH includes a supplemental fifth section that guides a candid conversation about equity, which is crucial to success. What barriers are both sides facing? What barriers exist within the population? How are these barriers being addressed? What commitments are both organizations willing to make to tackle those barriers?

This is a great tool if you are getting started with a CBO or assessing existing CBO relationships. Simply the process of sitting down and answering the questions together will be valuable no matter where you are in the relationship-building process.

CBOs also have to answer some questions that may be eye-opening in order to determine if they are truly prepared to take on these partnerships.

Considerations for CBOs:

• Look at the monetary bottom line. Can they fulfil the parameters of the grant? Do those parameters include items such as operating costs? If the grant does not, is the project still feasible?
  • Most federally funded government contracts only allow 10% of any funding given to nonprofits to cover overhead costs.
• Look at the size/scope of the partnership. If a major health system in a busy urban area is looking to partner with a small CBO and anticipates hundreds of annual referrals, can the CBO meet that capacity?
• Conversely, if the CBO is hiring an associate to tackle referrals and there is no guarantee referrals will come through, how else can that associate’s time be utilized? How is that position being paid for?

Bottom line: What do CBOs wish hospitals and health systems understood about the way that they work?

1. High upfront costs can be prohibitive to starting a relationship.
2. Delays in reimbursement can also put undue financial burden on the CBO.
3. Understand the realities of government funding, which often does not cover the full cost of services, and the burden of fundraising that might create for CBOs.
4. Just because a solution is non-traditional or not medication focused, that does not mean it’s the wrong path.
5. Unlike in the for-profit world, a client referral isn’t helping the CBO unless it comes with funding that covers the full costs of delivering services. Otherwise, it means more work and a bigger gap between costs and revenue, and the CBO might have to turn the referral away.

Many CBOs are already addressing inequities caused by Social Determinants of Health. They are working hard to support the people they serve in leading happy, healthy lives, which is everyone’s goal. They know that there are people whom they serve who struggle to pay their utility bills, who lack regular transportation, who live in food deserts, who are currently unhoused, who deal with violence on a regular basis. CBOs want to continue to provide support and to help hospitals and health systems tackle these needs. With the new mandate from CMS, the time is now for hospitals and CBOs to begin building deeper understanding and deeper relationships to address their communities’ needs together.