A Healthy Place to Live, Learn, Work and Play: Understanding Community Health Improvement Processes This presentation is designed to help bring all community participants up to speed on best practices and resources for effective community health improvement. We recommend using the following handouts to accompany the presentation: Improving the Health of Local Communities: The Wisconsin Way Community Health Improvement Requirements for Hospitals and Health Departments in Wisconsin Working Together: Effective Community Health Improvement Strategies (These are all available on the WALHDAB website: http://www.walhdab.org or www.wicommunityhealth.org) In addition, the last slide lists key resources for working on community health improvement. Note: This is a comprehensive presentation. Depending on your audience and the purpose of the presentation, you may choose to “hide” parts of it. For example, the slides on each stage of the CHIPP cycle could be skipped if you are not yet ready for that level of detail or your time is limited. Another example: you might skip the “getting started” slide if your audience is not at the stage yet. If you would like to use your own template for this presentation, you can edit the master slide by clicking on View then Slide Master.

Outline Definitions Key Principles What Makes a Community Healthy How a Community Can Become Healthier Best Practices by Phase Getting Started These are the topics that are going to be covered in this presentation.

Definition Community Health Improvement Processes: Working intentionally, strategically and collaboratively at the local level to improve the health of the community

Many Names, One Goal CHIP & CHA (public health) CHIPP (public health in WI) CHNA (hospitals) Similar steps Same goal: Make the community a healthy place to live, learn, work and play The concept of Community Health Improvement includes: CHIP = Community Health Improvement Plan CHA = Community Health Assessment CHIPP = Community Health Improvement Plans & Processes (terms used by local public health departments in Wisconsin) CHNA = Community Health Needs Assessment (terms used nationally by hospitals)

Public Health Department Requirements Wisconsin State Statutes and Administrative Rules Public Health Accreditation (voluntary) If desired, it could be noted that for local health departments and hospitals, community health assessments and plans are required by state statute (local health departments) and IRS rules (hospitals). A robust community health improvement process is also required for local health department accreditation (which is currently voluntary, and therefore would only be relevant to some local health departments). Public Health Department Requirements Since the early 1990s, LHDs have been required to conduct CHAs and CHIPs. Here is the statute and you can see the key steps in the Take Action cycle within the statute. Wisconsin State Statute s.251.05(3)(c) A local health department shall involve key policy makers and the general public in determining and developing a CHIP... AND s.251.05(3) Develop public health policies and procedures for the community: Complete a community health assessment; collect, review and analyze data on community health and identify population groups, families and individuals at high risk of illness, injury, disability or premature death.  Participate in development of community plans that include identification of community health priorities, goals and objectives to address current and emerging threats to the health of individuals, families, vulnerable population groups and the jurisdiction as a whole, and contribute to the planning efforts that support community strengths and assets.  Assure programs and services that focus on reducing health disparities and are based on evaluation of surveillance data and other factors that increase actual or potential risk of illness, disability, injury, or premature death.   Another driving force in the CHIPP movement is Public Health Accreditation. The public health sector is one of the last components of the health care sector to have a formal accreditation process. Accreditation started in 2011—based on work done collaboratively to design the system between the Centers for Disease Control and Prevention (CDC), National Association of County and City Health Officials (NACCHO), Association of State and Territorial Health Officials (ASTHO), Tribal Representatives, the Robert Wood Johnson Foundation (RWJF) and other public health partners. CHA & CHIP are required pre-requisites (along with a LHD strategic plan). If desired, the www.phaboard.org site could be consulted to determine the current number of accredited local health departments in Wisconsin. See also the “Hospital and Health Department Requirements” document on www.wicommunityhealth.org (Resources by Stage, Table of Resources). Wisconsin State Statute s.251.05(3)(c) A local health department shall involve key policy makers and the general public in determining and developing a CHIP... 

Not-for-Profit Hospital Requirements Every 3 years: Community Health Needs Assessments With community partners and public data Identify plans and roles for health improvement Another important partner, not for profit hospitals, have an IRS mandate to do CHIPP work. This guideline was a component of the Affordable Care Act. See the “Hospital and Health Department Requirements” document on www.wicommunityhealth.org (Resources by Stage, Table of Resources). The first assessments were due in 2013.

Benefits Effectiveness through collaboration Duplication of efforts Community engagement and awareness around health issues While there are certainly requirements for local health departments and hospitals, there are larger benefits for the entire community: --Increased effectiveness through collaboration --Reduced duplication of efforts --Increased community engagement and awareness around health issues

Benefits Health of community Build the community’s infrastructure Health care costs (including indirect costs such as lower productivity and absenteeism) Increase the health of the community Build the community’s infrastructure: Examples such as bike and walking paths increasing residents’ access to local businesses, increasing use of local farmers’ produce. Also this improved infrastructure may draw new residents and businesses to the community. Reduce health care costs: For more information see “Making the Business Case: Tips and Tools for Engaging Local Businesses” (on WALHDAB website or www.wicommunityhealth.org)

Key Principles Use best practices Actively engage all stakeholders Focus on underlying forces that influence health Pay attention to health disparities Use best practices in community health improvement: While there is not a great deal of scientific research on the impact of community health improvement practices, there is a strong body of expert opinion. Use those reliable sources to inform your process. Actively engage all stakeholders to make it a community-driven process: Shared ownership and participation will increase impact. Underlying forces: This will do more to “move the needle” on the issues of concern than focusing on outcomes. For example: looking at nutrition and physical activity (rather than cancer or heart disease). Health disparities: Some populations in your community may have a noticeable greater challenge in a particular health area. For example: individuals without a college education, recent immigrants, or particular neighborhoods.

Key Principles Move energetically from data into ACTION Use evidence- informed strategies Include policy and systems-based strategies Move from data into action: Don’t get too bogged down in reviewing the data; use it as a spring board to identify priorities and then implement strategies. Evidence-Informed: To assure your efforts have impact, consider using strategies with the strongest evidence base. Policy-based Strategies: By enacting local or state policies, your strategies have an impact on everyone and make that policy the default for all (ex: seat belt law). Systems-Based: Again, an entire system may change the way they do something and therefore affect everyone in that system. (Ex: Install point of decision prompts in public parking structures to encourage use of stairs instead of elevators.) Policy and systems changes are also more lasting.

What Makes a Community Healthy? You may choose to provide this slide as a handout because otherwise the image is quite small to read on a screen. Key Points: 1. Important to dig below the surface (morbidity & mortality) to look at what influences those outcomes; it allows for upstream thinking; provides the greatest opportunity for real change. 2. Many people assume that health behaviors and access to quality health care are what shape our health but there are two other major influences: Social & Economic (which accounts for 40%) Physical Environment (which accounts for 10%) Our efforts must evaluate and address all these areas. Note: County Health Rankings model is rooted in the multiple determinants of health models but focuses on those health factors (or determinants) that are modifiable and measurable at the community level: health behaviors, clinical care, social and economic factors, and the physical environment. County Health Rankings and Roadmaps © 2012 UWPHI

What Makes a Community Healthy? Refer to handout: “Improving the Health of Local Communities: The Wisconsin Way” (page 2) – this slide is to small to read otherwise This is a more detailed diagram than the last slide - presents same concept, adding: Emphasis on health disparities More topics under each category Link to State Health Plan (which many health departments and hospitals use as a framework for their community health improvement efforts)

Health Disparities = Differences between groups in their health status Examine disparities in health factors in your community Health Equity = striving for the best health for all Address disparities to achieve health equity Definition of health disparities: Differences between groups in their health status. Note that “health disparities” is a part of the diagram on the prior slide. It is critical in each health topic area to examine whether there are disparities/important differences between groups. Examples: race/ethnicity, gender, income groups, age. If we ignore these disparities, we may fail in improving the community’s health status because we did not focus efforts on those most affected. Example: An overall measure of the health of the elderly in Wisconsin gives us a “C.” But if you look just at African American or Native American elderly or just women or just those with high school or less education, the grade is an “F.” (Health of Wisconsin Report Card, 2010)

How a Community Can Become Healthier County Health Rankings and Roadmaps Model © 2014 Refer to handout: “Improving the Health of Local Communities: The Wisconsin Way” (page 3) Much as we use Quality Improvement (QI) processes within our organizations, community health improvement processes are ongoing improvement cycles but on the community level. This cycle has very standard steps (used by all organizations and literature related to community health improvement). You can see them here at a glance – we can go into each one in a little more detail. Notice: Engaging the community and collaborating with key stakeholders happens throughout the process. County Health Rankings and Roadmaps Model © 2014

Collaborate with Key Stakeholders Lead collaboratively with all core partners Involve community representatives throughout the process Engage community partners from under-represented groups Engage new partners as necessary after priority topics are chosen The following slides go into each section of the circular diagram on slide 12 in more detail. If you are not yet ready for this level of detail, or do not have time for this lengthy of a presentation, you can skip to slide #22 (Getting Started).

Benefits of Collaboration More thorough picture of complex health needs Different resources and perspectives are critical to success Shared ownership leads to shared responsibility to address health issues More focused effort when all work in one direction together

Engage the Community Include broad participation from the community throughout the process. In particular: Seek input on community needs and assets Seek input on the preliminary list of priority topics Seek commitment to support implementation Be sure to engage: Those affected by the issues being addressed Under-represented or underserved populations

Assess Needs & Resources Collect and analyze community health data. Include: Health disparities Underlying determinants of health Issues and themes identified by stakeholders and the community Community assets and resources Input from community members on health issues and assets

Focus on What’s Important Identify a set of priority community health issues to address Use a set of criteria for considering priorities Choose a manageable number of priorities Use a skilled facilitator

Focus on What’s Important Align the local health improvement plan with state and national priorities Summarize and disseminate the results of the assessment to the community

Choose Effective Policies and Programs Engage partners to plan and implement strategies Choose effective (evidence-informed) strategies Have multi-level approaches to change, including policy and systems- based approaches

Act on What’s Important Develop an effective organizational structure Develop and use a detailed action plan to: Organize steps Assign accountability Identify and secure needed resources Actively track progress Report progress to the community Celebrate success!

Evaluate Actions Design an evaluation plan at the beginning of the implementation process Evaluate and monitor both process and outcome measures Revise the action plan based on evaluation results Continually assess and address stakeholder involvement

Association for Community Health Improvement Getting Started Understand each other’s mission, purpose and requirements Create a shared vision and goals Form an organizational structure that will work for your community Determine clear roles, responsibilities, and levels of authority These steps come from ACHI: Association for Community Health Improvement Association for Community Health Improvement

Association for Community Health Improvement Getting Started Establish protocols for decision making and conflict resolution Create a communications plan Secure resources needed to begin Learn the best practices for community health improvement Draft a timeline for the steps in your process These steps come from ACHI: Association for Community Health Improvement Association for Community Health Improvement

Key Resources www.wicommunityhealth.org for the Wisconsin Guidebook on Improving the Health of Local Communities and other resources Healthiest Wisconsin 2020 Healthy People 2020 What Works for Health National Prevention Strategy County Health Rankings and Roadmaps Association for Community Health Improvement

A Healthy Place to Live, Learn, Work and Play: Understanding Community Health Improvement Processes Version 2.0 December 2014 This resource was developed with funding from the University of Wisconsin School of Medicine and Public Health from the Wisconsin Partnership Program. The resource is a result of a collaboration between the Wisconsin Association of Local Health Departments and Boards, the University of Wisconsin Population Health Institute, and numerous additional partners. For more information, please go to www.wicommunityhealth.org or www.walhdab.org. Title and source of this presentation.