Plan Strategies to Accelerate Health Equity
Developing comprehensive, multifaceted strategies to address the community health needs prioritized in your assessment is crucial to driving health equity. Regardless of whether you have been doing community health improvement work for many years or are new to this process, your community health assessment gives you the foundation to base your community health improvement strategies on collaboratively identified, evidence-based priorities and needs.
Engage strategic partners inside and outside the hospital. Refer to the “Types of CHA Partners” box to learn more about these partners. Actively encourage involvement in your implementation planning to ensure widespread buy-in, increase opportunities for equitable outreach and service provision and, overall, optimize the impact on community health.
You can consider specifically applying human-centered design principles to your planning and implementation. Both this AHA webinar and the article Design for Health: Human-Centered Design Looks to the Future by Global Health: Science and Practice offer an opportunity to learn more about taking this approach. Leveraging resources such as these can help establish an asset-based foundation to your strategy.
Align Hospital and Community Strategies
Engage hospital or health system leadership in a discussion about how the implementation plan aligns with your organization's population health management strategy and how the two efforts may be mutually reinforcing. Do the same with community stakeholders to identify how their current efforts may align as well. These and other conversations will build and strengthen a coalition to greatly impact improvements to community health.
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 to improve 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 and health systems can select strategies that impact the health needs of their population — such as improved access to care or chronic disease management — and/or social drivers of the priority needs — such as poverty, education or community safety. Both types of strategies are appropriate for a CHA. In determining strategies overall, consider the advantages of creating a balanced portfolio, intentionally selecting interventions that work together to address short- and long-term outcomes that are mutually reinforcing in delivering impact. Below are some considerations to be aware of as you develop the approach for your implementation strategies.
Type of Strategy
You can pursue multiple approaches to address the identified need. From the start, define whether your strategy is a way of approaching many types of projects or a specific intervention. Both are valuable and have the potential to make a significant impact on community health; however, instituting a practice or protocol may have longer-term sustainability as it becomes part of the daily workflow.
Level of Interventions
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 — or both? Will you address the specific needs of individuals or the community as a whole? Will your strategy contribute to a measurable reduction in health disparities? The following questions can help you define your strategy.
What level of interventions are you targeting?
Interventions to address population and community health can take place at a variety of levels, both in terms of aim and strategy. In addition to considering the level of intervention for your coproduced community health improvement plan, you may want to look at the domain(s) your work aims to impact. The Pathways to Population Health approach identifies four portfolios of population and community health and explicitly places equity at the core (Figure 4). Much of your CHA implementation will be centered on the right side, focused on community health and well-being and communities of solution. However, as implied by the infinity loop in the figure, these portfolios of work are designed to be self-reinforcing so that a community’s well-being strategies inform a hospital or health system’s population health management activities and vice-versa.
What type of interventions 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 communitywide 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 through policy or environmental changes.
How many facets of the prioritized need does your strategy address?
To move the needle on community health, develop a comprehensive strategy that addresses multiple facets of each CHA priority. This requires thinking “big picture” about health and the hospital’s or health system’s role in improving it.
A comprehensive approach includes:
- Multiple strategies, such as educational, environmental, policy and programmatic
- Various settings, such as schools, communities and workplaces
- Multiple groups, including individuals, the community at large and at-risk subgroups
- Methods to address the medical and nonmedical factors that contribute to the health issue
Identify Interventions with Evidence of Success
A wealth of evidence exists about the effectiveness of various approaches and interventions to guide your implementation strategies. It is possible to tailor a strategy to meet unique community characteristics while still addressing population health goals.
To that end, evaluate your intervention options using the following questions:
- 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?
For more information about program implementation options, review studies on various community health needs that report on the most promising, evidence-based practices. Do not assume an intervention might not be beneficial just because you have found no history of supporting data. Rather, if it seems a good fit, consider implementing it, measuring its success and contributing to building the evidence base.
Research the following implementation programs:
- 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. Targets 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 effective strategies to address priority community health needs based on existing research.
- The Social Interventions Research & Evaluation Network (siren). Compiles news and publications on successful programming for social and medical care integration.
Assess the Impact of the Strategies on Your Community’s Health
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.”2 This is a tool to use when evaluating prospective strategies.
The major steps in an HIA include:
- 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?
- Strive for quantifiable measures, but do not neglect critical issues whose importance may justify the development of nonstandardized 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 communitywide metrics to measure the collective impact of the strategies. Hospitals also have separate metrics to measure the impact of their specific strategies. Defining your specific goals and objectives will help focus the strategies. Make sure to set “SMART+PERCS” objectives.
Tailor Strategies to Community Culture
Strategies will 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 team up with. Be aware of how the culture and environment of your community fit with an intervention. The ongoing stakeholder engagement that you started and have maintained during your CHA process will be extremely valuable at this stage because you will be a step ahead in determining and obtaining buy-in on strategies that will be socially and culturally acceptable, most impactful and sustaining.
Build in Evaluation from the Start
Evaluation is built into the planning process of your implementation strategies, including how evaluation activities will be funded. Be able to describe the anticipated impact of these strategies and report on the impact. If your CHA does not contain the baseline data needed, collect baseline measures now so that you will be able to demonstrate your strategy is working.
Evaluation can look at short- and long-term outcomes as well as process metrics, or outputs. Short-term measures are most likely to be process measures &madash; for example, how many people used a service or attended a program — whereas long-term outcomes will monitor changes in health status and corollary reductions in health disparities — a result that takes more time to occur. Intermediate goals and benchmark metrics in the evaluation process will help you know whether you are going in the right direction and will be important when discussing progress with executives, leadership, other internal teams and external stakeholders. More information about evaluation can be found in Step 9: Evaluate Progress
Identify Funding Sources and Opportunities
New interventions or strategies require both human and financial resources to succeed. As you plan your strategies, consider the funding you have available and whether it needs to increase through grants. As noted in the toolkit’s introduction, hospitals are often assumed to have extra resources on hand, so it is important now and throughout this process to appropriately manage expectations. Because these strategies will take time to make a population-level impact, secure funding sources that support interim measures and sustainability.
Assess your needs using these questions:
- How can this intervention be sustainably funded by the hospital or health system or through grants?
- Does the hospital or health system have a foundation that would be interested in supporting this?
- What community foundations may want to invest?
- Are there community development financial organizations with which you could partner?
- 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 health system or community can be tapped?
- Is there potential for eventual payer funding or reimbursement, such as Medicare, Medicaid or commercial insurance?
Document the Implementation Strategies
Document your implementation strategies, including:
- Strategies for each need for each hospital
- Actions to address prioritized health needs
- Anticipated effects of the strategies
- A plan to evaluate the impact of the strategies
SMART + PERCS
Good goals have specific characteristics in common. We highlight from the SMART1 framework to help you sharpen your partnership’s goals. We have defined our Hospital Community Collaborative framework as SMART + PERCS. The goal of this exercise is to make sure you have developed an achievable goal that all your CHA collaborators can agree on. As a best practice, make sure your goal statement is simple and concise and that it identifies who will be affected and what will change as a result.
What specific need and population is our partnership designed to address?
How will we measure the success of our goals and their impact on our population and our respective organizations?
What makes this effort viable and sufficiently resourced and supported?
Why is this a pressing problem that needs solving?
Is the goal we have set forth for our partnership achievable within a reasonable time frame?
How does this effort put the residents of our community at the center?
How are we considering multiple approaches valued by a diverse population?
How does our effort include structurally marginalized populations and historically marginalized communities?
Have we recruited participants from diverse backgrounds and with diverse experiences to participate in and inform our effort?
Do we know what strategy we are supporting in our organization? What is it? How are we supporting it? Who in our management team supports our effort?