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A Personal History of the Evolution of Health Status Assessment

Burdine, James N. DrPH; Felix, Michael R. J. MSHA

Journal of Public Health Management & Practice: July/August 2017 - Volume 23 - Issue - p S9–S13
doi: 10.1097/PHH.0000000000000577
Commentary

Department of Health Promotion and Community Health Sciences and Center for Community Health Development, Texas A&M School of Public Health, College Station, Texas (Dr Burdine); and Community Health Development Specialists, Inc, Whitehall, Pennsylvania (Mr Felix).

Correspondence: James N. Burdine, DrPH, Department of Health Promotion and Community Health Sciences and Center for Community Health Development, Texas A&M School of Public Health, 1266 TAMU, College Station, TX 77843 (jnburdine@sph.tamhsc.edu).

This article was written from the perspective of a personal history—that of the experience of the authors' as participants in the evolutionary health status assessment over the past 30 years. As the result of being part of that process, we do not claim objectivity or represent that there might be other equally valid perspectives and recollections. We do, however, offer this to provide the reader with insights into our experiences in arriving at this point in the development of methods and models for health status assessment.

The authors have no conflicts of interests or funding sources to disclose.

In the early 1990s, the authors participated in the development of a community health status assessment (CHSA), initiated by a large regional health care system, Lehigh Valley Health Network (LVHN), and funded by a local health-oriented philanthropy, the Dorothy Rider Pool Health Care Trust. This was one of the first large-scale, comprehensive CHSAs conducted in the United States.1

The purpose of the assessment was 2-fold: first, to gather information to plan, implement, and evaluate interventions to improve the health of the population of the region; and, second, to create an opportunity for the development of a partnership among all the hospitals in the region to encourage working more collaboratively. This latter element was driven by leaders at the philanthropy and from the private sector (largely hospital board members) who saw increases in the cost of care as the result of unnecessary competition among the hospitals as an opportunity to exert their influence. There were 7 hospitals in the Lehigh Valley at the time, a 3-county region of Eastern Pennsylvania with a population of slightly more than half a million persons. All 7 hospitals were engaged to participate through a preliminary organizing activity called the Social Reconnaissance.2,3 The outcome of that activity was an entity called the Lehigh Valley Health Partnership comprising 3 representatives from each hospital (the CEO, Board Chair, and Chief Medical Officer) and the Chair of the Pool Trust and its Executive Director, Edward Meehan. Michael R. J. Felix served as the organizer/facilitator along Dr James Burdine, Vice President for Community Health at LVHN.

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The Organizing Strategy

The organizing and facilitation strategy utilized to convene a region-wide partnership that led to the development of the assessment methodology is called the Partnership Approach (PA) (see the Figure),4 initiated in the mid-1970s in one of the first large-scale community health mobilization projects, the Lycoming County Health Improvement Program (CHIP).5 The partnership developed in Lycoming County was a community health development-based process. The PA strategy began with a series of individual interviews of key stakeholders, public and private resource holders, and community residents to gauge local interest and needs and to seek advice on opportunities to build collaborative community health improvement initiatives. The approach helped project planners organize and facilitate the local partners in developing6,7 and evaluating leading edge health promotion activities during the projects demonstration period from 1978 to 1983.8

During the Henry J. Kaiser Family Foundation's (HJKFF's) National Health Promotion program in the mid-1980s, Drs Alvin Tarlov, Larry Green, Sol Levine, and Donna Hall and Mr Felix led a national team of consultants including Drs James Burdine, Richard Couto, David Chavis, and Paul Florin, Ms Marni Vliet, and Mr Edward Meehan in a state and community strategy that became known as the HJKFF's National, State, and Community Health Promotion Program.9 Implemented in 16 states (Alaska, Washington, Oregon, California, New Mexico, Wyoming, Montana, Utah, Colorado, Texas, Arkansas, South Carolina, North Carolina, Georgia, Mississippi, and Kansas), as well as Washington, District of Columbia, and the Lehigh Valley of Pennsylvania, the interview-driven methodology utilized by Felix in the Lycoming CHIP project was adopted by the Foundation as a key component of the strategy and dubbed the Social Reconnaissance by Dr Larry Green, reflecting its roots in earlier community research work done by Irwin Sanders.2

The PA was enhanced through the community health development thinking of Guy Steuart and others.10 The PA was utilized to organize the HJKFF partnerships. To facilitate the partnerships toward planning, implementing, and funding health promotion activities required the gathering of secondary health data, demographics, and other health determinant information that might be applied to demonstrate need and opportunity. The inclusion of Community Discussion Groups (CDGs) to gather additional qualitative information also became an important tool of the process. Unfortunately, disparate information from one state and its communities to another quickly became an issue for evaluators looking to compare experiences. This dilemma became a source of discussion over several years between the authors and one of the other consultants Ed Meehan in thinking about how to generalize data from one environment to the next.

During this same period at the HJKFF, Drs Tarlov and Levine hosted a series of meetings on “Society and Health.” One of the major outcomes of these meetings, and the topic of a subsequent publication of the proceedings, was the concept of the “social determinants of health.”11,12 The HJKFF also explored understanding the concept of functional health status through the work of Drs John Ware and Allison Davies and their development of the Short-Form 36 instrument from the Medical Outcomes Study.13–15

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The Assessment Approach

The confluence of the development of these tools and strategies assisted the Lehigh Valley team in identifying an array of elements for consideration to include in an assessment design. The overall assessment included (1) data collection from a random sample survey of households in the region, (2) data from individual interviews with key community leaders and CDGs, and (3) the examination of existing secondary data from local, state, and national sources. All of this was organized through the PA.

The survey component was designed to include state-of-the-art validated measures of a number of factors considered by the group to be essential in understanding what was driving community health status in that environment.16 Colleagues at the Health Institute at New England Medical Center, Tarlov, Safran, Ware, Amick, and others, assisted in the design and selection of instrument components. Among these was a component on functional health status. Based on the work of Ware and Davies, among others in the Medical Outcomes Study, as mentioned previously, we selected the SF-36 to measure functional health status (“overall” health status as well as physical and mental health status). Subsequent community surveys conducted by the authors employed the SF-12, an abbreviated version of the SF-36, until health-related quality-of-life measures advanced to the point of succeeding functional health status measures as the most common overall measures of health in population-based community assessments.15,17,18

In the early 1990s, while there were disease-specific assessment tools available, there was little in the way of validated tools for application at the community level. The Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System (BRFSS), for example, was in its infancy and largely focused, as its name suggests, on behavioral risk factors.19 While there was some discussion of social determinants of health in the literature, little in the way of instruments validated for community survey application existed.11

Other survey elements included physical activity and medical history (both provider and self-diagnosed as well as family history), women's health issues, perceptions of health-related community issues, health habits, and risk factors,20 participation in preventive screenings, and health insurance coverage. Access to care, communication with providers, satisfaction with and management of care were examined using the Primary Care Assessment Survey.21 Finally, demographic data for survey participants were included. In later years, measures of social capital, sense of community, and other factors would be incorporated into the survey.22–24

The CDGs were conducted by Felix, using a process modified from his work at the HJKFF. Designed to include representatives from all sectors and aspects of a community, CDGs followed generally the same agenda: describe their community, identify issues in their community, identify resources available in their community, describe the history of collaboration among organizations within their community, and give advice on how to most effectively work with their community if attempting to improve community health. These 5 topics provide a skilled facilitator with the opportunity to obtain in-depth insights into community characteristics critical to planning and implementing successful health improvement interventions.25

Finally, data from the US Census Bureau, Centers for Disease Control and Prevention, local and state public health agencies, and the hospital partners were obtained, examined, and incorporated into the final assessment report, largely for contextual purposes.

The PA, which is guided by community health development theory around local community and institutional capacity building, was used during the assessment planning and implementation process to bring together representatives from the local hospitals (generally the CEOs) in monthly meetings. The goal of those meetings was to obtain their input and subsequently their ownership of the assessment process and outcomes.26

The results of the assessment were presented to the sponsoring/partner organizations, and plans to implement programs and services to improve access to care for low-income persons (the primary assessment finding) were planned and implemented. Within 24 months, several hundred persons had been enrolled in a new Medicaid health maintenance organization sponsored by the partnering hospitals.

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Recent Application Experience

The authors have participated in more than 100 community health partnerships/assessments throughout the United States beginning with the Lehigh Valley Health Partnership. In general, the goal of these projects was to build community-based health partnerships to support and sustain health-related population health improvement activities. The PA, using a CHSA, is one of several important tools used to engage and build ownership among local public and private resources, community leaders, and residents for strategic health planning, program development, and evaluation of local health strategies.

The CHSA refinement over the last 3 decades has broadened its application to a wide variety of settings, populations, and institutional sponsors/partners including public or private organizations, governmental entities, funders, or communities that are interested in applying real-time data for strategic health improvement.

The following section describes 4 different examples of the application of the PA and the CHSA described earlier.

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Colorado

The Health District of Northern Larimer County, a special taxing district delivering community health programs and services to the region around Fort Collins, Colorado, has employed a locally tailored version of the strategy/methodology described in this article every 3 years since 1995. As a result of one of the findings from assessments in 1995 and 1998, the Mental Health Partnership was organized in 1999.27 Over the years, the Partnership has led the community toward the integration of mental health services, primary care, and care coordination. It developed one of the earliest versions of the Connections Program that links those in need of mental health and/or substance abuse support to local services. It has used the data collected to advocacy purposes, improving access to care and restructuring the community's emergency response to mental health– and alcohol-related issues.28

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Texas

In the Brazos Valley region of Central Texas, assessments cosponsored by local hospitals, the Center for Community Health Development at the School of Public Health, Texas A&M University, and other local partners have conducted assessments every 3 to 4 years since 2002. These assessments led to the creation of County Health Resource Centers providing “one-stop-shop” consolidation in rural counties of services previously only available in the urban hub. A national demonstration tele-mental health counseling program and a regional volunteer-based transportation system also resulted from the assessments, among other programs and services.29

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Florida

The Mental Health Collaborative of Indian River County, Vero Beach, Florida, applied this approach for strategic planning purposes. The results included a new Mental Health Court for first-time offenders, a local Connections Program that is integrating mental health, substance abuse, and primary care with care coordination and education to get people in need to appropriate resources. In addition, it has developed new access points within several primary care practice settings through the integration of primary care and behavioral health.30,31

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Missouri

The state of Missouri has aggressively adopted the PA and the CHSA methodology described in this article. Here are 2 examples. First, Missouri Primary Care Association has been using the PA for building Federally Qualified Health Center (FQHC) New Starts and for FQHC strategic planning since 2000. More recently, this approach has been applied in integrating local health and human services.32 In 2000, there were 10 health centers in Missouri serving about 200 000 people. Today, there are 30 FQHCs serving approximately 450 000 people, with more than 1.6 million encounters yearly.

Second, the PA is being applied in the Missouri Delta region with a Partnership led by Big Springs Medical Association, Inc, d/b/a Missouri Highlands Health Care (MHHC), in collaboration with 16 public health departments and 2 faith-based organizations. Known as Network Partners, they are working together to improve diabetes, cardiovascular disease, obesity, acute ischemic stroke, and mental health outcomes for the rural medically indigent and residents with, or at risk of, developing chronic diseases in the 16-county service region of Missouri.33 These rural counties are home to generational poverty and a culture whereby many residents view health care as a need only to be addressed in an acute stage, when pain is extreme. The acceptance of ongoing preventive care is seldom embraced. Network members are working on the following multifaceted project to address health concerns in the 16-county region:

1. Deploy community health workers throughout the 16 counties, providing services on-site at county health departments, community health center clinic locations, and 2 faith-based community organizations.

2. Utilize a Web-based database of health literacy information to incorporate best practices in patient education and service delivery in all the participating network partners.

3. Extend clinic hours at MHHC Patient-Centered Health Home clinic locations throughout the region, providing a critical access point for health care services in communities with significant access barriers.

4. Incorporate integrated behavioral health programs into all MHHC medical clinic locations, which will include screening patients using behavioral health vitals and, if needed, provide brief behavioral health intervention or traditional behavioral health therapy.

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Discussion

There are numerous models and methodologies for conducting community health assessments and developing/implementing/evaluating plans to impact health status.34 The purpose of this narrative was to describe the history of the development of one set of those methods that has been employed in numerous diverse settings with significant local impacts to give the reader an insight into how strategies and tools developed and were implemented and modified.

The authors maintain that like many ideas in America, health care is local.26 That being said, there are significant drivers external to local communities that encourage or require local entities to conduct CHSAs and develop community health improvement plans. The Affordable Care Act requires all nonprofit health hospitals to conduct a health assessment and an implementation plan every 3 years. A similar requirement exists for local health departments desiring to be accredited by the Public Health Accreditation Board. FQHCs and other community health–related organizations also participate or lead community health assessment efforts (eg, United Way organizations). We also recognize and celebrate that these processes and methods are continuing to develop and evolve.

As we have discussed, significant steps in the evolution of health status assessment to this point have been substantial. Our hope is that in the near future such an article will be able to chronicle equally meaningful improvements in strategy, methods, and measures of community health status.

Even as the health information technology movement leads our nation toward interconnectivity where quality, productivity, outcomes, best practices, and cost are available information at all levels of society to make health policy decisions, there will still be the need for information beyond the scope of patient-based data that CHSA will need to fill. For example, the qualitative side of the method offers real-time feedback on local needs, interests, and advice for policy makers, planners, funders, local leaders, and people interested in engaging local residents in a problem-solving solution-finding process. The CHSA will also continue to be a strong and viable planning, monitoring, and evaluation tool as it is focused on the population and the determinants of health impacting the population's health. Having participated in the evolution of the concept to the present day, the authors see through publications such as this special issue the multiple experiences many communities are gaining in conducting and applying to continue and grow. The accepted value for identifying, tracking, and monitoring individual and population health outside the institutional aspect is its greatest strength.

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