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Engaging the Community in Health Improvement Planning by Using Evidence-Based Tools

State: FL Type: Promising Practice Year: 2019

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Florida Department of Health in St. Johns County
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Engaging the Community in Health Improvement Planning by Using Evidence-Based Tools

Description of LHD: The Florida Department of Health in St. Johns County (DOH-SJC) is responsible for providing core public health services and limited clinical services to county residents and visitors. St. Johns County (SJC) is in Northeast Florida south of Jacksonville. St. Augustine is the county seat and is the nation's Oldest City” drawing approximately 6.5 million visitors annually. The 2017 population of SJC is 243,812 (89% White; 6% Black; 7% Hispanic), with a median income of $69,523. From 2010-2017, SJC has been the 14th fastest growing county in the US with an almost 30% growth in population, 2.4 times greater than Florida, and five times that of the nation. Currently, DOH-SJC (http://stjohns.floridahealth.gov/) employs approximately 55 fulltime employees. The Agency is led by the Director and Health Officer, Dawn C. Allicock, MD, MPH and a small Senior Leadership Team.

Public Health Issue: Dr. Allicock was appointed to her position in 2004. Shortly afterwards she found that there were poor outcomes in several key indicators of community health in SJC.  Additionally, community partnership was lacking and the perception of the health department needed improvement.

A focused effort at community partnership began in 2005 as a task force, now known as the St. Johns County Health Leadership Council (HLC), to develop the county's first triennial community health assessment (CHA) with the help of an outside consultant. Following the 2008 CHA, community involvement waned.  The consultant fee for the 2011 assessment was set to be $50,000 at a time when public health funding was limited and the population of the county was growing rapidly. The issue was to reignite interest in convening a large diverse group of partners to systematically build consensus around pressing short and long-term needs of the community and to take effective action to address these needs.

Goals/Objectives: To remedy this situation Dr. Allicock took a stronger personal role as Chief Health Strategist and leader of the local public health system. The goals of the improvement initiative included:

  • Improve community participation in the HLC and in the development of the triennial CHA
  • Improve the process used to develop the CHA to ensure better community buy-in and resolution of community issues
  • Increase staff expertise in the Community Health Assessment and Community Health Improvement Planning (CHA/CHIP) process to reduce consultant expenses and again facilitate better community buy-in and participation in improvement efforts
  • Improve measurability, set improvement targets, and make measurable improvements in the CHA/CHIP process to show trended improvement of results: In 2005 and 2008 CHA Reports, recommendations were stated in difficult-to-measure terms, for example: Focus efforts on substance abuse prevention and education for alcohol, tobacco and other drugs.” Poor measurability made it difficult to determine success as changes were made. Specific improvement targets needed to be set to show the community how to measure and celebrate success
  • Establish needed community services as identified in the CHIP

    How Implemented:

  • Dr. Allicock took on the role of Chief Health Strategist to build and maintain strong partnerships within the community and to oversee the actions listed below. This resulted in a restructured HLC to include both executive-level decision makers and Boots-on-the-ground-staff” from participating organizations.
  • Several staff members of the LHD underwent training to gain expertise in the Mobilizing for Action through Planning and Partnerships (MAPP) process and facilitated the 2011, 2014, and 2017 CHA/CHIP processes.
  • A strong emphasis was placed on ensuring that Health Equity and the Social Determinants of Health” are an important consideration in the development of the CHA/CHIP. This was done through the utilization of the County Health Rankings reports as an important input source.
  • A Community Balanced Scorecard” tool was developed and integrated into the MAPP process. This enabled a structured approach to set and track measurable targets along with critical actions aimed at the highest priority opportunities.
  • The community health status survey underwent an improvement process resulting in more than a doubling of the response rate and ensuring that community needs were identified and included in the CHIP.
  • The above stated objectives were met as described in the evaluation section of this application.


Public Health Impact of Practice:

Actions taken have proven to be highly effective with SJC ascribed the healthiest county in Florida for seven consecutive years by the Robert Wood Johnson County Health Rankings Report.  Additionally, the HLC received recognition by a University of Kentucky study as one of 12 highly successful Public Health/Hospital partnerships in the US.

This Model Practice application describes the creative use of several existing tools and practices in combination. They are the exercising of the Local Health Officer (Dr. Allicock) as Chief Health Strategist (as reported in The High Achieving Governmental Health Department in 2020 as the Community Chief Health Strategist”, by RESOLVE consulting group, (https://www.resolv.org/site-healthleadershipforum/files/2014/05/The-High-Achieving-Governmental-Health-Department-as-the-Chief-Health-Strategist-by-2020-Final1.pdf, accessed 12/4/2018), the usage of the Mobilizing for Action through Planning and Partnerships (MAPP) process for Community Health Assessment and Community Health Improvement Planning (CHA/CHIP), the implementation of a Community Balanced Scorecard (as reported in Paul D. Epstein, Alina Simone and Lyle D. Wray in The Public Health Quality Improvement Handbook published in 2009 by the American Society for Quality, Quality Press), and ensuring the goal of Health Equity” as measured by the Social Determinants of Health” and the County Health Rankings Report (Robert Wood Johnson Foundation and the University of Wisconsin) which have been embedded in the development of the (CHA/CHIP).

The MAPP process has served as the backbone for the development of the Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP) in St. Johns County since 2011 and the Local Health Department has served as the lead agency for this process since the first CHA done in 2005. The process first developed in 2011 and improved for the 2014 and 2017 iterations have used the six-phase MAPP process, including the four MAPP assessments, and many of the tools suggested in the MAPP User's Handbook”, NACCHO, 2013. 

Many of the Key Practices of the Chief Health Strategist, as referenced above, have been implemented as a means to improve the CHA process, embed new methods into the MAPP process, and ensure implementation of each subsequent CHIP. These include:

  1. Adopt and adapt strategies to combat the evolving leading causes of illness, injury and premature death: This has been completed through the development of a Community Balanced Scorecard which set targets for Community Health Status (Key Health Indicators) and focuses the community on the reduction of deaths and incidents that may lead to death.  The Scorecard also ensures a strong emphasis on Emerging Health Threats which focuses the community to identify and mitigate these threats. See below for a further explanation of the Community Balanced Scorecard concept.


  2. Develop strategies for promoting health and well-being that work most effectively for communities of today and tomorrow: This has been done through the advent of a Community Balanced Scorecard as a means to display the CHIP in a short easy-to-read and review format. The Community Balanced Scorecard concept is designed in a manner similar to a traditional Balanced Scorecard for business. (The Balanced Scorecard: Translating Strategy into Action, Robert Kaplan and David Norton, Harvard Press, 1996). The Community Balanced Scorecard for Public Health is a similar, but more recent concept which was presented by Paul D. Epstein, Alina Simone and Lyle D. Wray in The Public Health Quality Improvement Handbook published in 2009 by the American Society for Quality, Quality Press. As stated by Epstein, Simone and Wray, the purpose of the Community Balanced Scorecard for Public Health is to align with the stated community vision to:
  1. Pull the community together around common outcomes desired by residents and other stakeholders.
  2. Bring together decision-makers and leverage assets from all sectors for shared results.
  3. Align key community collaborators behind a common strategy for faster measurable results.
  4. Create mutual accountability for results.


    Like an organizational Balanced Scorecard, the Community Balanced Scorecard is divided into four perspectives. The
    difference is that these perspectives are aligned with the Ten Essential Public Health Services. The four perspectives of a Community Balanced Scorecard are defined as:

  1. Community Assets: Including engaged community members and public health partners, and competent health workforces
  2. Community Learning and Planning:  Including policies and plans, evaluation, health status monitoring, and research
  3. Community Implementation: including investigations, enforcement, health promotion, and health services
  4. Community Health Status: Includes key health outcomes

This results in a Strategic Plan for Health that focuses the community on planning for the building blocks of health and health equity, the knowledge and ability to implement important improvements, and the means to keep score to ensure that improvements made have been effective.  

  1. Chief Health Strategists will identify, analyze and distribute information from new, big, and real time data sources:

    The CHA/CHIP relies on many sources of data with a key source being the County Health Rankings Reports developed by the Robert Wood Johnson Foundation and the University of Wisconsin. The County Health Rankings Report's ranking system uses the Social Determinant of Health” as its basis for rating.  Heavy reliance on the County Health Ranking report enables the CHA and CHIP to stay highly focuses on Health Equity. Other sources of data include FLHealthCHARTS, a source of many state-level and county-level Key Health Indicators, the Behavioral Risk Factor Surveillance System, Healthy People 2020, the Florida Medical Examiner, and several locally developed data sources. While most of these systems are not real-time, they do provide a wide variety of population health data that guides the formation of community health improvement priorities.

  2. Build a more integrated, effective health system through collaboration between clinical care and public health:

    The HLC, developed and groomed by the Chief Health Strategist, Dr. Allicock, include a variety of collaborations with clinical and non-clinical partners along with the local health department. Clinical partners include the local not-for-profit community hospital, various not-for-profit organizations in the healthcare field including mental health, substance abuse reduction, health clinics, physical therapy, and hospice care. SJC is noted for the high degree of partnering that takes place among these agencies even those that compete with each other.

  3. Collaborate with a broad array of allies –including those at the neighborhood-level and the non-health sectors – to build healthier and more vital communities:

As stated above, the HLC includes and collaborates with many non-health sector partners. These include various social services agencies, the county government, the Sheriff's department, the Fire Department, Florida National Guard, the YMCA, the Library system, and the local Council on Aging.

Goal(s) and objectives of practice

The goals and objectives of the practice are as previously stated:

  • Improve community participation in the HLC and in the development of the triennial CHA. The objective was to increase regular community participation in the HLC from about 15 participating member organizations to more than 30. Also, the intent was to increase overall community input into the CHA process.
  • Improve the process used to develop the CHA to ensure better community buy-in and resolution of community issues. The purpose of this goal is not only to improve community participation but to show the effectiveness of the CHA process, that goals can be achieved and celebrated.
  • Increase staff expertise in the Community Health Assessment and Community Health Improvement Planning (CHA/CHIP) process to reduce consultant expenses and facilitate better community buy-in and participation in improvement efforts. The objective is to develop health department staff members to acquire expertise and community credibility in order to facilitate the MAPP process. The goal was to have three staff members with this expertise.
  • Improve measurability, set improvement targets, and make measurable improvements in the CHA/CHIP process to show trended improvement of results: In 2005 and 2008 CHA Reports, recommendations were stated in difficult-to-measure terms, for example: Focus efforts on substance abuse prevention and education for alcohol, tobacco and other drugs.” Poor measurability makes it difficult determine success as changes are made. Specific improvement targets should be set to be able to show the community how to measure and celebrate success. The goal was to have each strategic objective of the CHIP having at least one outcome measure, and with improvement targets set for each measure.
  • Establish needed community services as identified in the CHIP. It was anticipated that the CHIP would identify critical actions leading to the establishment of new and/or expanding services as a result.

What did you do to achieve the goals and objectives?

These goals were achieved through a long-term improvement effort. DOH-SJC has been a practitioner of the Baldrige/Sterling management model since 2004. This model focuses organizations on long-term continuous improvement through the implementation of leading edge management practice in response to the Baldrige Criteria requirements. For this project, Dr. Allicock took on the role of convener and Chief Health Strategist with joint health department and local hospital leadership of the project. An HLC Charter was created and updated for each MAPP cycle. The MAPP process is project managed with milestones developed and projected completion dates set with various health department staff asked to lead each task and partners assisting as appropriate. Estimated completion dates are established for each major milestone. Each MAPP cycle takes 12 to 18 months to complete in this manner.

Steps taken to implement the program:

The improved MAPP was implemented through the following steps:

  • Build the partnership (and rebuild/expand for each MAPP cycle). This was done by the Chief Health Strategist (Dr. Allicock) and her team by reaching out to key partners, asking for recommendations for new partners, inviting members to include Executive-level leaders and Boots-on-the-Ground staff members to participate, and creating a Charter and timeline for each triennial CHA cycle.  Prospective new HLC members receive a personal invitation and a one-on-one meeting (if desired) to learn more about the HLC.
  • Build internal expertise in MAPP. Initially three health department leaders were chosen to lead this project. They were organizational leaders who had attained expertise in the Sterling/Baldrige management model used by DOH-SJC, had a solid understanding of the strategic direction of the organization, were knowledgeable of the then new PHAB accreditation standards, and had shown a passion for public health. These staff members received advanced training in MAPP and in using a Community Balanced Scorecard concept taken from literature to enhance MAPP. For continued staff development, in the most recent 2017 cycle three newer staff members received similar training and took on important roles in the development of the latest CHA/CHIP.
  • Research best practice CHA/CHIP documents and methods. Numerous examples of CHA and CHIP documents from throughout the US were reviewed, many of which were recognized as NACCHO Model Practices. Ideas were taken from many of these and incorporated into each successive version of the SJC CHA/CHIP.
  • Work the MAPP process and embed additional tools/methods including Chief Health Strategist, Community Balanced Scorecard, and Health Equity. For the 2017 MAPP cycle several additional enhancements were made. For this cycle Dr. Allicock and the Director of Public Health Practice and Policy, Noreen Nickola-Williams, empowered a small team of health department staff to manage the process. DOH-SJC applied for and received a CDC Public Health Associate who was assigned to the team and provided expertise at no additional cost. The team was given autonomy to develop a project plan, find creative ways to engage partners and staff, and provide in-process review and evaluation as work was completed. This team developed innovative ways to educate, engage, and develop both staff and community through teambuilding, volunteer opportunities, and process suggestions. Sixteen health department staff members were cited in the CHA document for their outstanding contributions and subject matter expertise.
  • Engage partners in the various phases of MAPP. Partners have been engaged and taken leadership roles in this process through the HLC. To create even further partner engagement for the 2017 cycle a series of small one-on-one meetings were held and partners were asked to provide input to CHA and CHIP by providing feedback on the content and structure of process and documents.
  • Outstanding results were achieved in the team's approach to the MAPP Community Health Status Assessment. In the 2017 cycle 2,700+ responses were collected in a community-wide survey (more than 1% of the population) with far better representation of the various demographic groups than in earlier cycles. This is more than double the response rate achieved previously. Methods used included on-line surveys, DOH-SJC service centers providing surveys to clients as a part of the registration process, county-wide distribution of survey collection boxes at various partner locations, with staff and community partners assisting in delivery/collection of surveys throughout the county. More than 60% of completed surveys were paper-based. Results were reviewed weekly and appropriate process adjustments made.
  • Meet with the HLC as a group and individually through the cycle in order to gain buy-in and understanding of findings from community focus groups and surveys and from research findings
  • Determine highest priority community issues based on community needs and HLC capability and capacity.
  • Build the CHA, build the CHIP, review with staff and partners. The CHIP is displayed using a Community Balanced Scorecard which enables easier review and continuous update through the three-year MAPP Action Cycle.
  • Publish the CHA and CHIP. For the past several cycles the, the local community hospital (Flagler Hospital) has provided funding for publishing.
  • Work the plan. This is the three-year MAPP action cycle.
  • Improve the process for the next cycle

Any criteria for who was selected to receive the practice (if applicable)? N/A

What was the timeframe for the practice?  The SJC CHA and CHIP are completed in a 12 to 18-month cycle. The latest cycle began in October 2016 and the CHA/CHIP was published in March 2018. Several months were lost along the way due to recovery from Hurricane Matthew in 2016 and Hurricane Irma in 2017.

Were other stakeholders involved? What was their role in the planning and implementation process? The SJC HLC was very engaged throughout the process. The HLC is comprised of approximately 30 community partner organizations that include DOH-SJC, Flagler Hospital, County Government, and numerous not-for-profit healthcare and non-healthcare agencies. These organizations are involved in the leadership of the HLC for assisting in the development of the CHA/CHIP, and for taking responsibility for working critical actions leading to measured performance improvement on key indicators of community health.

What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s) The LHD and its Health Officer as Chief Health Strategist takes on the role as previously described to convene the HLC and other community partners to take on key roles in Health Improvement Planning and implementation of these plans.

Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Otherwise, provide an estimate of start-up costs/ budget breakdown

The primary cost to implement this process is the labor cost for individuals involved in developing and implementing the CHA/CHIP. It is estimated that approximately one person-year of LHD effort was expended for each CHA/CHIP cycle. This included the three staff members mentioned previously and various degrees of leadership oversight of the project. Workforce development cost were minimal as training consisted primarily of on-line training offerings through TRAIN and other means along with on-the-job coaching and mentoring similar to what is done for any staff member.

  • What did you find out? To what extent were your objectives achieved? Please re-state your objectives.

All goals were achieved. Most importantly actions taken have proven to be highly effective with SJC ranked as the healthiest county in Florida for seven consecutive years by the Robert Wood Johnson County Health Rankings Report.  Additionally, the HLC received recognition by a University of Kentucky study as one of 12 highly successful Public Health/Hospital partnerships in the US and also received recognition by Florida Tax Watch as a recipient of the state-wide Prudential Productivity Award. There is also strong evidence of improved collaboration and partnering within the community. For example, "Our County's consistent number one health ranking reflects years of focused collaboration, investment and a shared commitment to building healthier communities, together," said Flagler Hospital CEO Joe Gordy and A significant part of our community success is the collaboration between the various public and private entities that garner these accolades and allow for a healthy community to strive.”, said St. Johns County Sheriff David Shoar. 

As stated previously the goals for this effort were:

  • Improve community participation in the HLC and in the development of the triennial CHA. This has been achieved in two ways. First, regular membership and participation in the HLC has increased from about 15 to more than 30 organizations. Secondly, community response via the Community Health Assessment survey has more than doubled from approximately 1,200 survey responses for the 2011 and 2014 cycles to more than 2,700 in the 2017 cycle. This was due largely to better community partner participation and better day to day management of the survey process.
  • Improve the process used to develop the CHA to ensure better community buy-in and resolution of community issues. The process was improved in several ways. This includes the addition of the enhancements to MAPP mentioned previously (Chief Health Strategist Key Practices, Community Balanced Scorecard, Health Equity through the Social Determinants of Health and the County Health Rankings Report). This has resulted in a CHA/CHIP that is widely used and accepted by community organizations as important research documents, as data/information to support grant requests, and most importantly as The Strategic Plan for health in St. Johns County.
  • Increase staff expertise in the Community Health Assessment and Community Health Improvement Planning (CHA/CHIP) process to reduce consultant expenses and again facilitate better community buy-in and participation in improvement efforts. This was accomplished through the workforce development activities previously described. DOH-SJC now has five staff members with considerable expertise in the modified MAPP process being used. Also, DOH-SJC has incurred a savings of at least $50,000 in consulting fees for each MAPP cycle by using internally developed expertise.
  • Improve measurability, set improvement targets, and make measurable improvements in the CHA/CHIP process to show trended improvement of results: In 2005 and 2008 CHA Reports, recommendations were stated in difficult-to-measure terms, for example: Focus efforts on substance abuse prevention and education for alcohol, tobacco and other drugs.” Poor measurability makes it difficult determine success as changes are made. Specific improvement targets should be set to be able to show the community how to measure and celebrate success.  Performance measures and targets have been established for each Strategic Objective through the usage of a Community Balanced Scorecard. For the 2014-17 MAPP cycles there were eight strategic objectives with 17 performance measures. 14 of 17 measures achieved their targeted performance level. For the 2018-2020 MAPP Cycle there are 13 Strategic Objectives with 37 performance targets.
  • Establish needed community services as identified in the CHIP. Since the onset of the Health Leadership Council and the development of Community Health Improvement Plan began in 2005, there have been numerous significant achievements for the SJC community. Examples include the opening of a free medical and dental clinic for low income people without health insurance, the opening of a Federally Qualified Health Clinic, the opening of a Detoxification Center, the expansion of the local public transportation system, and the opening of St. Johns Care Connect which offers care coordination services within the community.


  • Did you evaluate your practice?
    • List any primary data sources, who collected the data, and how (if applicable)
      • Through the MAPP process, primary data is collected in three ways, through community partner participation in the HLC, through a series of community focus groups, and through a community-wide health status survey. Success for these is measured in terms of how much community participation was achieved and how did it compare to previous MAPP cycles. This data was collected and evaluated locally.
    • List any secondary data sources used (if applicable)
      • Through the MAPP process, a great deal of secondary data is collected through many sources. These include: the County Health Rankings Report, FLHealthCHARTS, a source of many state-level and county-level Key Health Indicators, the Behavioral Risk Factor Surveillance System, Healthy People 2020, the Florida Medical Examiner, and several others.
    • List performance measures used. Include process and outcome measures as appropriate.
      • The primary means of evaluating success for the community is through the County Health Rankings report, which provides long-term indicators of Health Outcomes and Health Factors. Process measures include the factors already discussed including success in completing the CHA/CHIP with meaningful levels of community participation and success in achieving the goals and targets set through the Community Balanced Scorecard.
    • Describe how results were analyzed.
      • Results of the County Health Rankings Report are reviewed to determine SJC overall performance in terms of Health Outcomes and Health Factors each year. SJC has been best in Florida for the past seven years in both Health Outcomes and Health Factors. Additionally, SJC results are compared to all other Florida Counties in terms of each of the 5 indicators used to calculate Health Outcomes and each of the 34 indicators used to calculate Health Factors. The 39 indicators are also compared to the results of 33 national counties identified as peers in the County Health Rankings Report. These results along with preferences expressed within the community are key to determining Strategic Objectives as identified in the CHIP and the Community Balanced Scorecard.
    • Were any modifications made to the practice as a result of the data findings?
      • A number of modifications/improvements have been made since the 2011 MAPP cycle resulting in the improvements discussed in the document. These include the use of the County Health Ranking Report (and Social Determinants of Health), the usage of the Chief Health Strategist Key Practices, improvements to the Community Health Status Survey process, and improved community participation in the CHA/CHIP process.

Lessons learned in relation to practice

It is always important to be preparing for the next CHA/CHIP cycle in terms of workforce development and partner development. For example, a key staff member who led the MAPP 2011 and 2014 CHA/CHIP decided to retire shortly after 2014 cycle. Fortunately, there were two other staff members with the needed expertise to begin the process. During the 2017 cycle, three new LHD staff members took key roles so that there are now five DOH-SJC employees with the skills needed to sustain the process.

Lessons learned in relation to partner collaboration (if applicable)

  • The lesson learned for partner collaboration is similar. Several executive-level partners have retired since the 2014 MAPP cycle and a number of Boots-on-the-ground staff have turned over or changed positions. The lesson learned is that partner relations and partner development is never complete. The remedy is to have frequent one-on-one meetings with partners especially as turnover occurs. It is often the good personal relationship that causes good partnership to occur. Most critical actions listed in the Community Balanced Scorecard are owned by partners. The creation of these strong partnerships through the HLC has enabled DOH-SJC to leverage these partnerships at other times such as in emergent Public Health situations. A recent example is the Zika outbreak in 2017. Without good partnership we all fail.

      

  • Did you do a cost/benefit analysis? If so, describe.

A formal cost-benefit analysis was not completed. A CHA and CHIP are required for Public Health Accreditation and not-for-profit hospitals are required to complete a CHA. By building internal expertise in the MAPP process, the LHD and the local community hospital have saved considerable consulting fees, and the partnership created in this process cannot be easily quantified.

  • Is there sufficient stakeholder commitment to sustain the practice? Describe sustainability plans


    The process used for the 2017 MAPP cycle has been well documented including time-lines, milestones, and specific tasks. The sustainability plan is to continue to identify ways to further improve the CHA/CHIP process, to make certain that sufficient LHD staff have the needed skills to continue the process for the next cycle and that partner interest and engagement remain high. It is anticipated that the next MAPP cycle will begin again in late 2019 with lessons learned in hand.

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