As the health care system shifts from paying for volume to paying for value, there is increasing interest in addressing the nonmedical determinants that influence health.1 Evidence shows that social and environmental factors have a major influence on health outcomes and that health care services alone are not sufficient to sustain a healthy population.2 In recent years, there has been significant progress in demonstrating how health care systems can improve health outcomes by addressing individuals' social needs alongside clinical care delivery.3 However, many existing approaches remain focused on targeting select segments of the population, particularly high-cost and high-need groups, and transforming the way care is delivered to individual patients.4 Health care organizations still need assistance, particularly from the public health sector, to move beyond their traditional clinical focus and incorporate total population health into their missions and practices.5 The Community-Centered Health Home (CCHH) model, developed by Prevention Institute (PI), calls on health care organizations to contribute to improvements in upstream community conditions that influence health such as employment or housing.6
The Louisiana Public Health Institute (LPHI) designed and implemented the nation's first demonstration of the CCHH model. This article provides an overview of the CCHH model and LPHI's implementation. Five participating community health centers put the model into practice, and the article discusses the outcomes of the implementation at these sites. On the basis of this demonstration, we identify several opportunities to further operationalize the model in the primary care setting and to leverage the CCHH model for broader health system transformation efforts by systematically exploring innovative applications of CCHH concepts in other health care and community settings.
The CCHH Model
The CCHH model is a framework for health care organizations to actively engage in community prevention. The model expands the traditional role of clinical service providers to also embrace the role of community partner and change advocate. Using the 3 functional elements outlined in the Figure—inquiry, analysis, and action—the model guides health care institutions, with a focus on community health centers, to (1) leverage their clinical data infrastructures to gather information about the community's clinical, social, and environmental conditions; (2) analyze and share health and community condition data to contribute to community prioritization and strategic planning; and (3) coordinate with partners to put the community change agenda into action.6
The model asserts that by stepping outside of the facility walls to address community environments, health care organizations can contribute to improvements in population health outcomes, build more trusting relationships with their communities, and increase satisfaction among clinicians and other health care professionals who are often frustrated by the external factors that limit their patients' opportunity to be healthy.
The goal of the CCHH Demonstration Project was to assess whether CCHH could be operationalized in a community health center setting. The program also intended to generate valuable insights into how CCHH can be implemented in practice and what it takes to support community health centers to do this work. In collaboration with PI, LPHI designed a Request for Proposals (RFP) for a 2-year demonstration. Eligibility was limited to 20 community health centers in select coastal communities of Louisiana, Mississippi, Alabama, and Florida that were already engaged in a program administered by LPHI. Five awards were made available with the intention of funding at least 1 site per state within the program's targeted geography. Nine health centers submitted applications, and a review committee used a scoring rubric to assess each applicant's readiness to implement CCHH. Scoring criteria included leadership engagement, change management capacity, community relationships, prior experience performing CCHH-like functions, proposed CCHH initiatives, and proposed plans for sustainability. On the basis of the highest-scoring proposals, the final selection of awardees included 2 health centers in New Orleans, Louisiana, and 1 each in Biloxi, Mississippi; Mobile, Alabama; and Pensacola, Florida. Health center awardees received $280 000 in total grant funds. The majority of funds were used to support staff salary, primarily for full-time CCHH managers dedicated to supporting the day-to-day CCHH work.
LPHI developed a technical assistance curriculum to educate and train participating health centers on the foundational knowledge and skills that are central to the CCHH model. Technical assistance modules focused on best practices and strategic tools relevant to topics such as community prevention, collaborative leadership, change management, data and analysis, and community engagement. The modules were delivered during group webinars and in-person meetings. CCHH managers were required to participate in technical assistance offerings, and relevant leadership and clinical staff were encouraged to join. In addition, each health center received tailored coaching and support from an LPHI staff member through regular phone calls (every 2-4 weeks) and periodic site visits (∼3 per health center). Phone calls and site visits were used to monitor health center progress and provide personalized technical assistance and guidance based on unique needs and interests. In general, the CCHH managers were the primary recipients of technical assistance.
Information presented in this article was obtained through program monitoring data and qualitative evaluation interviews. LPHI staff took structured notes during phone calls and site visits. LPHI developed a structured work plan template in which health centers documented detailed information about their activities within the inquiry, analysis, and action elements of the CCHH model. The notes and work plans were reviewed and the content was analyzed to assess each health center's progress in implementing planned activities and their alignment with the CCHH model. LPHI's evaluation team conducted qualitative interviews with each health center and facilitated 2 group roundtable discussions—one with CCHH managers and one with senior leadership. Evaluation data were reviewed and key themes were extracted about the challenges and opportunities of operationalizing CCHH in a community health center setting.
Participating health centers pursued a range of CCHH initiatives. Table 1 provides an overview of their areas of focus and the types of community partners involved.
Despite differences in their CCHH activities, health centers faced a number of common challenges and exhibited similar patterns of progress throughout the Demonstration Project.
Rethinking the health center's role in the community
Health center applicants expressed enthusiasm about the CCHH model and the opportunity to develop skill sets in community engagement and community prevention. However, their proposals in response to the RFP demonstrated that they did not fully understand the model or its implications for a health center's role expanding beyond the provision of health care services. All applicants proposed activities that resembled clinical quality improvement (CQI) projects and focused on providing direct services to a specific set of patients. For example, one health center was interested in addressing high rates of diabetes and proposed a plan to link patients to cooking and exercise classes offered by a partnering community organization. While the proposed project was aimed at identifying and addressing the health-related social needs of individual patients, it included no plans to influence the upstream community conditions that generate and perpetuate poor health, such as the availability of healthy and affordable food options, or transportation or safety barriers that further impede access to healthy food options. LPHI quickly learned that in addition to orienting health centers to the CCHH model and concepts, substantial guidance was needed to help them think about addressing community-level problems affecting the populations in the areas they serve and not just those who use the clinic.
In response to the deficiencies of the proposals received, LPHI instituted a 6-month period of intensive training and coaching for all awarded health centers to lay the necessary foundations for success in implementation of the model. During the 6-month training phase, LPHI staff worked with health centers to help them move beyond their clinical conception of a community issue and an associated direct service solution and to develop a revised proposal grounded in community prevention. To help health centers evaluate their original proposals and develop their new plans for CCHH implementation in fidelity with the model, LPHI developed a visual tool, shown in Table 2, to compare the foundational characteristics of CQI and community prevention and highlight the key differences between them. Over the course of the Demonstration Project, in addition to leveraging this tool, LPHI staff continued to provide intensive coaching to health centers to move away from a service-oriented mindset and focus on opportunities to influence policy, systems, and environmental change.
By the end of the program period, health centers made significant progress in their ability to understand and implement CCHH. In several cases, health centers implemented service-oriented activities as part of their CCHH initiatives before fully understanding what a more upstream activity might look like. For example, one health center partnered with a food bank and a university to offer an educational class to food-insecure families about shopping for, cooking, and eating healthy foods. Participants also received a Crock-Pot and a weekly box of healthy food items. The health center acknowledged that it was providing resources to a group of individuals rather than targeting the root causes of food insecurity but felt it was the right approach at that point in time. The health center has used the program to engage in valuable conversations with families about their experiences and their thoughts on potential solutions to the area's food insecurity, establish trusting relationships with a subset of the community, and initiate a planning process for a more sustainable way to address the problem, like bringing a grocery store to the area or creating a mobile market. LPHI viewed participating health centers' progress in understanding CCHH concepts as important milestones and indicators of success, even if they were not able to show the same progress in their implementation activities before the end of the program.
Working with data
The CCHH model asks health care organizations to collect new data elements and to explore existing clinical and community data sources in order to identify trends between patient health indicators, such as increases in asthma-related visits to a clinic, and community indicators, such as changes in air quality or poor housing conditions. One of the examples used by PI in presenting the CCHH model describes an increase in pedestrian injuries and fatalities that are linked back to a particularly dangerous intersection. In investigating reasons why the intersection was dangerous, a nearby health center worked with community organizations to understand determinants of traffic patterns and built environment features. These combined data revealed how an intervention could be designed to make the intersection safer.
In the Demonstration Project, health centers were generally able to monitor health conditions and to identify populations likely impacted by community conditions. However, they struggled to capture social or community data. Measurement of community conditions, such as environmental hazards, was a particular challenge, as knowledge of community data sources or data collection instruments was minimal. The CCHH model imposed a social research orientation upon health center staff who were not necessarily trained to interpret social determinants in an analytical context. Three participating health centers did collect new social or community data elements from their patients as part of their standard office visit documentation. Of the 3 health centers, 2 used their electronic health records (EHRs) to enter the data and only 1 collected data from its entire patient population, whereas the others limited it to specific subpopulations, such as pediatric asthma patients. Data collected included questions on sexual orientation and gender identity, food security measures, and home and environmental hazard measures. Importantly though, getting health centers to the point of identifying measures, gathering data, and incorporating it into a standardized collection process was a challenge.
Although implementation of the data components of the CCHH model had a strong focus on EHR integration, several health centers found alternative data collection strategies useful. One team reported that a basic survey allowed it to bypass the lengthy internal processes of adding new fields in the EHR and the delays associated with pulling the data into reports. Another health center reported that a paper assessment tool was more appropriate for its initiative, which focused on teen pregnancy prevention, because it allowed patients to privately respond to the questions on a paper form rather than openly discuss them with the provider. While these were effective means of collecting new data, this approach limited any exploration of correlations between social or community data and clinical data available in the EHR because of the additional time, sophistication, and skill required to aggregate and match the 2 data sources.
In general though, analyzing and interpreting data were a challenge for health centers. Again, the fact that they were relatively inexperienced at working with data proved to be an issue for analysis and interpretation. This was the case even with input from the health centers' quality improvement staff as well as LPHI staff. For example, one health center was relatively advanced in merging health data with social data, as it benefited from partnering with a nearby university. However, it did not receive assistance in analyzing the data, and in its interpretation of various measures, it overlooked the fact that multiple measures for employment issues (eg, unemployment and poverty), when considered together, provided strong evidence for employment obstacles as the primary social determinant of health impacting its population of interest. Put differently, measures were examined individually rather than through a wider conceptual lens to see how measures intersect and compound. This was a problem not only because it raised concerns about objective analyses but because it complicated applications of findings as well. Measures guide interventions, and selection of the wrong, or less meaningful, measures could lead to interventions that may be less likely to impact health.
In sum, data collection, analysis and interpretation, and application all proved to be challenging. The most successful in the Demonstration Project were clinics that had external partners with training or more experience with data-related work.
Listening to the community
Another challenge that health centers faced was learning how to build trusting relationships with community partners. An important feature of CCHH is authentic engagement with community partners, which involves listening to their wishes and supporting shared decision making rather than mandating to their partners how the plan should be implemented. Early on, some CCHH teams took the lead on designing and implementing their CCHH plans, with limited input from their community partners. For example, one clinic executive director remarked, “We saw that there was high levels of hemoglobin A1c in the community so we wanted to start with diabetes, but that did not match with the community priorities. They wanted to talk about food.” In describing the same clinic's approach to the project, the CCHH manager said, “We are taking clinical information, taking it to the community, and they are leading the change.” After working more closely with community partners and engaging in “action learning,” almost all teams shared stories of the moments in which they realized that it was critical to listen to and take into consideration their community's priorities. Community-based participatory research (CBPR) efforts have encountered similar challenges, and successful examples of CBPR show that when the community is involved, efforts are more likely to meet community needs.7
Engaging senior leadership to enable organizational transformation
On the basis of the early challenges that health centers faced in expanding their role in the community and interacting with partners in a new way, it became clear that they had to integrate the principles of CCHH into their organizational culture in order to successfully implement CCHH in fidelity with the model. As a result, LPHI felt it was important to explicitly align the model with organizational and culture change theory. Active support from some level of leadership is necessary to pave the way for organizational transformation. Leadership, whether senior managers or executives, can be powerful champions in guiding change coalitions, creating and communicating a vision, and institutionalizing changes in organizational culture.8 To account for this, LPHI made it clear to health center leadership that they were expected to be fully engaged in CCHH initiatives. LPHI also introduced a learning module on adaptive leadership into the technical assistance curriculum. Since then, PI has embedded engaged leadership into the CCHH model as a core organizational capacity.9
One participating health center offers an example of how active leadership involvement can substantially impact successful CCHH implementation. When the current health center's executive director was first stepping into her role, the organization was just emerging from a financial crisis. Employee morale was low, but there was a strong and continued connection to the health center's mission and purpose. When the health center began engaging in the CCHH Demonstration Project, the executive director saw it as an opportunity to provide a vision and a frame for the organization's path forward. She developed a presentation to communicate her vision and “make the case” for CCHH and presented it to her senior staff, all employees across 12 clinic sites, and eventually the board of directors. Now CCHH is officially part of the organization's long-term strategic plan and something that all new staff members learn about in orientation because, as the executive director has said, “this is inherently who we are.”
Despite challenges, LPHI believes CCHH could be a promising tool to help community health centers shift their thinking and their practices to move beyond delivering health care services to individual patients and begin responding to upstream community conditions that affect the health of all residents. In monitoring and supporting the participating health centers' implementation efforts, LPHI observed that participating health centers faced a common set of challenges and exhibited similar patterns of evolution. Several characteristics and capacities stood out as potential facilitators of success in putting CCHH into action.
First, as previously discussed, engaged leadership is critical to integrating CCHH into internal organizational strategies and external interactions with community partners. Second, an established staff role, whether partially or fully dedicated to CCHH, is also needed to ensure that the day-to-day work moves forward. During the Demonstration Project, health centers found that building partnerships is a lengthy process and significant coordination and logistical support are needed on the back end to drive effective, multiorganizational collaboration. Third, optimal partnerships include a diverse set of stakeholders with a range of skill sets that complement one another. Health centers should consider all opportunities to leverage the community's expertise and capacities when building partnerships and planning for CCHH implementation. In particular, to compensate for shortcomings in analytical and data skills, partnering may be essential. In the absence of needed partners, the health center should have the required skills to fill in the gaps. Finally, significant technical assistance is needed to educate and train health center leaders and staff on CCHH principles. In particular, tailored coaching can help them understand CCHH in theory and then enable them to bring CCHH from theory to practice in the context of the communities.
Implications for Policy & Practice
- As the delivery system progresses toward value-based models of care, acute and post-acute care providers that account for significant portions of health spending will be important partners in CCHH. Anchor institutions such as large health systems and academic medical centers already make long-term investments in their surrounding communities. In addition, tax-exempt hospitals are well-positioned to pursue CCHH efforts by leveraging their mandated community benefit programs.
- Given the existing interest in targeting high-cost, high-need populations, there is opportunity to leverage the CCHH model to address the needs of certain vulnerable populations. One participating health center already began exploring this by focusing its program on the transgender population in its service area. Older adults are another vulnerable population whose health outcomes may be significantly impacted by community factors such as the built environment and social connectedness.10
- To demonstrate the impact on population health outcomes, CCHH investors and implementers will need to partner with researchers and evaluators to develop a standard program evaluation framework, including a basic set of core process and outcome measures. In addition to assessing population health outcomes, a standard program evaluation will help answer questions related to effective CCHH implementation.
One of the most important takeaways of the CCHH Demonstration Project was the recognition that implementing the model is not a clear, linear process.9 Organizations pursuing CCHH do not need to follow a strict path from inquiry to analysis or from analysis to action. Rather, they should view the model as a fluid and flexible framework for engaging in community change. They need to begin where they can generate the most momentum and traction. For example, several health centers and their partners hosted community events to educate patients and other residents about their community prevention focus areas. While these events may appear to fall into the action element of the model, many of them were primarily intended to give the CCHH teams an opportunity to talk with community members and learn more about their perspectives and priorities, which is an essential part of the inquiry element. Health centers and their community partners benefit from the flexibility to find creative ways to implement the components of the model in accordance with their needs and at their own pace. This realization helped the LPHI team begin to see the model as a set of practice guidelines and a compass for transformation rather than a rote set of requirements or deliverables to complete.
To supplement LPHI's findings, further demonstrations are needed to learn more about how community health centers and their partners can successfully implement CCHH and how CCHH activities can contribute to improvements in population health.
Lastly, health care organizations will benefit from a clear articulation of how CCHH can fit into the broader range of health system transformation and population health improvement frameworks, strategies, and payment models. For example, the Center for Medicare and Medicaid Services' Accountable Health Communities model and California's Accountable Communities for Health both provide additional opportunities for exploring interplay between CCHH and other systemic health transformation initiatives. There is a general consensus that, regardless of what happens to health reform under the shifting political climate, the health system will continue to move away from volume-based to value-based models of care.11 Therefore, it will be important to clearly articulate where CCHH components overlap with or mutually reinforce components of other existing models so that all stakeholders can more effectively leverage and apply the growing body of innovations.
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