Training: The Nuts and Bolts of Community Health Improvement Planning Teresa Daub, CDC Jessica Solomon Fisher, NACCHO

Learning Objectives Following this session, you will be able to: Identify common elements of community health improvement models, including Mobilizing for Action through Planning and Partnerships (MAPP) Determine skills and expertise needed to conduct a community health improvement process and develop a community health improvement plan (CHIP) Identify common challenges to the CHIP process (pitfalls) and develop strategies to avoid or overcome them Utilize related resources to plan and implement a CHIP.

Definition: Community Health Improvement Process An ongoing, collaborative, community-wide effort to identify and address health problems through coordinated activities. It may include environmental, business, economic, housing, land use, and other community issues indirectly affecting the public’s health. (Adapted from National Public Health Performance Standards Program, Acronyms, Glossary, and Reference Terms, CDC, 2007. www.cdc.gov/nphpsp/PDF/Glossary.pdf). PHAB includes this definition in their glossary Community health improvement is not limited to issues classified within traditional public health or health services categories, but may include environmental, business, economic, housing, land use, and other community issues indirectly affecting the public’s health. A community health improvement process involves an ongoing collaborative, community-wide effort to identify, analyze, and address health problems; assess applicable data; develop measurable health objectives and indicators; inventory community assets and resources; identify community perceptions; develop and implement coordinated strategies; identify accountable entities; and cultivate community “ownership” of the process. Important to understand that this is about a process. A CHA and a CHIP are not stand-alone products; rather, conducting a CHA and developing a CHIP are parts of a larger process.

Common Elements for the Overall Health Improvement Process Prepare and organize Engage the community Develop a goal or vision Conduct community health assessment(s) Prioritize health issues Develop community health improvement plan Implement community health improvement plan Evaluate and monitor outcomes

Examples of CHA/CHIP Models or Frameworks PREECEED-PROCEED (1970s) Healthy Communities (1980s) Planned Approach to Community Health (PATCH) (1983) Assessment Protocol for Excellence in Public Health (APEXPH) (1991) Institute of Medicine CHIP framework (2003) Mobilizing for Action through Planning and Partnerships (MAPP) (2001) Association for Community Health Improvement (ACHI) Toolkit Catholic Health Association State-specific models/frameworks

Here are some examples of community health improvement process frameworks/models, some of which you may have heard of…this matrix presents a comparison of the details of these models. Several differences worth noting as you examine models/frameworks are in the ‘principles’ and ‘notable characteristics’ sections [speaker notes: you may consider pointing out some of the differences in these two sections, especially re: co community participation/ownership, agency vs. system-focus, etc.] **NOTE THE DIFFERENCES btw them ‘notable characteristics’ section. The steps are pretty common regardless of framework.

[speaker note: See notes from previous slide that can be carried over here] NACCHO and CDC consider MAPP the gold standard of frameworks/models, although we recognize not every community is ready to take on a MAPP process. MAPP is unique in that it focuses LPHS focus rather than agency, focuses on assets, in addition to needs, etc.

Mobilizing for Action through Planning and Partnerships (MAPP) A strategic approach to community health improvement Developed by NACCHO in collaboration with the CDC; released in 2001 One common framework for overall process, with which you may all be familiar.

MAPP: An Accreditation Preparation Tool Mobilizing for Action through Planning and Partnerships (MAPP): Community focused approach to health improvement efforts Assessment and prioritization of strategic issues Results in: Community health assessment Community health improvement plan A community-based strategic planning process for improving public health A method to help communities prioritize public health issues, identify resources for addressing them, and take action NACCHO’s gold standard in community health assessment & improvement planning A CDC supported initiative.

MAPP as a Framework Organizational or Community Visions NPHPSP Assessment Qualitative data on Community Perceptions Community Health Assessment Priority Areas Strategies Pubic Health Activities 10

Common Steps in Conducting a CHA Develop an assessment plan Engage the community and local public health system partners Define the population Identify community health indicators that align with your Community’s vision* or goals for the assessment Collect data on identified indicators Analyze data Summarize key findings Report results back to community and partners *not a PHAB requirement and in some cases visioning may come before the CHA conduct We are not focused on the CHA today, but it is one crucial step in the overall comm hlth impr process and precedes development of a CHIP, so we are noting the common steps here. More information was presented earlier in the training meeting. *What I’m presenting today are common elements in conduct of a CHA and development and implementation of a CHIP for the purposes of PHAB accreditation. We know in some cases, health departments and communities may seek to go above and beyond these standards and measures and in the spirit of quality improvement NACCHO supports these efforts and does have resources for LHDs looking to do this. However, for these purposes of today’s presentation please note that I am focused on presenting you with the common elements of these items specific to what PHAB ultimately is looking to see. Community health assessments build upon the strengths of existing assessment models including organizational, marketing, and needs assessments; as a result, community health assessments can identify the full magnitude of a health problem.1 A comprehensive community health assessment process utilizes broad networks of data, mobilizes community members, and garners resources to comprehensively approach public health issues.3,4 Data on health status, health needs, community assets, resources, and other determinants of health status are collected through a community health assessment process.4   Community representatives are an integral part of a community health assessment because they know community habits, customs, attitudes, social groups, and where things happen. Successful community health assessments build trust and community ownership of the process through active engagement of organizations and residents. Meaningful engagement involves community in the development of assessment protocols, identification of priorities, and implementation and monitoring of community improvement efforts.3 Moreover, community members help promote and bring visibility to community health assessment and improvement initiatives.5 Most community health assessment processes include some variation of the following steps: Develop an assessment plan Engage the community Define the population Identify community health indicators Collect data Analyze data Identify health priorities Report results Institute of Medicine of the National Academies. (2003) The Future of the Public’s Health in the 21st Century. Washington, DC: The National Academies Press. Edberg, M. (2007). Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, Mass.: Jones and Bartlett Publishers.

Definition: Community Health Improvement Plan A long-term systematic effort to address issues identified by the assessment and community health improvement process Is broader than the health department and should include partners Considered current by PHAB if developed or updated within a 5 year time period prior to application Based on community health assessment Relates directly to Domain 5 A community health improvement plan is a long-term, systematic effort to address public health problems on the basis of the results of community health assessment activities and the community health improvement process. Definition used in Healthy People 2020, PHAB, and NPHPSP

Purpose of the CHIP The purpose of the community health improvement plan is to describe how public health stakeholders and system partners will work together to improve the health of the community. Adapted from PHAB Standards and Measures Version 1.0

PHAB HIP Standards and Measures Version 1.0 Standard 5.2: CONDUCT A COMPREHENSIVE PLANNING PROCESS RESULTING IN A TRIBAL/STATE/COMMUNITY HEALTH IMPROVEMENT PLAN Measure 5.2.1 S: Conduct a process to develop a state health improvement plan Measure 5.2.2 S: Produce a state health improvement plan as a result of the health improvement planning process Measure: 5.2.1 L: Conduct a process to develop a community health improvement plan Measure 5.2.2 L: Produce a community health improvement plan as a result of the community health improvement process Measure 5.2.1 T: Conduct a process to develop a Tribal community health improvement plan Measure 5.2.2 T: Produce a Tribal community health improvement plan as a result of the health improvement process Measure 5.2.3 A: Implement elements and strategies of the health improvement plan, in partnership with others Measure 5.2.4 A: Monitor progress on implementation of strategies in the community health improvement plan in collaboration with broad participation from stakeholders and partners

PHAB HIP Process (Standard 5.2 Measure 5.2.1 A) Broad participation of public health system/community partners Information from the SHA/CHAs Issues and themes identified by stakeholders Identification of state/local/Tribal assets and resources A process to set state/local/Tribal health priorities

PHAB HIP Components (Standard 5.2 Measure 5.2.2 A) Dated within last five years Health priorities, measurable objectives, improvement strategies, and performance measures with measurable and time-framed targets Policy changes needed to accomplish health objectives Individuals and organizations that have accepted responsibility for implementing strategies Measurable health outcomes or indicators to monitor progress Alignment between state/local/national/Tribal priorities

Examples of how the plan was implemented Measure 5.2.3 A: Implement elements and strategies of the health improvement plan, in partnership with others Reports of actions taken related to implementing strategies to improve health Examples of how the plan was implemented

Evaluation reports on progress made in 5.2.4A Monitor progress on implementation of strategies in the HIP collaboration with broad participation from stakeholders and partners Evaluation reports on progress made in implementing SHIP strategies must show: Monitoring of performance measures Progress related to health improvement indicators The health department must show that the health improvement plan has been revised based on the evaluation

Common Steps in Developing and Implementing a CHIP Ongoing engagement of community and public health system partners Review findings of CHA Determine health priorities based on HA findings and community and partner input and how these were chosen CHIP implementation plan/ work plan: develop goals, measurable objectives, strategies, timeline, and organization/persons responsible* to address each identified health priority [*not limited to HD responsibility-refer to PHAB CHIP standard/measure language]. Devise process for monitoring progress on work plan implementation and meeting goals and objectives Distribute CHIP throughout the community/state Action and monitoring action Note back to MAPP slides, ID strat issues forward.

CHIP: Bergen County, NJ Partner Participation Three co-sponsoring organizations Nine members of a Core Group, the leadership body that oversaw the entire process Fifty-member CHIP Committee representing a broad spectrum of organization and community perspectives

CHIP: Bergen County, NJ Varied Inputs/Information Community Themes and Strengths Assessment (community forums, telephone survey, and focus groups) Local Public Health System Assessment/NPHPSP (undertaken by a volunteer public health partnership coalition) Community Health Status Report (population-based health status, quality of life, and risk factor data) Forces of Change Assessment (a facilitated 1/2 day workshop with CHIP Committee members as “community experts”)

CHIP: Bergen County, NJ Priority Health Issues Access to Health Care Mental Health Obesity – Nutrition and Physical Activity Alcohol, Tobacco and Other Drugs Communication of Health Issues Community Assets and Resources Identified resources for each priority Established a countywide task force for each priority Measurable Objectives Connected goals and objectives back to assessment data Identified risk factors, contributing factors, suggested interventions, available resources and barriers related to each goal area

Bergen County, NJ Alcohol, Tobacco and Other Drug Outcome and Impact Objectives

Bergen County, NJ

CHIP: East-Central District, NE Partner Participation Used MAPP process to “strengthen and deepen” relationships Thirty-eight agencies and many community members participated in the process Varied Inputs/Information Community Themes and Strengths Assessment (focus groups, surveys, information from other initiatives) Local Public Health System Assessment/NPHPSP (completed by MAPP Subcommittee) Community Health Status Assessment (collected data on 10 health indicators, interviewed key stakeholders) Forces of Change Assessment (MAPP Subcommittee examined how the broader environment was affecting the community and the local public health system)

CHIP: East-Central District, NE Priority Health Issues Access to Health Care Mental Health Dental Health Substance Abuse Transportation Communications Public Health Web Site Community Assets and Resources Committees took on each priority issue Developed 5 year visions Measurable Objectives Established overall goals for the local public health system and as well as specific goals for the East-Central District Health Department

East-Central District, NE They began with only $30,000, and no local tax base. Six years later, they had increased service coverage from two to four counties, and boosted their annual budget from $30,000 to $3.75 million without access to a local tax base.

CHIP review activity

What skills and expertise are need to conduct a CHIP process and develop a health improvement plan? Prepare and organize Engage the community Develop a goal or vision Conduct community health assessment(s) Prioritize health issues Develop community health improvement plan Implement community health improvement plan Evaluate and monitor outcomes EXERCISE: 5 minutes as a large group, brainstorm what is needed. Brainstorming exercise for them. We have the steps listed, now you know. Divide different steps among the room and think through the skills/expertise they would need to have/have access to. Epi, communications, facilitation, etc.

Common Pitfalls Time and Engagement Communications Resources Other? Ineffective partner engagement Loss of momentum Insufficient time for developing strategies Communications Needs of different stakeholders Resources Allocation of financial and human resources for whole process Other? Credit CHA/CHIP sites, but these are common/what we’ve heard for years. Define how people experience each of these as a pitfall and it impedes their progress. State the problem, allow them to strategize and then present our solutions (turning statements below into solutions) Turn each point below into solutions. E.g. ‘allow time up front to…. Time and Engagement Should have planned for the following: More time upfront to engage partners properly, get them up to speed, etc. More time throughout the process to ensure partners are on the same page – to keep momentum going. For example, should have explained CHIP part from the start and not only when about to start the CHIP. How to engage different partners in the process who aren’t the ‘usual suspects’. More time to plan strategies before beginning process (e.g. estimated amount of time for x, y and z activities, at what point to start a certain activity (for example, at what point in the process should you start data mining, etc)). Alignment of similar initiatives prior to starting this one. Trying to do this now (mid-process) is much more challenging. Marketing/Buy-in/Communications Should have done the following: Started thinking about marketing the project earlier on even before really starting the work. Thought ‘outside of the box’ as far as communications with core team, community members, partners goes – develop a website, develop a shared site for core team, etc. Resources Should have better anticipated financial burden and considered this at the outset so appropriate resources/staff could have been allocated.

Activity: Avoiding Pitfalls 15-20 minute small group discussions on how to avoid common pitfalls (or identify other potential pitfalls). Report back.

Time and Engagement Allow time upfront to engage and orient partners Build in time to ensure partners are on same page Plan to engage new partners throughout the process Anticipate partner questions and address alignment of similar initiatives Develop a work plan and timeline from the beginning Time and Engagement Should have planned for the following: More time upfront to engage partners properly, get them up to speed, etc. More time throughout the process to ensure partners are on the same page – to keep momentum going. For example, should have explained CHIP part from the start and not only when about to start the CHIP. How to engage different partners in the process who aren’t the ‘usual suspects’. More time to plan strategies before beginning process (e.g. estimated amount of time for x, y and z activities, at what point to start a certain activity (for example, at what point in the process should you start data mining, etc)). Alignment of similar initiatives prior to starting this one. Trying to do this now (mid-process) is much more challenging. Marketing/Buy-in/Communications Should have done the following: Started thinking about marketing the project earlier on even before really starting the work. Thought ‘outside of the box’ as far as communications with core team, community members, partners goes – develop a website, develop a shared site for core team, etc. Resources Should have better anticipated financial burden and considered this at the outset so appropriate resources/staff could have been allocated. ous things into solution statements

Communications Plan for different levels of communications (from core circle to champions) from the beginning Allocate sufficient staffing resources for communications and marketing activities

Resources Leverage internal and external resource from the beginning Think beyond development of CHIP to implementation

CHA/CHIP Resources NACCHO Accreditation Preparation and Quality Improvement Prerequisites website www.naccho.org/prerequisites MAPP Clearinghouse www.naccho.org/mapp Performance Improvement Technical Assistance Teleconference Series Send us your performance improvement questions to performance@naccho.org Association for Community Health Improvement: www.communityhlth.org Catholic Health Association http://www.chausa.org/Assessing_and_Addressing_Community_Health_Needs.aspx In summary: don’t start from scratch and don’t go it alone. Bring partners on board and allow the process to be of the community. There are a number of resources to help, including monthly conference calls, individualized TA and much more, which you’ll hear about in more detail this afternoon. CHA/CHIP Resource Cent ACHI: Assessment toolkit, list serve, newsletter and moreer launching soon

Contact Information Jessica Solomon Fisher, NACCHO jfisher@naccho.org (202) 507-4265 Teresa Daub, CDC tdaub@cdc.gov 404-498-0317