Description of the LHD
The Springfield-Greene County Health Department (SGCHD) is established as a city-county partnership that serves a combined population of approximately 278,000 people in southwest Missouri. With a budget of nearly $10 million and a staff of 110, SGCHD operates to protect the health of the community and help citizens live longer, healthier, happier lives through education, collaboration and prevention. In Greene County, 91.3 percent of the population is white, followed by those that classify as Multiple Races and Black at 2.9 and 2.8 percent, respectively. In addition, 96.7 percent of the population is non-Hispanic, while 3.1 percent classify as Hispanic or Latino. Additionally, 18.7 percent of the population lives below the poverty level.
Need to Collaborate with Healthcare to Improve Community Health
Across the health services continuum, many health organizations are required to assess the health of their community. The advent of the Affordable Care Act (ACA) brought new requirements for charitable hospitals to conduct Community Health Needs Assessments (CHNA). Additionally, public health departments conduct similar assessments to maintain accreditation through the Public Health Accreditation Board. In the Springfield Community, the first iterations of CHNAs conducted by healthcare organizations after the passage of the ACA were completed independent of one other and public health agencies were not directly included in the process. This created duplication of efforts and a siloed approach to addressing community health needs. In order to improve efficiency, public health and healthcare leaders convened to discuss an approach to align assessment activities and develop collaborative strategies to improve community health. This laid the foundation for the development of Ozarks Health Commission, a first-time collaboration spanning four states Missouri, Oklahoma, Arkansas and Kansas 51 counties, and four hospital systems.
Goals and Objectives of Ozarks Health Commission
The purpose of Ozarks Health Commission (OHC) is to serve as a convening organization for community stakeholders to build consensus about community health needs and leverage common strengths and strategies to move in the same direction on significant health concerns. OHC did this by using a systematic approach to:
1) Complete a joint CHNA to satisfy requirements of the Internal Revenue Service (IRS) for non-profit hospitals and the Public Health Accreditation Board (PHAB) for local health departments.
2) Complete Community Health Improvement Plans (CHIP) that include evidence-based system and policy level interventions to address priority health needs identified in the CHNA.
The RHA and each community's respective CHIPs will allow decision-makers to have a more holistic and up-to-date picture with which to strategically address community health concerns in their own jurisdictions.
How the Regional Health Assessment and Community Health Improvement Plan was Completed and Implemented
OHC convened health departments, four hospital systems, a multi-county mental health center, a local university, and other community agencies to complete a 51-county health needs assessment and implementation plan. Because little was known about similar assessments, the unique collaboration used a common sense methodology that fit community resources and needs. Primary data was collected from new reports generated by health systems, community focus groups, and a regional survey. Secondary data included the collection of over 150 indicators from a variety of sources such as the Centers for Disease Control and Prevention, Department of Health and Human Services, Community Commons, and County Health Rankings. Once the data was analyzed and ranked, the group agreed on community specific health priorities, which led to the development of synergistic and complementary implementation plans.
During the process, public health and healthcare administrators learned about and experienced a promising collaborative model to create lasting community health improvement and meet reporting requirements. Similar partnerships are needed to develop this type of collaboration into a best practice approach for Community Health Needs Assessments.
Public Health Impact of Regional Health Assessment Approach
The National Association of County & City Health Officials (NACCHO) recent policy statement describes the role of the local health department to serve as the Community Chief Health Strategist (CCHS). The SGCHD's leading role in developing OHC for the purposes of completing and implementing the joint RHA and CHIP provides a foundation for SGCHD to serve as the CCHS moving forward. Additionally, aligning health assessments and CHIPs across the region provides a framework for the most pressing community needs to be addressed systematically and concurrently. Thus, SGCHD is providing leadership in the region to coordinate efforts to efficiently and effectively improve community health.
Website for Ozarks Health Commission and SGCHD
Statement of the Problem
In the Springfield Community, efforts to improve community health through primary prevention efforts have been made on a varying scale by multiple organizations, including non-profit agencies, mental health institutions, private funders, public health and healthcare organizations. Depending on funding streams and/or organizational strengths, these organizations have worked in silos to meet reporting requirements. While these efforts have met the health needs of specific populations, systematic large-scale approaches to address priority health needs of the community at-large have not been made, thus impeding progress to eliminate health disparities.
However, within the evolving era of health reform, there are improved pathways for public health and healthcare to align community health improvement efforts, as well as position public health to lead community-wide efforts to systematically prevent disease, disability, and death and improve health equity. A logical first step towards building a public health and healthcare partnership to address the most pressing community health needs is through a collaborative Community Health Needs Assessment (CHNA), which satisfies Internal Revenue Service (IRS) reporting requirements for hospitals and Public Health Accreditation Board (PHAB) requirements for public health accreditation. The joint CHNA provides a foundation for community stakeholders to agree upon and develop complementary Community Health Improvement Plans (CHIPs) that reduce silos and improve efficiency in the collective effort to eliminate health disparities.
In early 2015, public health and healthcare leaders met to identify the region for the joint CHNA. In order for participating healthcare organizations to capture their entire population, the region assessed includes the service areas of CoxHealth, Mercy, Freeman Health System, and Citizens Memorial Healthcare. The region is composed of 51 counties and extends into Missouri, Oklahoma, Arkansas and Kansas. The 51-county region is divided into nine communities to ensure the reports are localized and can be used to develop targeted Community Health Improvement Plans. According to the 2015 Community Commons report ran by Ozarks Health Commission, the region includes 2,289,281 people, of which 50.5% are female, 88.0% are white, 3.6% classify as multiple races, and 2.4% are Native American/Alaska Native. Additionally, 7.1% are Hispanic or Latino and 18.6% live below the Federal Poverty Level.
The entire population was assessed using both primary and secondary data. Secondary data sources included Community Commons and County Health Rankings. Secondary data provided a holistic view of regional health needs, whereas primary data provided more in-depth information and a real-time perspective of community specific needs. Primary data sources included a region-wide survey to the public and partner agencies, focus groups in each community, and emergency department data from hospital partners.
Previous Efforts to Address Community Health Needs
In the first iterations of CHNAs across the region, hospitals conducted these alone, in a siloed approach, and developed CHIPs specific to their findings. Additionally, the CHIPs have been program-based instead of implementing system and policy-level interventions. This approach is inefficient in addressing community-wide health needs and does little to address root causes of health inequities.
Efficiency and Effectiveness of a Collaborative CHNA
The collaborative CHNA streamlines data collection across facilities, which reduces redundancy and provides a means for participating entities to agree upon priority health needs. It also creates a platform for stakeholders to identify system and policy-level interventions to address root causes of health issues that are often treated downstream through programming. Upstream interventions will produce more sustainable and positive health outcomes over time, thereby reducing healthcare associated costs.
Creative Use of CHNA and CHIP Requirements
The practice of completing Community Health Assessments in public health is not new. Additionally, the final regulations issued by the IRS under the Additional Requirements for Charitable Hospitals (79 C.F.R. Â§ 250, 2014) provides guidance for hospitals to complete joint CHNAs with other healthcare facilities. Because public health agencies have a similar requirement to complete community health assessments and community health improvement plans for accreditation by the Public Health Accreditation Board (PHAB), these regulations opened a door for public health to partner with healthcare to align assessment efforts. To the knowledge of Ozarks Health Commission, the joint CHNA completed in this model is the largest joint CHNA completed to satisfy both IRS and PHAB requirements.
Additionally, the practice of completing a joint CHNA with public health and healthcare partners in an effort to align community health improvement initiatives provides a foundation for public health to position itself to serve as the Community Chief Health Strategist. Through the health department's leadership and technical assistance, healthcare partners are working with the department to ensure resources are directed towards the most pressing community health issues in a way that will make lasting change.
Evidence-Based Strategies Utilized for the Collaborative Assessment and Implementation Plan
The work of Ozarks Health Commission (OHC) aligns with the best-practice outlined in Best Practices for Community Health Needs Assessment and Implementation Plan Development: A Review of Scientific Methods, Current Practices, and Future Potentialâ€ published by the Public Health Institute. OHC brought a diverse group of stakeholders to the table and garnered support for a shared sense of ownership for community health. Additionally, OHC utilized best practice throughout the assessment activities and built the CHIP based on evidence-based initiatives. For example, the ranking system used to prioritize health needs was based on the Hanlon Method, which is recognized by NACCHO as a tool for gathering stakeholder input for prioritizing health needs. Also, the focus groups were conducted by a researcher from the Missouri State University's Sociology Department. The researcher had experience with healthcare and focus group development, implementation and analysis. Finally, the CHIP initiatives developed in the Springfield Community target system and policy level changes that will have lasting and broad impact. The initiatives use best practice approaches and include, but are not limited to, the development of a comprehensive tobacco control strategy, creation of a comprehensive case management system, advocacy for Medicaid expansion, and adoption of an active transportation plan.
Nutrition, Physical Activity, and Obesity|Tobacco
Goals and objectives of the collaborative Regional Health Assessment through Ozarks Health Commission
The overarching goal of Ozarks Health Commission (OHC) is to serve as a convening organization for community stakeholders to build consensus about community health needs and leverage common strengths and strategies to move in the same direction on significant health concerns. OHC does this by using a systematic approach to:
Complete a joint CHNA to satisfy requirements of the Internal Revenue Service (IRS) for non-profit hospitals and the Public Health Accreditation Board (PHAB) for local health departments.
Complete Community Health Improvement Plans (CHIP) that include evidence-based system and policy level interventions to address priority health needs identified in the CHNA.
How OHC achieved the goals and objectives
The Springfield-Greene County Health Department (SGCHD) brought key stakeholders together, including four healthcare systems, a regional behavioral health system, and four other health departments, to conduct a Regional Health Assessment (RHA). This group formed Ozarks Health Commission, which unified regional partners in a coalition dedicated to identifying priority health needs across the region using sound methodology.
The partners of the Ozark Health Commission developed a multi-faceted approach to collect data and complete the assessment. Throughout the process, research was conducted to find evidence-based methods to help guide the committee. When evidence-based resources were not available, the committee used logic and rationale to create methods that would not inhibit progress of the assessment. The committee began the discussion of data collection and analysis with the end in mind by determining what data was needed to best understand and, subsequently, improve health in the community. The group decided to use a comprehensive approach to provide greater breadth and depth of information. The core of the data to be used in the assessment was secondary community health indicators, as the data is already available across various health categories. Secondly, the committee determined that having primary hospital data was a key component of the assessment. Not only does the data provide a unique and timely examination of a community's health, but it also provides the collaborative process to pilot this type of collection and use of hospital data. Third, to garner the perspective of partners and individuals within each of the Communities, it was decided that both a survey and focus groups would be conducted to provide firsthand information and feedback on health issues.
The following section, Role of the Stakeholders in the Planning and Implementation of the Regional Health Assessment, describes how the stakeholders worked together to achieve the goals and objectives of OHC through the following:
Collection of secondary data
Collection of primary hospital data
Conducting a region-wide survey
Conducting community-level focus groups
Identifying and and prioritizing health issues
Developing a health indicator scoring matrix
The Regional Health Assessment began in February 2015 and concluded in September 2016.
Role of SGCHD to foster community collaboration
The Springfield-Greene County Health Department initiated conversations with CoxHealth and Mercy Hospital, two major health systems in Springfield, Missouri, to discuss the possibility of completing joint Community Health Needs Assessments. After the health systems agreed to move forward, the 51-county OHC region was identified by overlapping the service areas of CoxHealth and Mercy. The SGCHD sent invitations to all local health departments in the region to participate in the collaborative assessment. Also, the SGCHD invited smaller hospitals in the region to participate. SGCHDs initial efforts to invite key stakeholders led to the formation of OHC, which included five health departments, four health systems, and a regional behavioral health provider.
The SGCHD fostered collaboration by serving as a convener between healthcare systems and local health departments. The SGCHD provided leadership to OHC by providing project management, technical assistance, and development of the final reports. Additionally, if communities struggled in coming to consensus, the SGHCD intervened, when invited, to help move communities forward. Community partners have expressed that without the leadership of the SGCHD, the project would not have progressed, much less been initiated.
Role of Stakeholders in the Planning and Implementation of the Regional Health Assessment
In order to accomplish the large assessment, subcommittees were formed and included all stakeholders involved in the assessment process. Throughout the primary and secondary data collection, the steering committee provided direction, feedback and guidance; whereas, the detailed research and efforts took place within subcommittees or with third-party contractors. The majority of the research and development of the methods was completed by four subcommittees. The subcommittees completed work on community health secondary data indicators, survey development and linkages to focus groups, primary hospital data indicators, and health issues and prioritization. Much of the work completed by the subcommittees happened concurrently, with the majority of the work occurring between May 2015 and February 2016.
Secondary Data Process
A committee on community health secondary data indicators was formed to identify indicators, collect and compile relevant data, and conduct an initial assessment of the findings. The committee was comprised of public health partners from the steering committee. The committee began their work to develop the methods and data collection in March 2015. The committee first completed research on health needs assessments conducted by other healthcare and public health throughout the nation. This research helped develop the set of indicators the committee would examine. The examination focused on recommendations of the CDC and several assessments identified as high quality by the National Association of City and County Health Officials. The following category of indicators were identified: demographics, social determinants of health, nutrition, quality of life, environmental quality, access to health services, clinical preventive services, physical activity and obesity, tobacco, maternal, infant and child health, substance abuse, behavioral health, oral health, reproductive health and sexual health, communicable and chronic disease, hospitalizations, death and mortality, and injury and violence. As indicators were selected, they were also defined and sources were identified. The committee determined the indicators would be collected at the county-level and then combined into the Community-level for comparison. County-level data is available for individual Communities, health systems, public health agencies, and partners to examine the data on a more granular level.
To collect the secondary data, a graduate-level student was hired as an intern. The student collected and compiled more than 150 indicators from May 2015 through August 2015, which can be located in Appendix E. The primary collection point of data was Community Commons, through the Community Health Needs Assessment portion of the website. Data was also collected from County Health Rankings and the U.S. Census Bureau. These sources provide a comprehensive dataset that are available for all counties within the OHC Region.
As the secondary data was collected and compiled, it was also aggregated into selected Communities and placed into comparison tables to allow for a side-by-side examination of the data between Communities, the OHC Region, states and the nation. The committee then took the data and began to put some context with the indicators, which occurred in September and October 2015. The committee first reviewed each indicator to determine the relevance of the data based on the definition and significance of the dataset. Subsequently, the committee made observations about the indicators and how the OHC Region and Communities performed in comparison to the nation, states and the OHC Region. After the data was reviewed, the committee provided their findings to the steering committee.
Primary Hospital Data
Another key component of the assessment was the collection of the partnering hospitals' Emergency Department (ED) data. The steering committee determined that this data was essential for the assessment process, because it provided current information about the specific Communities and the assessed populations. It also helps in identifying community specific needs, therefore assisting in the creation of the strategic implementation plans. The combination of individual hospital data to this extent had not been attempted in the OHC Region. As such, the committee felt that it was essential to identify key indicators that would provide valuable information, but not overwhelm either the individual organizations or the collaborative process. To develop a process to determine the indicators and collection methods, a Primary Hospital Data Committee was created. The committee was comprised of hospital representatives from three of the four partnering systems and public health representatives. The committee began meeting in September of 2015 and completed its work by February 2016.
The Hospital Data Committee chose to focus on patients that enter the health systems through the ED, because the ED captures patients with all insurance types, including those without insurance. This approach provides the opportunity to assess potential health disparities across patient groups. Also, the Hospital Data Committee wanted to assess the impact of mental health illness in the OHC Region. Therefore, the data collected emphasized patients with a primary and/or secondary mental health diagnosis. The list below includes all data sets collected by each hospital partner:
ED Only vs ED Admitted
ED by Top 20 Patient Home Zip Codes
ED by Emergency Severity Index
ED by Principal Diagnosis Group
ED by Age Groups
ED by Principal Diagnosis Group, Age 0 - 17
ED by Principal Diagnosis Group, Age 18 - 64
ED by Principal Diagnosis Group, Age 65+
ED by Payer Group
ED by Payer Group, by Principal Diagnosis Group
ED by Patient Race
ED by Patient Race (Top 5 Race Groups by Volume), by Principal Diagnosis
ED Visits with a Behavioral Health (BH) Principal Diagnosis by Top 20 Coded Diagnosis
ED Visits with a BH Secondary Diagnosis (non BH Principal) by Principal Diagnosis Group
Community Survey Process
A committee was formed to create and implement the survey used in the assessment. The committee also used the initial findings of the survey to help develop the questions for the focus groups. The committee began meeting in June 2015 and was comprised of hospital, academic and public health partners.
The committee met regularly over a two-month period to develop the survey. As the goals were determined, the committee decided that, although the survey could provide useful information, a full-scale scientific process including question validation would not be used. With that in mind, the survey committee performed a scan of other community surveys that had been conducted throughout the nation to guide and inform the process. As the committee reviewed other surveys, themes and approaches to guide the questioning emerged. In particular, the focus became to garner feedback from residents in the OHC Region on prioritizing issues that are barriers to improved health. In addition, the committee determined that there was significant value in obtaining perspectives on health from both individuals and organizations that provide services to the community. As a result, an additional survey that had minor adjustments made for the organizational perspective was also administered. After the survey was developed, the Intuitional Review Board through the Office of Research Administration at Missouri State University approved it and translated it into Spanish.
As is common with many surveys, basic demographic information was collected. On the individual survey it included: age, gender, race/ethnicity, educational attainment, the presence of children in the home and geography (zip code). On the organizational side, it included: the type and size of organization and geography (county). The survey included three Likert-based matrices. The matrices focused on ability to access care, severity and impact of health issues, and the severity and impact of social issues on health. A four-point Likert scale was used for one of the questions and the other two used a different five-point Likert scale. Each included options for not having enough information to answer the question and for the question not applying to the respondent. Three ranking questions were focused on placing priorities on health issues, social issues and health improvement opportunities. In one of the questions, respondents were asked to identify the top issue of concern. In the other two, they were asked to rank the top three items. In addition, seven other questions were asked, primarily focusing on their perception of the community (e.g. Is the community a good place to raise children?).
Survey Monkey was used to streamline the data collection, compilation and analysis. The survey included four potential paths based on two links (English and Spanish) and the first question (Individual or Organization). The announcement of the survey was made through a joint effort of all participating partners with a coordinated press release. Individual organizations promoted the completion of the survey through email, networking, social media and promotion at point of service within facilities. Incentives were not offered to participants at any point of survey collection. To maximize the response rate, the survey was kept open and promoted from August 2015 until December 2015. Preliminary results were collected at the beginning of November 2015 to inform the line of questioning developed for the focus groups. Final results were then tabulated in December 2015 and January 2016. The following are the key findings of the survey, which were then used to help develop a line of questioning to be used in the focus groups and to provide the committee with some feedback, albeit not validated, on the concerns of both individuals and organizations in the OHC Region.
Focus Group Process
A researcher from Missouri State University's Sociology Department was contracted to complete the focus groups. The researcher has experience with healthcare and focus groups. The researcher also served on the survey committee and was an integral part of the process. After the topics of focus were identified in August 2015, the researcher developed the focus group questions and submitted them to the survey committee and the steering committee to review and provide feedback. The survey committee also helped determine the number of focus groups and the target audience for the focus groups. The committee determined that residents were the most important group from which to receive in-depth feedback. Additionally, the committee determined that it was necessary to conduct focus groups in each of the nine Communities due to variances in local perceptions and barriers. Focus group facilitator trainings were conducted in September and October 2015, with focus groups occurring in November and December 2015. The following section, which was extracted directly from the researcher's report, details the methods, recruitment of participants and the instrument used in the focus groups.
A typical focus group consists of a facilitator, note-taker, and 4-10 participants and is 45-90 minutes in duration. The aim of a focus group is to collect qualitative information (perceptions, opinions, experiences, and details that help explain, for example, closed-ended survey responses). Focus group findings, like all interview findings, are not expected to be able to be generalized to a larger population; rather, focus group findings are a snapshot of the dynamics of a few people, each with their own perspectives and experiences, at a particular point in time. A local facilitator and a local note-taker were identified and then trained to conduct the Ozarks Health Commission Focus Group Interview. Next, eligible participants were recruited for the focus group event.
From the survey, we realized that that older adults and women were overrepresented respondents in the initial electronic survey, while Medicaid recipients and those with no health insurance were underrepresented respondents; therefore, we attempted, when recruiting for the focus group interview, to achieve a balanced variety of health and healthcare experiences. Our goal was to compose a focus group of not less than six people with the following characteristics:
Age: A maximum of three older adults
Gender: A minimum of two men
o A minimum of one individual without insurance
o A minimum of one Medicaid recipient
o A maximum of two Medicare recipients
o A maximum of two private insurance recipients
Behavioral Health: a minimum of two individuals
The goal of our focus group interview was to better understand citizens' perceived connections to health information and services in their community. The theme of connection arose from the preliminary findings of the 2015 Citizen Survey, in which lack of social connectionâ€ was identified by many citizens to be a reason for poor health. Literature abounds in the social sciences, in epidemiology and more recently, in medicine that supports the correlation between strong social connections and positive health status and outcomes. For these reasons, citizens' perceptions of their connections to health information and services in their communities was the main theme of the focus group interview.
The key terms used in the focus group interview were health, community, and connection. They were defined as follows:
Health: the physical, mental, and social aspects of health across the life course (inclusive of behavioral or mental health and aging related matters)
Community: family, friends, acquaintances, and all the people you see on a day to day basis â€“ the mailman, your pastor, a grocery clerk, your physician, elected officials and more.
Connection: who you know, how comfortable you feel with them, whether you know about services and programs in your area and how important those things are to you.â€
Identification and Prioritization of Health Issues
Lastly, a committee was formed to develop the process of identifying and prioritizing the health issues for the OHC Region and Communities. This committee included representation from both healthcare and public health. The committee began meeting in October 2015 and concluded their work by March 2016. The process began with narrowing the roughly 150 secondary indicators by focusing on indicators in which the OHC Region and Communities performed poorly, compared to the nation. This process revealed that the OHC Region was under-performing in 34 indicators. In the individual Communities, the process revealed that between 35 indicators (Springfield) to 51 indicators (Fort Smith) were under-performing compared to the nation. These indicators highlighted the areas of health and risk factors that the OHC Region experiences more challenges to improved health than the rest of the nation.
In the OHC Region, 34 indicators were examined and placed into similar groupings to create health issues. This process identified seven groupings that are considered Assessed Health Issues (AHI) and several other groups of social determinants of health. The committee then identified associated indicators and grouped them within the AHI. For example, high blood pressure and cholesterol, as well as other health issues related to the cardiovascular system, were collapsed into cardiovascular diseaseâ€. If relevant, an indicator was used in multiple groupings. For instance, tobacco use was used in both lung disease and cancer. In addition, the list of poor-performing indicators for each Community was examined to ensure that additional health issues were not present. This process did not present any additional health issues. The AHI identified were: Cancer, Cardiovascular Disease, Lung Disease, Oral Health, Mental Health, Maternal and Child Health, and Diabetes. The social determinants of health were poverty and access to health services. The committee then developed an objective review process for scoring the AHI. The scoring system included both key data points and community perspective providing a more thorough examination of the AHI.
Health Indicator Scoring
Information from Kaiser Permanente and the National Association of County and City Health Officials (NACCHO) were used as guides in the process. These resources provided guidance for a Prioritization Matrixâ€ to be used to identify AHI. A prioritization matrix is a commonly used tool for prioritization and is ideal when health issues are considered against multiple criteria. Decision matrices provide a visual method for prioritizing and accounting for criteria with varying degrees of importance. Ideas for the criteria were based on the Hanlon Method. The committee modified Hanlon's criteria (seriousness, magnitude and effectiveness) to better fit the data and Communities within the OHC Region. The Hanlon Method also incorporates the â€˜PEARL' Test, which screens for propriety, economics, acceptability, resources and legality. The actual test was not performed in this process, but some of the concepts were used as criteria for the matrix (i.e. community readiness). This modification was required due to condensed timeline, the diversity within the Communities and consistent partner engagement throughout the OHC Region.
The scoring system used two key componentsâ€”evidence from the data and evidence from the community. The data used in the scoring system includes morbidity and mortality for each of the AHI, comparisons of these indicators to national performance, and the pervasiveness of health issues presented in the primary hospital data. The data used to provide community evidence of momentum around the health issue were feasibility to change the health issue and the readiness of the Community. With the data elements, the committee decided to use a best-fit approach. For each AHI, a key indicator was selected to represent the entire issue. While this provides a more focused examination of each AHI, it also provides a more clear and objective examination of each AHI. In addition, to help inform the process of ranking and prioritization, the committee decided to include whether or not AHI were identified in the focus groups. The committee did not feel that the initial process to coordinate and integrate the focus groups and the survey results was compatible enough to include them with a scoring mechanism. The committee did feel it was important to include them to inform the prioritization process, but not provide a score. Additionally, the results of the survey were not given a score in the prioritization matrix. The terms in the survey were too general (e.g. chronic disease) and would not allow for individual AHI to be identified.
To complete the ranking for each of the Communities, prevalence, mortality, their associated comparison to national rates and primary data were completed by the OHC committee. For the final two criteria, Communities completed Feasibility to Change and Community Readiness to Change, which generated the final score.
This score was then used by Communities to have conversations around which, and how many, AHI to select as the priorities for the Community. In addition, Communities could also add other health issues that were not identified in the process outlined herein. Priority AHI ranged from three to five in number. The priority AHI provided the basis for developing Community Health Improvement Plans in each Community.
Hiring the researcher from Missouri State University to develop, plan, implement, and analyze the focus groups cost $20,000. Aside from this expense, the OHC committed thousands of hours of time to the 18-month project. The majority of the costs associated with the project were provided in-kind and not tracked. However, the following expenses were estimated after the completion of the project.
OHC Staff Time: $171,000
OHC Travel: $5,000
Total estimated costs: $197,000
All of the following objectives were met:
Complete a joint CHNA to satisfy requirements of the Internal Revenue Service (IRS) for non-profit hospitals and the Public Health Accreditation Board (PHAB) for local health departments.
Complete Community Health Improvement Plans (CHIP) that include evidence-based system and policy level interventions to address priority health needs identified in the CHNA.
After the reports were completed, representatives from the health department met with key stakeholders in each community to garner feedback about the joint assessment process. The same questions were asked in each community, a note-taker recorded the responses and results were analyzed by reviewing for common themes. The results were organized by Strengths, Weaknesses, Opportunities, and Threats. Modifications to future assessments will be made based on the following results.
Strengths included the following:
The people involved in the process were dedicated to the project and were skilled to producing a quality product
The Springfield-Greene County Health Department was engaged and responsive and displayed strong leadership
A central coordinating entity helped make the process smooth.
The group was flexible to needs of partners and displayed strong teamwork
The final report was well designed, credible, consistent in formatting, strong methodology and well-written narratives.
Weaknesses included the following:
Timeline was difficult to achieve for all communities. Also, some communities had reporting deadlines that preceded others.
Local Public Health Agencies (LPHA) in rural counties and/or those not pursuing accreditation had little capacity and/or motivation to participate in the Regional Health Assessment.
Working across state boundaries posed difficulties because of hospital system and public health structure.
A common platform for sharing reports/documents was difficult due to hospital firewalls.
Because there was not a CHNA of this magnitude conducted elsewhere, OHC did not have a roadmap to replicate.
Some primary data collection was lacking. The surveys were disseminated across the region; however, some rural counties did not provide responses. Also, one focus group in each community was conducted. Yet, these groups were small and OHC did not feel that each group provided a good representation of their respective community.
Opportunities included the following:
OHC expects more buy-in to the process now that the first iteration of the Regional Health Assessment has been completed.
The methodology can be refined in future iterations to improve upon the model built.
A clearly defined project plan will help the process go more smoothly.
Expectations for involvement need to be clearly outlined at the beginning.
It is important that a person with clinical background provide perspective into the process.
Identify funding mechanisms to support future iterations of the regional approach.
Maintain feedback from an IRS and PHAB expert to ensure all regulations are met accordingly.
Threats included the following:
Failure to garner future support from LPHAs may impede future success.
Hospital investments have competing demands on finances.
Without the proper funding and resources, the Springfield-Greene County Health Department cannot commit the same level of commitment in the future.
The Springfield-Greene County Health Department is currently exploring the use of Community Commons as an outward and inward facing platform for OHC partners to use as a means to track community health indicators, measure progress towards CHIP initiatives, and provide more streamlined data collection for future assessments.
The Springfield-Greene County Health Department learned a great deal about convening community partners for the purpose of completing a joint CHNA. Hospitals have a vested interest in improving population health. The joint assessment required public health to learn about specific hospital regulations and financial interests of local health systems. By learning about these motivations, public health could identify areas of overlap where community partners can begin working together in a way that benefits the community, as well as the bottom line of healthcare.
As SGCHD works to sell this model to local health systems, it will be important the health department speak healthcare language. For example, leveraging community benefit and community building dollars is a powerful way for health systems to target social determinants of health, such as housing, transportation, and lack of access to quality food, as a means to reduce Emergency Department recidivism. At the same time, it will be important to educate our healthcare neighbors about the upstream health determinants that contribute to chronic disease, death, and disability. Together, we are finding our way through the provisions of the Patient Protection and Affordable Care Act. We are learning how to compliment the work of each other and build strong, healthy communities and health systems.
Through the work of Ozarks Health Commission the SGCHD is positioned to serve the Springfield Community as the Community Chief Health Strategist. However, it will be important to not only sell future iterations of the Regional Health Assessment to healthcare partners, but to maintain and grow a sense of shared ownership for community health among key stakeholders. The SGCHD will do this by supporting the CHIP initiatives of community partners and provide technical assistance wherever is needed. Additionally, the SGHCD will work with healthcare leaders to identify and agree upon financing of future CHNAs.
Currently, there is strong stakeholder commitment from some partners in the OHC region to sustain the practice. However, healthcare facilities in Arkansas may abstain from future work with OHC because the organizational structure and community needs to do fit well within the model. Yet, core organizations that have the means to fund future cycles are vocally supportive. The SGCHD is to in the process of building a cost structure to present to key stakeholders.