Now is the Time to Press Hospitals for Community Benefit Agreements

New Orleans       Community benefit agreements have increasingly become part of the conversation in cities throughout the country when it comes to major developments at the intersection of private interest and public authority, regulations, and landholding.  Few large cities under assault from major and minor sports interests to support stadium projects have not found themselves engaging in negotiations around community benefit agreements for example.  There are other opportunities though, as we discussed with Enid Eckstein on a recent Wade’s World radio interview that was triggered by her article in Shelterforce advocating for community benefit agreements with hospitals, particularly nonprofits.

Eckstein knows the healthcare industry well, both inside and out.  She was an officer in SEIU’s giant healthcare local, 1199, based in Boston, and more recently has been a researcher and advocate focusing on the role of hospitals and healthcare in communities.  The notion of community benefit agreements or CBAs has gained a lot of traction in Massachusetts in no small part, Eckstein argued, because of aggressive work by the Attorney General of the state in stepping up to regulate and codify the requirements under Massachusetts law that hospitals provide community benefits that were something other than developments of their own programs and self-interest, whether expanding a clinic or marketing their services.

Massachusetts is pathbreaking in this area, partially because they were a leader in providing mandatory health care in the state that was an inspiration for the Affordable Care Act.  The ACA also sets the stage for activity in this area because it requires that hospitals do a community assessment survey of health needs every three years, and mandates that the assessment integrate the community itself into the process.  The amendments offered by Senator Chuck Grassley (R-IA) put the Internal Revenue Service in this play because of his concern that nonprofit, tax exempt hospitals need to prove that they were providing charity care and if not, the IRS should pull their exemption.

The IRS has only recently begun enforcing some of the ACA regulations on penalties for smaller businesses not providing insurance for their workers, so it is unlikely that they are doing much in this area yet either.  Nonetheless, as Eckstein argues from the Massachusetts experience the opportunity is there for organizations of all shapes and sizes to start pushing hospitals to do right and do more.

And, why not?  One of the most compelling examples she offered in her Shelterforce piece occurred in Portland, Oregon, which like so many cities nationally, is facing an affordable housing crisis.  As part of a hospital CBA, $21 million was set aside by the hospital to build affordable housing and that leveraged almost $70 million for the project.

Now is the time to start pressing everywhere for hospitals to open up the doors to community organizations and others to be part of their required community assessment process.  Once in the door, we all need to press for real community benefit agreements while we have the opportunity.

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De-escalating Violence

New Orleans   Getting more experience in hospital emergency and waiting rooms is on no one’s top ten list, but, trust me, you do the time and this comes with the territory.  If you can call it luck, it’s not you personally, though the anger and aggravation when it is family is every bit as bad. People are unhappy, scared, nervous and more.  Voices are raised.  Fists are slammed on counters.  Guards are around.  Sometime police are in and out.  Sirens are blaring outside.  Receptionists know little and say less.  Medical personnel are over worked and understaffed.  Come to think of it, the possibility, if not the prospect, of violence breaking out is ever present.  Reading a piece in The New York Times by Douglas Starr on the ways that medical personnel have learned to de-escalate volatile situations and what police can learn from them and vice versa suddenly resonated with me as an, “Oh, yeah!” moment, because it seemed so obvious and so right.

Let’s admit though from the very beginning that there are big differences from the streets to hospital sheets.  The biggest is that not everyone on one side is armed and possibly everyone on both sides are fully strapped.  That fear and uncertainty undoubtedly moves many a trigger finger.

Nonetheless, if medical staff who unarmed and are not allowed to “attack, shoot or otherwise harm patients” can learn techniques to defuse tense situations, so can police.  Compared to other professions they “report nonfatal violence-related injuries at many times the rate of other occupations including law enforcement” even though police have higher rates of fatalities which is another way of saying that they find themselves in tense and potentially violent situations but have been trained and have created a culture to contain violence.

Ironically, Starr’s examples come from tips they gained from police themselves as well as veterans hospitals that deal with the military in often traumatic situations.  Part of it is reading “body language” and creating a “reactionary space” that allows the health worker to respond, but a lot of it starts with taking a step back to realistically assess the situation in a “tactical pause” without firing first, so to speak, as many policemen seem prone to do.  The rules matter, but so does the person’s humanity. Makes sense.

Other common sense tips were helpful.  Never say “calm down” or “its policy” or refer to something as their “problem,” but to look for a collective solution.  Never point a finger was another great tip.  One that would help all doorknockers on home visits in dealing with a situation that turns uncomfortable or frightening by teaching a person to say, “Let me get right back to you because I need to go get a Form 9.”  There was no Form 9.  Substitute a flyer or survey or petition or anything that changes the space.

The piece notes that seventeen states passed laws mandating de-escalation training for police and some city police shops have acted on their own, some in response to the Ferguson shootings.  Change could be hard, he notes, with 18,000 police departments and no centralized policy making body for police, but Starr ends with the revolutionary notion that police, like doctors, should adopt a policy of doing “no harm.”

What a relief it would be for the rest of us if our dealings with police could be based on an assumption that they meant us no harm, so that we could unlearn the reality now which is an expectation of the opposite.

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