Step 7: Plan Implementation Strategies
Developing comprehensive, multifaceted strategies to address the community health needs prioritized in your assessment is crucial to improving community health. Regardless of whether you have been doing community health improvement work for many years or are new to this process, you can build or supplement services or programs to address the needs identified in your community health assessment (CHA).
Engage strategic partnerships both within the hospital and with external stakeholders
Actively encourage involvement in the implementation strategies planning process to ensure widespread buy-in and to increase the odds of making an impact on community health.
Internal partnerships: Individuals and departments across the hospital may be able to assist with development and implementation of community health improvement strategies by helping to scale the strategies across the hospital or engaging clinicians who focus on the needs identified in your CHA. The support of hospital leadership can be crucial for securing funding and resources to implement desired strategies. Engage with C-suite executives and hospital trustees to share the CHA findings and discuss intervention approaches.
External partnerships: Develop a plan with community stakeholders to garner support for implementation efforts. You may want to form an implementation committee including individuals who participated in previous stages as well as new stakeholders who can offer fresh insight and resources. It is particularly important to involve members of the population who will be affected by the implementation strategies to ensure plans are culturally appropriate. Many hospitals are also engaging their local and state health departments in developing their CHAs. Reinforcing and strengthening these relationships can be important as hospitals move from the assessment phase to developing and implementing strategies to address identified community health priorities.
Align strategies with the hospital and other community stakeholder organizations
Part of engaging hospital leadership can include a discussion of how strategies around the identified priorities can be aligned with the hospital’s population health management strategy to increase the odds of sustainability and commitment to success. Additionally, as you have conversations with other hospital departments and organizations, you may find there is already an alignment of interests and goals. Leverage this alignment so that there are multiple components addressing the health need.
Collaborative strategies increase potential for impact
The Collective Impact Framework posits that no single entity or sector alone can tackle our society’s most complex problems1. The health needs identified in your CHA are likely the result of complex social, economic and environmental factors, making Collective Impact an appropriate model to apply to your implementation strategies. Widespread collaboration among community stakeholders around shared health challenges can catalyze positive change in the community. The Collective Impact Framework has five key elements:
- Participants have a common agenda with a joint approach for solving an agreed-upon problem.
- Data and results are measured consistently across participants.
- Action plans have mutually reinforcing activities.
- Open communication is necessary to build trust and ensure mutual objectives.
- A backbone organization coordinates the collaborative effort.
Consider adopting some or all of these elements as you shape your approach for addressing community health needs.
Determine your community assets
Assets in your community can be leveraged for your collective health improvement efforts. There is no need to duplicate services or programs that already exist. Reflect on your asset map to identify potential assets and partners within your organization and your community at large. Ensure that the partnership would be mutually beneficial for all stakeholders. It can also be helpful to develop a visual representation of where services are physically located in relation to each other, utilizing a tool such as the Public Health Foundation’s Community Stakeholder Services Map.
Identify the drivers of community health improvement
Developing a Population Health Driver Diagram tailored to each priority health area in your CHA can be useful for identifying primary and secondary drivers as well as specific interventions to which different community stakeholders can contribute that will achieve improvement in the priority area. A program logic model helps guide the theory and assumptions underlying the implementation strategies. It is a systemic way to visualize the relationships among the resources, activities, inputs and projected changes that you hope to achieve. The Population Health Driver Diagram framework can be thought of as an actionable logic model. This framework details the aim you are striving for, along with specific goals, primary drivers and secondary drivers. In addition, the driver diagram can help multiple stakeholders identify contributions they can make towards improving the priority health area and begin aligning their efforts with other stakeholders
Select strategies to address priority needs
Develop a strategy for each need prioritized in your CHA. Hospitals can select strategies that impact the clinical needs of their population (e.g., improved access to care, chronic disease management) and/or social determinants of the priority need (e.g., poverty, education, community safety). Both types of strategies are appropriate for a CHA. Below are some considerations as you develop the approach for your implementation strategies.
Type of strategy: There are multiple approaches you can take to address the identified need, but the overarching dichotomy is between a practice (a way of doing things) and an intervention (a program or initiative). Both are valuable and have the potential to make a significant impact on community health; however, instituting a practice may have longer-term sustainability as it becomes part of the daily workflow.
Level of intervention: Think critically about the level at which you are intervening and how your efforts can make the most impact. Will your strategy be clinically based, or will it take place in the community? Will you address the specific needs of individuals or the community as a whole? The following models may help you conceptualize how you want to target your strategies.
Which level of prevention will your strategy address?
- Primary: Targeting an entire population to prevent a problem by thinking upstream about the social determinants of health and fostering circumstances and environments that promote health and well-being for all.
- Secondary: Targeting at-risk populations to prevent escalation of a problem by identifying these populations and trying to address risk factors.
- Tertiary: Treating individuals diagnosed with the problem through intensive, individualized treatment or interventions.
What level of intervention are you targeting?
To make an impact at the population level, be sure that the strategy gets at the root of the identified need. Frieden’s health impact pyramid (2010)2 suggests that interventions to address socioeconomic factors and changing the context of individuals’ decision-making may have a greater impact on population health than more traditional, clinically focused or educational actions.
Health Impact Pyramid
Source: Frieden, T. R. (2010). A framework for public health action: the health impact pyramid. American Journal of Public Health, 100(4), 590-595.
What type of intervention are you proposing?
- Traditional clinical prevention: This type of prevention occurs in a clinical setting as part of a one-on-one patient-clinician encounter. Prevention activities in this bucket include vaccinations and screenings.
- Innovative clinical preventive interventions: Interventions in this bucket extend care from the clinical setting to the community, but these services are not historically paid for by insurance. Prevention approaches in this bucket include using community health workers to support chronic disease management.
- Total population or community-wide interventions: Activities in this bucket target entire populations in a given geographic area and are based outside of clinical offices in communities, schools or workplaces. Interventions are accomplished though policy or environmental changes.
How many facets of the health need does your strategy address?
To move the needle on community health, it is helpful to develop a comprehensive strategy that addresses multiple facets of each health need. This requires thinking of the big picture of health and the hospital and health care system’s role in improving it. A comprehensive approach includes:
- Multiple strategies (e.g., educational, environmental, policy, programmatic)
- Various settings (e.g., schools, communities, workplaces)
- Multiple targets, including individuals, the community at large and at-risk subgroups
- Methods to address the medical and non-medical factors that contribute to the health issue
Identify interventions with evidence of success
A wealth of evidence exists regarding the efficacy of various approaches and interventions to guide your implementation strategies. Strategies need to be tailored to meet the unique characteristics of each community. By identifying the key elements of a program or intervention, you can adapt the rest of the program to meet your needs and goals. Strategic questions to consider include:
- What has been successful in the past?
- What does the research suggest is most effective?
- What is feasible to be implemented in our situation and circumstances?
- What research is appropriate to replicate?
Some organizations have synthesized studies on various community health needs to provide you with the most promising, evidence-based practices. Those are available at:
- The Guide to Community Preventive Services (The Community Guide) : Resource to help identify programs and policies proven to improve health and prevent disease.
- CDC Community Health Improvement Navigator: An interactive database of interventions to address socioeconomic factors, the physical environment, health behaviors and clinical care.
- CDC’s 6|18 Initiative: Accelerating Evidence into Action: Targeting six common health issues with 18 proven interventions.
- CDC’s Health Impact in 5 Years (HI-5): Strategies for achieving health impact in five years.
- County Health Rankings and Roadmaps: What Works for Health provides evidence of effectiveness strategies to address priority community health needs based on existing research.
Some interventions may be promising but do not yet have a body of data to qualify them as “evidence-based.” This does not mean that such interventions may not be beneficial. By implementing similar interventions in your community and measuring their success, you could contribute to building that evidence base.
Assess the impact the strategies would have on health in your community
Health Impact Assessment (HIA) is “a systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. HIA provides recommendations on monitoring and managing those effects.”4 This is a tool to use when evaluating prospective strategies. The major steps in an HIA include:
- Screening (identifying plans, projects or policies for which an HIA would be useful)
- Scoping (identifying which health effects to consider)
- Assessing risks and benefits (identifying which people may be affected and how they may be affected)
- Developing recommendations (suggesting changes to proposals to promote positive health effects or to minimize adverse health effects)
- Reporting (presenting the results to decision makers)
- Monitoring and evaluating (determining the effect of the HIA on the decision)
Set goals and objectives for the implementation strategies
Set goals for each of the strategies you decide to adopt. What do you want to change? Are you seeking a quantitative change in disease morbidity or a qualitative change in social norms or attitudes? Defining your specific goals and objectives will help focus the strategies. Make sure to set “SMART” objectives5:
Strive for quantifiable measures, but do not neglect critical issues whose importance may justify the development of non-standardized measures and/or new data sources. Do not shy away from challenges or setting audacious goals—this is your opportunity to tackle the most pressing health issues facing your community. If possible, work with community stakeholders to develop community-wide metrics to measure the collective impact of the strategies. Hospitals should also have separate metrics to measure the impact of their specific strategies.
Tailor strategies to community culture
Strategies should be unique to your community based on its needs, the demographics of individuals in the community, the capacity of the hospital and the community partners you decide to work with. Be aware of how the culture and environment of your community fits with an intervention. This is an area where engaging external stakeholders can be extremely valuable, as they can provide guidance regarding which strategies would be socially and culturally acceptable.
Consider evaluation from the start
Evaluation should be built into the planning process of your implementation strategies, including how evaluation activities will be funded. You will need to be able to describe the anticipated impact of the implementation strategies and report on the evaluation of the impact. If your CHA does not contain the baseline data needed, collect baseline measures now so that you will be able to tell the extent that your strategy is working and make sure you are measuring the right things in the right way.
Evaluation can look at short- and long-term outcomes as well as process metrics. The short-term measures are most likely to be process measures (how many people used a service or attended a program), while long-term outcomes will monitor changes in health status—a process that takes more time. Intermediate goals and benchmark metrics in the evaluation process will help you know if you are going in the right direction and will be important when discussing progress with executives, leadership and other internal teams, as well as external stakeholders. More information about evaluation can be found in Step 9.
Identify funding sources and opportunities
New interventions or strategies require resources—both human and financial—to succeed. As you plan your strategies, consider what funding you have available and how it may need to be increased through grant funding. Reflect on these questions:
- How can this intervention be sustainably funded? What funding within the hospital or health system might be available? What grant opportunities are available?
- Does the hospital have a foundation that would be interested in supporting this?
- What community foundations may want to invest? Are there community development financial institutions that you could partner with?
- How much of your community benefit spending can go toward the strategy?
- Are there any collaborative grant opportunities?
- What in-kind resources from the hospital or community can be tapped?
Because these strategies will take time to make a population level impact, secure funding sources that will allow the strategy to be sustainable.
Document the implementation strategies
Document your implementation strategies, including:
- Strategies for each need for each hospital
- Actions to address prioritized health needs
- Anticipated impacts of the strategies
- A plan to evaluate the impact of the strategies
1. Hanleybrown, F., Kania, J., and Kramer, M. (2012). Channeling change: Making collective impact work. Retrieved from http://jcisd.org/cms/lib/MI01928326/Centricity/Domain/218/Making%20Collective%20Impact%20Work%20Stanford%202012.pdf
2. Frieden, T. R. (2010). A framework for public health action: the health impact pyramid. American Journal of Public Health, 100(4), 590-595. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2836340/
3. Hester, J., Auerbach, J., Seeff, L., Wheaton, J., Brusuelas, K., and Singleton, C. (2016). CDC’s 6|18 Initiative: Accelerating evidence into action. Retrieved from https://nam.edu/wp-content/uploads/2016/05/CDCs-618-Initiative-Accelerating-Evidence-into-Action.pdf
4. National Research Council (U.S.). Committee on Health Impact Assessment. (2011). Improving health in the United States: The role of health impact assessment. Washington, DC: The National Academies Press, p. 5. Retrieved from http://www.nap.edu/read/13229/chapter/1
5. Centers for Disease Control and Prevention. (2011). Develop SMART Objectives. Retrieved from http://www.cdc.gov/phcommunities/resourcekit/evaluate/smart_objectives.html