Using Measurement in Community Health Improvement Processes to Identify Priorities and Drive Change Michael A. Stoto, PhD Collaborative Working Group on CHNAs Principles & Practices National Academy of Medicine, Washington, December, 2018

Measurement for Community Health Improvement Processes Background Builds on work with Mary Davis and Abby Atkins Funded by the Robert Wood Johnson Foundation Changes in the U.S. healthcare delivery system Transformation from volume to value Manifestations: ACOs, AHCs, CMS goals, SIM, etc. Accountability for outcomes, which must be measured Multi-sector collaboration on “community health improvement” (CHI) processes Kania & Kramer Collective Impact framework Common agenda, Mutually reinforcing activities, Backbone support organization, Continuous communication, Shared measurement systems Measurement for Community Health Improvement Processes

Measurement for Community Health Improvement Processes Background CHNA requirements have potential to bridge efforts of healthcare delivery sector, public health agencies, other organizations to improve population health Case studies of 10 exemplary CHI processes found “Excess variation” in how hospitals define the community they serve identify priorities More focus on conducting CHNAs than on developing implementing strategies monitoring efforts and evaluating the results Methods: document review + site visits Measurement for Community Health Improvement Processes

Shared CHNAs 10/10 processes created a shared CHNA or CHA Includes Usually prepared by local health department Includes population description (demographics) Based on Census, American Community Survey, etc. population health profile Based on vital stats, survey data, public health surveillance data, hospital & ED data, etc. Does not have to be a survey! Population of interest typically = one county hospital service areas cover more or less area some identified more targeted populations of interest Specific measures and presentation varies markedly Data lag more of an issue for performance measures

Shared CHNAs Suggestions Make more effective use of small area data to identify priority populations Community Needs Index (Dignity Health) Area Deprivation Index (University of Wisconsin) US Small-area Life Expectancy Estimates Project (CDC) to highlight disparities and inequities hospital data by Zip code (varies by state) UDS Mapper (safety net clinic data, AAFP) model-based estimates (CDC‘s 500 Cities project) Standardize CHNA measures to allow for benchmarking trends peer communities among priority populations

ACHI Community Health Improvement Model Performance measures to monitor accountability for actions Steps 1-6: High alignment among collaboratives and members ACHI model – CHI improvement Planning model Shared Community Health Profile with standard measures for benchmarking Steps 7-9: Least developed and more variability in format and content than CHNAs Measurement for Community Health Improvement Processes

Performance measures Performance measurement is not well developed despite involvement with ACOs and AHCs may be a function of who does the CHNA/IS The most developed IS’s had Population-level goals/objectives Cecil County (chronic disease priority): By, 2019, reduce high blood pressure among adults by 5%; baseline: 30.1% in 2006-2012 Strategies, activities, … with clear accountability & metrics (Bexar County) Methodist Hospital (diabetes priority) Strategy: Provide diabetes education to patients Measure: number of classes & individual instruction provided to patients. Target: 1,500 diabetes educator visits in 2017 Other IS’s are less developed “We’re so busy doing assessments that we don’t have time for implementation”

Performance measures Suggestions Implementation and performance monitoring should be a continuous process Performance measures ≠ population health profiles As in other areas, performance measures should be tailored to a joint implementation strategy, with clear indication of individual organizations’ accountability include a range of output and process measures (for evidence- based interventions) also outcome measures (as a “north star”) all with established validity and reliability More integration/collaboration among CHNA/IS staff Community Benefits office hospital management and strategic planning ACO and other population health staff