Many factors influence a community’s health and well-being, and many entities and individuals in the community play a role in responding to community health needs. The committee sees a need for a framework within which a community can take a comprehensive approach to maintain and improving health, including assessing its health needs, determining its resources and assets for promoting health, developing and implementing a strategy for action, and determining who should be held accountable for specific results. This chapter describes a process for improving community health that provides such a framework. Performance monitoring activities are critical to this process because they ensure that responsible parties are taking the appropriate steps and that those actions are having the intended impact on community health. The chapter also discusses the capabilities required to support performance monitoring and health improvement activities.
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Every community must consider its unique circumstances when developing a health improvement program, including health concerns, resources and capacities, social and political perspectives, and competing needs. The committee cannot prescribe what actions a community should take to address its health concerns or who should be held accountable for what, but it does believe that communities must address these issues and that a systematic approach to health improvement that incorporates performance monitoring tools will assist them in meeting their objectives.
Go to: Proposing a Community Health Improvement Process
The committee recommends a community health improvement process (CHIP) 1 as the foundation for accountable community collaboration in monitoring overall health and addressing specific health issues. This process can help to develop shared community goals for health improvement and to put those goals into action in a planned and integrated manner.
A CHIP would operate in two primary interacting cycles that rely on analysis, action, and measurement. Figure 4-1 depicts the components of a CHIP. In summary, an overarching problem identification and prioritization cycle focus on forming a coalition of community stakeholders, tracking community-level health indicators, and identifying specific health issues as community priorities. In the second type of CHIP cycle—an analysis and implementation cycle—a community addresses its priority health issues. The basic components of this cycle are analyzing a health issue, assessing resources, deciding how and who should respond, and selecting and using stakeholder-level performance measures in conjunction with community-level indicators to determine whether desired outcomes are being achieved. If a community deals with multiple health issues, more than one analysis and implementation cycle may be running simultaneously. Both cycles’ components are discussed in greater detail below.
The actions taken for CHIP should take a broad view of health and its determinants into account. The committee believes that the field model (Evans & Stoddart, 1994), discussed in Chapter 2, provides a good conceptual foundation for tracing the multifactorial influences on community health. In order to determine how to address a health issue, a CHIP must also use an evidence-based approach. Evidence is required not only for an accurate assessment of the factors influencing health but also for selecting an appropriate process for effecting change. Immunizations, for example, are an effective method of preventing some infectious diseases, but many children and the elderly have not received the recommended doses. According to research, efforts to increase immunization rates should focus on the barriers preventing people from using available immunization services and the provider practices that result in missed opportunities to administer vaccines (IOM, 1994b).
As envisioned by the committee, CHIP can be implemented in various community settings. Communities can start working at different points in either cycle and with varying resources. For example, the need to improve data systems should not discourage communities from utilizing the CHIP framework. The process can direct attention to data requirements and the methods for meeting them. Participation from the public and private sectors is required, and leadership to kickstart the process could come from either. However, according to The Future of Public Health (IOM, 1988), public health agencies are responsible for ensuring that something resembling a health improvement process is in place. As a result, the committee advises local and state public health agencies to ensure that communities have an effective CHIP. These organizations should, at the very least, be CHIP participants, and in some communities, they should provide leadership or an organizational home. Strong state-level leadership in places like Illinois, Massachusetts, and Washington has aided community progress.
The ongoing health improvement process must be viewed as iterative and evolving rather than linear and short-term. One-time events hastily assembled coalitions, and isolated solutions will not suffice. A CHIP should not obstruct the effective and efficient operation of accountable community entities expected to respond to specific health issues. It should accommodate the dynamic nature of communities and the interdependence of community activities. It should also structure complementary efforts by facilitating the flow of information among accountable entities and other community groups. Community-level monitoring data and more detailed information about specific health issues must be continuously fed into the system to guide subsequent analysis and planning. This information loop also serves as the conduit through which a CHIP connects performance to accountable entities among community stakeholders.
The committee does not want to overlook the larger state and national contexts for community efforts by emphasizing the community perspective. For example, health policymakers at the federal and state levels could consider community-level performance indicators when planning and evaluating publicly funded health services programs such as managed care for Medicaid populations. Community performance measures could also help states manage federal block grants (for example, Maternal and Child Health Title V grants or Community Mental Health Services Block Grants) and the proposed federal Performance Partnership Grants (PPGs) (USDHHS, no date).
Some state health departments play prominent roles in community-level health improvement initiatives. For example, in Massachusetts, which has only one county health department, the state has taken the lead by establishing 27 Community Health Network Areas (CHNAs; see Chapter 3) to serve as the foundation for local health improvement activities (Massachusetts Department of Public Health, 1995). Similarly, state-level accreditation for local health departments can include measurable targets for community-level performance and accountability for meeting those targets during accreditation. For example, Illinois has implemented performance-based state certification for local health departments (Roadmap Implementation Task Force, 1990). Similarly, state agencies that license private-sector health plans or design Medicaid-managed care programs can specify performance measures that will be used to evaluate the services provided.
The History of Community Health Improvement
The committee’s proposal for a community-based health improvement process builds on many other efforts in health care, public health, and public policy, some of which are listed below.
The Health Care Industry
Proposals for collaborative community-wide efforts to address health issues date back to the early 1930s in the United States (Sigmond, 1995). Comprehensive health planning (CHP) emerged as a voluntary effort to rationalize the configuration of private healthcare facilities, services, and programs, often emphasizing hospitals (Gottlieb, 1974). The federal government supported formal programs for the state- and community-level CHP from the 1960s to the 1980s as a strategy to improve the availability, accessibility, acceptability, cost, coordination, and quality of healthcare services and facilities (Benjamin & Downs, 1982; Lefkowitz, 1983). However, CHP was hampered locally by limited control over resource allocation and its responsibilities to regulate the introduction of new healthcare facilities and programs (Sofaer, 1988). Furthermore, strict federal requirements regarding their organization and operation weakened local “ownership” of these activities.
Nonetheless, local planning agencies’ governing bodies brought together a diverse range of stakeholders, including healthcare professionals and other “experts,” consumers, and, in some cases, private-sector healthcare purchasers (Sofaer, 1988). To identify high-priority health problems, CHP efforts combined data on a community’s healthcare services, epidemiology, and socioeconomic characteristics. Indeed, some planning theorists explicitly based their approach on a model of the health determinants (Blum, 1981), which could be considered an early version of the field model.
Concerns about the quality of healthcare services prompted measurement and monitoring efforts. Evidence of widespread variations in medical practice patterns (e.g., Wennberg and Gittelsohn, 1973; Connell et al., 1981; Wennberg, 1984; Chassin et al., 1986), insufficient information about the outcomes of common treatments (e.g., Wennberg et al., 1980; Eddy & Billings, 1988), and evidence of marked variations in treatment outcomes across providers (e.g., Bunker et al., 1969; Luft (e.g., IOM, 1990). Continuous quality improvement (CQI) techniques have been adapted for use in healthcare settings from their origins in the industry (e.g., Berwick et al., 1990; IOM, 1990; Batalden & Stoltz, 1993), and clinical practice guidelines provide criteria for assessing the quality of care (e.g., IOM, 1992; AHCPR, 1995). Community health programs are implementing the basic Plan-Do-Check-Act cycle used in CQI (Nolan & Knapp, 1996; Zablocki, 1996). Health departments are also investigating their role in promoting healthcare quality (Joint Council Committee on Quality in Public Health, 1996).
Community-oriented primary care (COPC), which gained popularity in the 1970s and 1980s, begins with a healthcare provider’s goal of combining individual care with an emphasis on the health of the community in which they live (Kark & Abramson, 1982; IOM, 1984). Although performance monitoring is not an explicit focus of COPC, this healthcare approach emphasizes the importance of community-based data in understanding the origins of health problems.
Another factor broadening the health care focus from individual patient encounters to population health needs is the emergence of managed care and various integrated health systems. The primary population of interest is enrolled members. However, many of these organizations participate in activities that benefit the larger community, such as violence prevention, immunization, AIDS prevention, and school-based health clinics. Some have formalized their commitment to community-wide efforts through mechanisms such as the Group Health Cooperative of Puget Sound’s Community Service Principles (1996). Nationally, organizations such as the Catholic Health Association (CHA) and the Voluntary Hospitals of America (VHA) have adopted community benefit standards that call for accountable participation in meeting community needs. The characteristics of a “socially responsible managed care system,” as proposed by Showstack and colleagues (1996), also encourage participation in community-wide health improvement initiatives.
In general, financial incentives encourage health care organizations to consider community-wide health needs. Nonprofit hospitals and heal, health plans established by provider organizations and insurers are addressing the “community benefit” requirements required to maintain their tax status. Furthermore, managed care plans serve an increasing proportion of Medicare and Medicaid beneficiaries whose health may be harmed by problems that are difficult to resolve in the healthcare setting (Armstead et al., 1995). (e.g., violence, poverty, social isolation). Because limited periods of Medicaid eligibility necessitate frequent enrollment and disenrollment, health plans may increasingly see value in services that improve the health of nonmembers who may become part of their enrolled population.
Why should a community health improvement plan be implemented?
A local government may want to implement a CHIP for two reasons. The first is that the mission of health departments is to identify and address a community’s most pressing health needs. Addressing those needs in partnership with citizens has proven effective for health departments. CHIPs have reduced or prevented infant mortality, chronic disease, substance abuse, and other health issues. By considering different perspectives and experiences, departments can broaden their reach into the community and avoid insular approaches. The common goal is always to improve health quality.
The other reason is that implementing a CHIP may be required by the state government or as part of the accreditation process (such as PHAB). Accreditation with CHIPs in place can improve a city’s chances of receiving grants, strengthen partnerships, and improve public relations and marketing efforts.
Six Steps to Developing a Community Health Improvement Plan
1. Conduct a health assessment of the community.
Before developing a strategy, a city must have a firm grasp of the community’s health. What has the greatest impact on citizens’ health? What do the people want? What needs to be altered? What medical services does the city lack? Answering these questions will necessitate extensive research and fact-finding. Surveys, interviews, focus groups, and external organizations such as the CDC can all be used to collect data.
2. Recruit members of the community.
Successful community coalitions have a diverse membership, a clear goal in mind, and consistent resources. Consider who might be interested in the community’s health when looking for people who would play important roles in a CHIP. This could include business leaders, nonprofits, schools, health-focused neighborhood groups, and anyone who has been an advocate in this field.
3. Create a shared vision.
The steps may look familiar at this point. Because CHIPs are essentially subsets of strategic plans, they are developed using the same general procedures. Step three sees the creation of a vision and mission statement by the community and health department coalition. These statements should define the reasons for implementing CHIP and the ultimate goal for the future. You must always ensure alignment with the health department’s overarching strategic plan in this and all subsequent steps.
4. Determine the importance of health issues.
There is no limit to the number of priorities you can establish. Still, a CHIP will be ineffective unless you are specific and focused on the most pressing health issues (quality over quantity!). Begin with the strategic plan’s goals and narrow your priorities from there. Consider the size of the affected population, the severity, trends over time, available resources, potential intervention strategies, and other factors.
5. Establish objectives, strategies, and owners.
After you’ve identified your priorities, you’ll develop associated goals, which you can think of as your community health improvement solutions. Goals are concrete ways to address health issues. Then you can create strategies, which typically take the form of initiatives and measures, that outline how you intend to carry out your CHIP. Goals and strategies should reflect the vision and mission statements while being realistic about resources and implementation barriers.
Assign owners to the strategies responsible for demonstrating progress to ensure that a CHIP does not stall. Consider the skill sets of health department employees and community members when filling roles. Remember, this is a coalition, and ownership of the plan should be shared to increase its chances of success.
6. Monitor and report on progress.
Chips must be evaluated regularly. This includes gathering and analyzing quantitative and qualitative data to arrive at conclusions. Accreditation boards, such as PHAB, may specify how data should be reported in some cases. In other cases, a city should decide how to report progress.
Improving community health is an ongoing process. Even though CHIPs last three to five years, the plan should be reviewed annually to evaluate the data and determine whether any changes should be made. Step six is the most important because it reveals not only how the CHIP is progressing but also any gaps in data or strategies.
After reviewing Module 3: Lecture Materials & Resources, briefly describe one community health problem from your community’s health improvement plan. What structure, process, and outcome standards would you use to evaluate a program addressing this problem?
Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
Read and watch the lecture resources & materials below early in the week to help you respond to the discussion questions and to complete your assignment(s).
(Note: The citations below are provided for your research convenience. You should always cross-reference the current APA guide for correct styling of citations and references in your academic work.)
Rector, C. & Stanley, M.J. (2022).
Chapter 10 – Communication and Collaboration in the 21st Century: Informatics and Health Technology in Community Health Nursing
Chapter 11 – Health Promotion: Achieving Change Through. Education
Chapter 12 – Planning and Developing Community Programs and Services
Chapter 13 – Policy Making and Community Health Advocacy
Centers for Disease Control and Prevention. (2018, November 8). Solve the outbreak. https://www.cdc.gov/mobile/applications/sto/sto-web.htmlLinks to an external site.
Windshield Survey (00:11:17)
Schreiner School of Nursing (2017, October 4) Windshield Survey [Video] YouTube https://www.youtube.com/watch?v=Rbcdi0yM8Hk