1. The Latest in Tools for State and Community Health Improvement Planning Melody D. Parker Public Health Advisor, Health Department and Systems Development Branch Division of Public Health Performance Improvement Office for State, Tribal, Local and Territorial Support APHA Annual Meeting Monday, October 29, 2:30–4:00 pm Session
Centers for Disease Control and Prevention
Office for State, Tribal, Local and Territorial Support

2. No relationships to disclose
Presenter Disclosure
Melody Parker, Centers for Disease Control and Prevention
Denise Pavletic, Association of State and Territorial Health Officials
Lowrie Ward, National Association of County and City Health Officials
Michael Bilton, Association for Community Health Improvement
The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:
No relationships to disclose

3. Learning Objectives At the end of this session you will be able to
List at least three questions to consider when choosing a health improvement planning tool
Identify common elements in health improvement planning models and frameworks
Find additional resources on health improvement planning from a variety of sources

4. Importance of Tools PHAB Accreditation Program Key Elements
Standards and measures across 12 domains
10 Essential Services, administrative capacity, and governance
Intended to provide a strong foundation for all public health programs
Three prerequisites
State or community health assessment
State or community health improvement plan
Health department strategic plan
Accreditation assessment process

5. Key Definitions (Excerpted)
Community Health Assessment—identify key health needs and issues through systematic, comprehensive data collection and analysis
Community Health Improvement Process—ongoing collaborative effort to identify, analyze, and address health problems through coordinated strategies
Community Health Improvement Plan—written document used to set priorities and coordinate resources
Excerpted from PHAB Standards and Measures, Version 1.0,

6. Common Elements in Community Health Improvement Process Models
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
For further reading: Appendix C-Financing Mission-Critical Investments in Public Health Capacity Development, sub-section Community Health Improvement Planning of IOM’s For the Public’s Health: Investing in a Healthier Future (2012). Authored by Eileen Salinsky, former director of public health policy in the Office of the Assistant Secretary for Planning and Evaluation at the U.S. Department of Health and Human Services.
Community health improvement planning has been conceptualized and implemented in a variety of ways. Typically these strategic planning activities include at least three distinct phases: the completion of a community health assessment, the identification of health priorities, and the development of an action plan to respond to priorities identified (Jacobs and Elligers, 2009). The evidence base regarding the optimal nature and scale of investments in each of these phases is underdeveloped (Friedman and Parrish, 2009; Myers and Stoto, 2006). However, the need for some level of capacity in community health assessment and related health improvement planning is widely recognized. Because these activities are often viewed as fundamental elements of public health practice, PHAB will not consider a health agency for national accreditation if the organization has not developed a community health assessment, a community health improvement plan, and an agency strategic plan. -p. 163
There are several steps that are common across improvement planning frameworks.
It’s interesting that there were a few early models – PATCH (1983), APEXPH (1991), and MAPP (2001)– and then all was momentarily quiet, when there was a sudden jump in the number of available models. Organizations and topic areas are now creating their own, implying a great deal of interest in the topic.
The common element that is not listed here is that nearly all community improvement models are cyclical – there is no beginning and no end, and you can come into the process at various points along the continuum. Each cycle informs the next.

7. A Variety of Tools Over Time
PATCH (1983)
APEXPH (1991)
PACE-EH (2000)
MAPP (2001)
Catholic Health Association (updated 2010)
Association for Community Health Improvement (updated 2011)
ASTHO/CDC SHIP Framework (2011)
PATCH, the acronym for Planned Approach to Community Health, is a cooperative program of technical assistance managed and supported by the Centers for Disease Control (CDC). PATCH is designed to strengthen state and local health departments' capacities to plan, implement, and evaluate community- based health promotion activities targeted toward priority health problems. The PATCH concept emerged in 1983 primarily as a CDC response to the shift in federal policy regarding categorical grants to states. One of those categorical grant programs was the Health Education-Risk Reduction (HERR) Grants Program.
APEXPH is a voluntary process for organizational and community self- assessment, planned improvements, and continuing evaluation and reassessment. Collaborative project of APHA, ASPH, ASTHO, CDC, NACCHO, US Conference of Local Health Officers
CDC’s National Center for Environmental Health and the National Association for County and City Health Officials partnered to develop PACE-EH, Protocol for Assessing Community Excellence in Environmental Health. This methodology guides communities and local health officials in conducting community-based environmental health assessments.
Mobilizing for Action through Planning and Partnerships (MAPP) is a community-driven strategic planning process for improving community health. The MAPP tool was developed by NACCHO in cooperation with the Public Health Practice Program Office, Centers for Disease Control and Prevention (CDC). A work group composed of local health officials, CDC representatives, community representatives, and academicians developed MAPP between 1997 and 2000.
XlR=hospital CHNA
ACHI's Community Health Assessment Toolkit, a guide for planning, leading and using community health needs assessments to better understand -- and ultimately improve -- the health of communities.

8. Community Health Assessment and Improvement Models: Differences to Consider
Who’s facilitating the process?
What’s the scope of collaboration?
How comprehensive are the data used and issues addressed?
Are there underlying models or concepts?
Who is implementing the improvement process? What is the scope of collaboration?
Level of collaboration or shared ownership
Lead organization or focus of the tool guidance: jurisdiction (state / tribal / local), programmatic area, health department, healthcare organization, community organizations, non-health sectors
How comprehensive are the data used and issues addressed?
Broadly comprehensive or focus on categorical programs such as environmental health, chronic disease, maternal and child health, preparedness, etc.
Inclusion of other inputs - policy, system, assets, etc.
Are there underlying models or concepts?
Biomedical model, socio-ecological model, social justice/health equity, performance measurement, strategic planning, health promotion, policy

9. Thank you! Melody D. Parker, MM, MLIS
Public Health Advisor, Health Department and Systems Development Branch
Division of Public Health Performance Improvement
Office for State, Tribal, Local and Territorial Support
Centers for Disease Control and Prevention
Office for State, Tribal, Local and Territorial Support

10. The Nuts & Bolts of State Health Improvement Planning Denise Pavletic RD, MPH Director, Public Health Systems Improvement

11. What is a State Health Improvement Plan?
Link to PHAB:
PHAB Standard 5.2: Conduct a comprehensive planning process resulting in a tribal/state/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

12. SHIP Environmental Scan
ASTHO collaborated with Purdue University’s Healthcare TAP and the CDC in 2010
In depth look into state health improvement planning to find trends, common themes and examples
ASTHO SHIP Guidance and Resource found at Performance/

13. A Look at National Data State Health Improvement Plan :
• 54% of states reported having a SHIP developed within the last 3 years, while 46% of states had a SHIP that was developed over 3 years ago.
• 58% of states indicated SHA data was used to develop the SHIP
• 63% of states reported the SHIP linked to LOCAL health improvement plans

14. Lessons Learned From the Scan
Our research identified 9 Basic Components of what went into a State Health Improvement Process
Establish a Planning Process or Select Model
Identify and Engage Stakeholder in Planning and Implementation
Engage in Visioning and Systems Thinking
Collect or Analyze Data
Establish Priorities & Identify Issues Through Priority Setting
Communicate/Vet Priories
Develop Objectives, Strategies, and Measures
Develop and Implement Workplan
Monitor, Evaluate, and Update the SHIP

15. Key Components 1. Establish a Planning Process or Select Model
The SHIP development process can range from 12 to 48 months. A good planning process builds commitment, engages system partners as active participants, uses time efficiently and produces a plan that can be realistically implemented.
Remember to:
Identify someone to drive the development process
Engage health department leadership
Engage broad-based stakeholders early on
Possible Products or Activities:
Process Timeline
Steering or Planning Committee
Asset Map (Personnel and Financial)
Communications Plan
Link to PHAB:
According to measure 5.2.1S, the state health department must provide documentation of a completed state health improvement planning process using a model that supports a participatory process.

16. Key Components
2. Identify and Engage Stakeholder in Planning and Implementation
Developing a SHIP is an opportunity to drive an ongoing state collaborative improvement process. The development, implementation and monitoring of a SHIP can be led by the state health agency but should be a shared responsibility among state health system partners.
Your partners should:
Be committed
Provide a broad range of perspectives
Contribute necessary resources
Be able to impact outcomes
Be diverse
Throughout the process you should:
Evaluate partner participation
Link to PHAB:
PHAB measure 5.2.1S requires documentation of a health improvement planning process that includes broad participation of public health system partners.

18. Key Components 3. Engage in Visioning and Systems Thinking
According to the MAPP strategic tool, a vision is a picture of the future you wish to create. It can help provide focus, purpose, and direction…, and mobilize participants to collectively achieve a shared vision of the future. Identifying a vision for the state can support health improvement.
During this step, the state partners address questions such as “What would we like our state and our state’s public health to look like in 10 years?”
Points to Consider
Can other visioning efforts be incorporated?
Conducts a vision effort that includes broad state representation
Hold a visioning session
Make sure to capture information and disseminate with planning group
Use a facilitator
Refer to vision statement throughout SHIP development process
Link to PHAB:
Indirectly relates to measure as this step includes broad system partner participation and focuses on identifying what is important to all partners regarding health.

19. Key Components
4. Collect or Analyze Data
There are several types of data that can be used and methods for collecting data for a SHIP. For PHAB requirements, a SHIP must be data driven (should incorporate data from the state’s community health assessment) and evidence based. Including data supports the rationale for choosing the priorities and indicators in the plan.
Remember that Data Should
Align with the community/state health assessment
Include health indicator and infrastructure/system capacity data
Data Can Provide Information on the Following:
Themes and Strengths
Forces of Change
Health Status
System Capacity Data (e.g., NPHPSP results)

20. Link to PHAB:
As part of PHAB measure S, evidence that system partners identified issues or themes to be addressed in the plan is a requirement. Additionally, states must show that assets and resources were identified and considered in the SHIP process.
PHAB measure S requires evidence that issues (and themes) were identified by stakeholders.
PHAB measure S indicates that states must be able to show that data from the community health assessment was used to inform the SHIP. Additionally, other data sets used in the plan must be identified.
PHAB measure S indicates that states must be able to show that data was used to inform the SHIP.

21. Key Components
5. Establish Priorities & Identify Issues Through Priority Setting
A SHIP should describe the priorities that a state chooses to address over a period of time. The information gathered in the previous steps should provide the necessary information to determine what the critical issues are that need to be addressed in the SHIP.
Priorities can center on health outcomes, as well as system or infrastructure improvements
Remember to:
Identify issues through priority setting exercise(s)
Priorities are supported by data
Communicate and vet priorities among partners
Be Strategic
Link to PHAB:
Priority setting must be described in the SHIP (PHAB measure S), including evidence that system partners contributed to the process. Additionally, priorities must align with tribal (where appropriate), local and national priorities.

22. Key Components 6. Communicate/Vet Priorities
To ensure momentum and support from leaders and stakeholders, build momentum for implementation, and utilize broad expertise related to the selected SHIP priorities, it is important to seek input and communicate progress throughout the SHIP planning and implementation process.
Steps:
Identify who needs to be communicated with
Determine how communication will occur and if feedback is necessary
Develop a communication plan with a timeline
Suggestions for Modes of Communication:
Online reports, presentations, public hearings, press releases, social media, newsletters, etc.
Link to PHAB:
Indirectly linked to measure S by engaging broad participation in the SHIP process.

23. Key Components 7. Develop Objectives, Strategies, and Measures
Link to PHAB:
PHAB measure S requires that all SHIPs include objectives, improvement strategies and performance measures with time-framed targets. Strategies should be evidence-based. Policy changes needed to accomplish objectives must also be described in the SHIP. Accountable parties for each objective must be identified.
Including time-framed measurable objectives in a SHIP provides a foundation for a SHIP implementation workplan and helps states track progress on the objectives for each priority over time.
While objectives should push states toward achieving higher levels of health or performance, they should also be achievable and take into account the resources available to reach them.
Tips
Use evidence based interventions
Consider time frames, resources, and policies.
Be SMART!

24. Key Components 8. Develop and Implement Workplan
As states identify strategies and measures for assessing outcomes, this information should be conveyed in an implementation plan (workplan). The implementation plan should indicate which organization(s) will carry out the SHIP strategies.
Steps
Develop an implementation workplan
Identify responsible partners
Include measurable outcomes, policy changes, and guidelines for monitoring
Implement the workplan by carrying out the objectives and strategies
Link to PHAB:
States must submit a SHIP that was developed within five years of applying for accreditation. Measure S also requires that evidence be provided to show the actions taken to implement strategies, partners involved and status of strategies. This can be done through a SHIP workplan.

25. Key Components 9. Monitor, Evaluate, and Update the SHIP
SHIP efforts should be developed as part of a cycle that facilitates continuous quality improvement. A SHIP can be a guide for ongoing system performance measurement and quality improvement for each identified priority. States should also monitor progress and make changes to the process as needed.
Activities:
Determine appropriate check-in opportunities
Develop an evaluation for the SHIP
Determine who will evaluate the plan and make changes
EVALUATE the plan
Adjust plan as needed
Share updates
Use information for next process
Link to PHAB:
PHAB measure S requires evidence that plans are being monitored. States should be able to provide evaluation reports of annual progress for measures and health indicators as well as any revisions made to SHIPs based on evaluation results.

26. More State Resources To Come…
State Health Assessment
State Health Improvement Plan
Strategic Plan

28. Thank You! For more information: Denise Pavletic dpavletic@astho.org
Web address:
Performance/

29. Community Health Improvement Tools and Support from NACCHO
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Community Health Improvement Tools and Support from NACCHO
Lowrie Ward, MPH, CPH
Program Analyst, Accreditation Preparation & Quality Improvement
National Association of County & City Health Officials

30. The Community Health Improvement Process
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The Community Health Improvement Process

31. Community Health Improvement Process
Community Health Assessment
Community Health Improvement Plan

32. Local Public Health System
MCOs
Home Health
Parks
Economic Development
Mass Transit
Employers
Nursing Homes
Mental Health
Drug Treatment
Civic Groups
Laboratory Facilities
Hospitals
EMS
Community Centers
Doctors
LHD
Churches
Philanthropist
Elected Officials
Tribal Health
Schools
Police
Fire
Corrections
Environmental Health
Urban Planners

33. Common Elements in Community Health Improvement Process Models
Prepare and plan
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

34. Common Community Health Improvement Process Models/Frameworks
PRECEDE-PROCEED (1970s)
Planned Approach to Community Health (PATCH) (1983)
Healthy Communities (1980s)
Assessment Protocol for Excellence in Public Health (APEX PH) (1991)
Protocol for Assessing Community Excellence in Environmental Health (PACE EH) (2000)
Mobilizing for Action through Planning and Partnerships (MAPP) (2001)
Association for Community Health Improvement (ACHI) Toolkit
State-specific models/frameworks

35. Mobilizing for Action through Planning and Partnerships (MAPP) is…
A community-wide strategic planning process for improving public health.
A method to help communities prioritize public health issues, identify resources for addressing them, and take action.

36. Mobilizing: Engaging the community
Action: Implementing a health improvement plan
Planning: Applying strategic planning concepts
Partnerships: Involving local public health system and community partners

39. Community Health Assessment
A community health assessment is a systematic examination of the health status indicators for a given population that is used to identify key problems and assets in a community.

40. Community Health Assessment
participating in a CHA process
N=2,091
Source: 2010 Profile of National Health Departments

41. PHAB Standards and Measures: CHA
Standard 1.1: Participate in or conduct a collaborative process resulting in a comprehensive community health assessment Measure: T/L: Participate in or conduct a local partnership for the development of a comprehensive community health assessment Measure T/L: Complete a local community health assessment Measure A: Ensure that the community health assessment is accessible to agencies, organizations and the general public

42. Community Health Improvement Plan
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.

43. Community Health Improvement Plan

44. PHAB Standards and Measures: CHIP
Standard 5.2: Conduct a comprehensive planning process resulting in a Tribal/state/community health improvement plan Measure 5.2.1L: Conduct a process to develop a CHIP Measure 5.2.2L: Produce a CHIP as a result of the community health improvement process Measure 5.2.3A: Implement elements and strategies of the health improvement plan, in partnership with others Measure 5.2.4A: Monitor progress on implementation of strategies in the CHIP in collaboration with broad participation from stakeholders and partners

45. CHA and CHIP Resources
NACCHO Accreditation Preparation and Quality Improvement website

46. CHA and CHIP Resources NACCHO CHA/CHIP Resource Center

47. CHA and CHIP Resources
Mobilizing for Action through Planning and Partnerships:

48. CHA and CHIP Resources
Mobilizing for Action through Planning and Partnerships:

49. Hospitals as Community Health Assessment and Improvement Partners
Michael Bilton )
Executive Director
Association for Community Health Improvement (ACHI) –
American Hospital Association
October 29, 2012
Prepared for the American Public Health Association (session SCI)

50. “Community health assessment is a critical strategic planning and management tool for health care organizations.”
Community Health Assessment Checklist.
VHA, Inc

51. Healthcare Executive, July/August 2010

52. CHNA and Affordable Care Act of 2010
Section 9007 of the Act created IRS Sec. 501(r)
Requires community health needs assessments (CHNA) by tax exempt hospitals every three years
“Input from persons who represent the broad interests of the community… including those with special knowledge of or expertise in public health”
Adopt an “implementation strategy to meet the community health needs identified”

53. CHNA Documentation Guidance per IRS Notice 2011-52*
Community served, and how determined
Assessment process and methods
Data sources & dates, analytical methods, gaps, collaborators, contractors
Prioritized community health needs, including methods/criteria to determine
Existing health care and other resources available to meet needs
MB note: IRS Notice contains “Anticipated Regulatory Provisions” concerning a dozen aspects of CHNA. Well worth reading. *
Michael Bilton
Association for Community Health Improvement

54. Implementation Strategy Documentation, per IRS Notice 2011-52*
Describes how hospital plans to meet each identified community health need (or explains why the hospital does not intend meet a given need)
Identifies programs and resources, and anticipated impact
Describes any planned collaboration
Approved by “authorized governing body” of the hospital organization *
Michael Bilton
Association for Community Health Improvement

55. CHNA Resources Used by Hospitals
Association for Community Health Improvement’s ACHI Community Health Assessment Toolkit (
Catholic Health Association’s Assessing and Addressing Community Health Needs (
Many non-profit organizations, academic institutions, firms and consultants are offering assessment tools and services, to both hospitals and public health

56. Six Step Community Health Assessment Process
ACHI and AHA members have access to this online guide.
Six Step Community Health Assessment Process

57. Examples of Hospital Associations Engaged in CHNA Support
Hospital Council of Northwest Ohio ( has been conducting collaborative CHNAs since 1999.
Dallas–Fort Worth Hospital Council Foundation ( offers a community health data warehouse and assessment tools.
Iowa, Missouri and New Jersey hospital associations have offered CHNA training (webinars, conferences).
The North Carolina hospital association’s “collaborative CHNA” program with public health, focused on reducing care costs and health disparities.
MB: Add comments on others of which we are aware, and the prospect of a loose national network.

58. Examples of Collaborative CHNAs with Hospitals
St. Croix County, Wisconsin Healthier Together (
Lancaster County, Pennsylvania Lancaster Health Improvement Partnership (
Greater Cincinnati, Ohio A.I.M. (Ask. Inform. Make a Difference) for Better Health (healthcareaccessnow.org)
Jacksonville, Florida Health Planning Council of Northeast Florida (
San Francisco, California Building a Healthier San Francisco and the Community Benefit Partnership (
Kearney, Nebraska Buffalo County Community Partners (

59. Hospital Community Health Improvement Planning in a Context of Health System Change

60. Suggests partnerships to “conduct CHNAs and develop community health improvement plans”
Its health priorities are reflected in many hospitals’ existing community programs
Many of its recommendations lend themselves to action based on CHNA data
Relevant to your community health outreach programs, health education, safety net health care, and more.
Many of the Strategy’s recommendations lend themselves to action based on CHNA:
-- “Support implementation of and reduce barriers to community-based preventive services”
-- “Engage and empower people… to plan and implement prevention policies and programs”
-- “Standardize and collect data to better identify and address disparities”
-- “Ensure a strategic focus on communities at greatest risk”
As do many of the steps one would need to take to address its seven health priorities:
-- Tobacco
-- Drug/alcohol
-- Healthy eating
-- Active living
-- Injuries and violence
-- Sexual health
-- Mental health

61. Current Context and Related Factors
National Quality Strategy (March 2011)
One of three Aims: “Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and environmental determinants of health in addition to delivering higher-quality care” (emphasis added)
One of six Priorities: “Working with communities to promote wide use of best practices to enable healthy living”
Source:
Note: “Triple Aim” linkage. Health care “quality” being defined in a way that incorporates concern for and attention to community factors that influence health outcomes.

62. Current Context and Related Factors
Accountable Care Organizations
Patient-Centeredness Criteria: Evaluate health needs of assigned population, identify high-risk individuals and develop care plans for targeted populations, including use of community resources. (emphasis added)
Quality Measurement: Includes measures for readmissions, and admissions for ambulatory care sensitive conditions
Source: AHA Regulatory Advisory on ACO Final Rule, Nov. 8, 2011
This can be accomplished largely in a health care delivery, clinical care setting.
BUT, there are connections to the information CHNAs provide, and to community factors that can support or inhibit health.

63. Note: Hospital and Public Health in this graphic
Note: Hospital and Public Health in this graphic. The population at the center.
-- Accountability for outcomes
-- Financial incentives
-- Integration of community into strategic business planning

64. Working with Hospitals on Community Health Improvement Planning
Become acquainted with hospitals’ requirements
Approach them early, if possible
Find out who is leading their assessment (it will vary)
Ask about their assessment process and goals
Offer to help with data, community input, facilitation or staff expertise, as appropriate
Balance short-term needs (fulfilling IRS or public health accreditation requirements) with longer-term opportunities (sustained health improvement collaboration)

65. Hospitals as Community Health Assessment and Improvement Partners
Thank you