Community health assessments (CHAs) and community health improvement plans (CHIPs) provide opportunities for stakeholders to learn about their community and plan strategies to address issues that are identified.1 This includes gaining a better understanding about the population's health, factors that contribute to higher health risks or poorer health outcomes in subpopulations, and assets to improve health. In recent years, the Public Health Accreditation Board's (PHAB's) accreditation requirements for state, local, Tribal, and territorial health departments and federal requirements for nonprofit hospitals have created additional incentives for collaborative CHA (or community health needs assessment [CHNA]) and CHIP processes. This study analyzes the CHAs and CHIPs of PHAB-accredited health departments to identify the types of partners engaged in these processes and the objectives that communities select to measure their progress toward improving the community's health.
When PHAB launched the national, voluntary accreditation program in 2011, the CHA and the CHIP were 2 of the 3 prerequisites that health departments were required to submit as part of their application for accreditation,2 signaling the foundational nature of the community health improvement planning process. Developing collaborative CHAs and CHIPs and updating them over time remains a requirement in Version 1.5 of the PHAB Standards & Measures.3 The percentage of local health departments that have conducted a CHA and a CHIP has increased over time, from 61% and 50%, respectively, in 2010, to 78% and 67%, respectively, in 2016.4
Among health care providers, the implementation of policies such as the Affordable Care Act's requirement that nonprofit, tax-exempt hospitals complete a CHNA every 3 years,5 and the Health Resources and Services Administration requirement that Federally Qualified Health Centers complete a CHA every 3 years,6 , 7 has led to an increase in the amount of community assessment activities being conducted by hospitals and other health care organizations. Hospitals are required to receive input from individuals with “special knowledge of or expertise in public health”8—although the IRS requirement does not specify that the expertise come from governmental public health. These policies have also led to an increase in collaboration between health departments and other community resources such as hospitals, community service organizations, and the media.9 As described in a 1988 Institute of Medicine report, CHAs have long been considered a basic function of public health departments and the conduct of them a skill in which public health professionals should be proficient.10 Hospitals and other health care organizations have taken advantage of the opportunity to collaborate with health departments because by doing so, they gain access to the public health skill set and expertise11 as they fulfill their own CHNA requirements.
Several studies have examined the traits of hospitals and health departments that engage in these collaborations. For example, in a study conducted among all local health departments in Missouri, 94% of hospitals working with local health departments were tax-exempt hospitals that needed to conduct CHNAs per IRS requirements.12 Another study, which featured regression analysis on data from the National Association of County & City Health Officials Profile, found that local health departments that collaborated with tax-exempt hospitals on CHAs/CHNAs served larger populations and were more likely to be locally governed.11 Public health accreditation was cited as a factor that increases the likelihood of conducting CHA/CHIP activity,13 and collaborating on CHAs/CHIPs may also increase the likelihood of interest in pursuing accreditation.12
This collaboration between health departments and other community groups has been observed to be beneficial, and a history of collaborative activity among community stakeholder groups appears to bolster CHA/CHIP completion.13 Collaboration ensures that a local public health system is in place, which provides the capacity to improve the public's overall health.14
With the move from more clinical preventive measures to the consideration of social determinants of health, community-wide involvement in CHA/CHIP development is even more important.15 Collaborating on CHAs/CHIPs allows partners to accomplish mutual goals,12 and CHA/CHIP processes have been shown to involve a wider array of partners than may be typical in other types of local health department partnerships.16
Cross-sectoral partnerships are required in the accreditation standards related to the CHA, the CHIP, and throughout other PHAB domains. Other initiatives also highlight the importance of cross-sectoral work. For example, the US Department of Health and Human Services' Public Health 3.0 initiative calls for the formation of “vibrant, structured, cross-sector partnerships designed to develop and guide Public Health 3.0-style initiatives and to foster shared funding, services, governance, and collective action,”17 (p5) and fostering cross-sector collaboration is an action area in the Robert Wood Johnson Foundation's Culture of Health Action Framework.18
In addition to fostering collaboration, public health improvement planning places an emphasis on taking action as a community to address challenges and developing specific, measurable outcome objectives to track progress in those priority areas.3 To build on this, PHAB requires that health departments report on the population health outcomes for which they are collecting data on an ongoing basis.19 This may include the health data they are tracking as part of their CHA/CHIP processes. Starting with the first cohort of health departments eligible for reaccreditation in 2018, health departments will report on these outcomes when they undergo the reaccreditation process (5 years after they are accredited) and in subsequent years as part of their annual reports. This will lead to the establishment of a national database of outcomes tracked by accredited health departments and will help document how the work associated with maintaining accreditation contributes to improved community health outcomes. As an organizing framework, PHAB used the population health model developed by Dr David Kindig.20 From that model, the reaccreditation requirements identify 7 broad areas—mortality, health-related quality of life, preventive health care, individual behavior, social environment, physical environment, and genetics—in which population health outcomes are categorized. Each broad area has a list of specific topics associated with it. This study uses that framework to categorize the objectives in accredited health departments' CHIPs; as such, it serves as a preview of the type of analysis that might be possible when health departments begin reporting these data for reaccreditation.
By requiring population health outcomes reporting to maintain accreditation during the reaccreditation process, PHAB is building on the focus in initial accreditation on health departments working collaboratively with partners to develop specific health goals to address. Evaluation data suggest that health departments that are accredited perceive that the process has helped them in both partnership and identification of health priorities. For example, in a survey of state health departments, accredited agencies indicated they have already experienced the following benefits: “increase agency capacity to identify and address health priorities” (80%) and “strengthen agency relationships with key partners in other sectors” (65%).21 Findings from the national evaluation of both state and local health departments also indicate that health departments that have been accredited for 1 year perceive those same benefits (correspondence with Alexa Siegfried, NORC at the University of Chicago, Bethesda, MD, unpublished data, August 15, 2017).
This analysis complements these self-reported evaluation data about the benefits of accreditation by examining the documentation submitted by accredited health departments to learn more about their CHA/CHIP processes. Specifically, the purpose of this study was to identify the types of organizations that accredited health departments partner within their CHAs and the health outcomes they are tracking in their CHIPs in order to better understand how accreditation may impact health improvement planning.
Data were extracted for state and local health departments that were accredited between 2013, when the first health departments were accredited, and the end of 2016. A total of 161 state and local health departments were accredited in that time period. Of those, 2 health departments were excluded because they submitted multiple CHAs/CHIPs, representing different geographic areas within the health departments' jurisdiction. In addition, 2 accredited health departments submitted the same CHA/CHIP, which covered both their jurisdictions and was included in the analysis but is only counted once. In total, 158 CHA/CHIP processes were reviewed, based on documents that were submitted to demonstrate conformity with Measures 1.1.2 and 5.2.2 of the PHAB Standards & Measures.2 , 3 If health departments were asked to submit further documentation that addressed these measures as part of an action plan, those documents were used instead to ensure the most recent documentation submitted by the health departments was analyzed.
Seven data analysts coded the data over a 2-year period of time. A codebook was created with clear definitions to ensure consistency among all analysts. The data set was reviewed by one analyst and cross-checked by another to ensure that the same reasoning was used across analysts. Data were categorized in a template created for this study.
The data extraction and coding template was an Excel spreadsheet with 2 data tabs. The first tab provided information on the population size, health department type (state or local), a list of data sources, and the types of partners involved in the collaboration. The types of partners in the collaboration were a series of dichotomous variables collected by reviewing the CHA/CHIP to see if at least one partner of each type was listed. Finally, there was an opportunity to indicate if the CHA/CHIP was explicitly linked to Healthy People 2020 goals. The list of partner types and data sources was derived from an earlier study of state health improvement plans.22
The second tab contained the specific objectives included in the CHIPs. Analysts extracted the health outcome objectives and added each as its own row in the spreadsheet. They then selected the Healthy People 2020 Leading Health Indicator (LHI) that most closely matched the objective, if such a match were possible. The LHIs are access to health services; clinical preventive services; environmental quality; injury and violence; maternal, infant, and child health; mental health; nutrition, physical activity, and obesity; oral health; reproductive and sexual health; social determinants; substance abuse; and tobacco use.23 Classifications were made on the basis of the description of each LHI from the Healthy People 2020 Web site.23 For example, indicators related to employment and education were coded in the social determinant category. Each objective was also categorized into one of the 7 broad areas in PHAB's reaccreditation framework, listed earlier. Within the broad areas, the topics from that framework allow for further specificity in coding the objectives. The list of topics from the reaccreditation guidance was expanded as part of the coding process, in consultation with the research team.
Data analysis was conducted using Microsoft Excel and SAS 9.4 (Cary, North Carolina). The research team determined the percentage of CHAs/CHIPs that included each type of partner and data source and the total number of partner types per CHA/CHIP. The team also calculated whether the CHIPs had at least one objective from each LHI, broad area, and topic. Frequencies were run by size of the jurisdiction (≥100 000 or <100 000) and health department type (state or local).
Documentation from 158 CHAs/CHIPs was reviewed. Of those, 138 were from local health departments and 20 from state health departments. In terms of population size, 121 served a population of 100 000 or greater, whereas the remaining 37 served smaller jurisdictions. The CHAs were published between 2006 and 2015, whereas the CHIP dates ranged from 2009 to 2014.
All CHAs/CHIPs documented collaboration with diverse partners, as illustrated in Table 1. Hospitals and health care organizations were cited most frequently, with all but 2 of the CHAs/CHIPs (99.0%) explicitly indicating this collaboration. About 85% of CHAs/CHIPs referenced collaboration with service organizations (nonprofits that render services to the community, including the American Red Cross and Boys and Girls Club). Partners from a range of other sectors were represented, including education (74.7%) and business (74.0%). In addition, 80.0% of the CHAs/CHIPs explicitly described general citizen participation in their processes.
The percentage of CHAs/CHIPs that stated engagement with each type of partner was also considered by population size and health department type. For most partner types, health departments serving fewer than 100 000 people were more likely than large health departments to include that partner. For example, law enforcement was listed in 59.4% of the CHAs/CHIPs representing small jurisdictions and in only 43.0% of documentation for larger jurisdictions. Similarly, education was included in 86.4% of the small-jurisdiction CHAs/CHIPs and in 71.1% of the larger jurisdictions. Local CHAs/CHIPs were more likely than state ones to reference several of the partner types, including business, faith-based, and law enforcement.
Of the 11 partner designations, all CHAs/CHIPs referenced at least 2 types of partners and 3.8% (6 CHAs/CHIPs) referenced all 11 of them. Health departments had on average 7.0 of these 11 partner types. A CHA/CHIP was coded to a partner type if it referenced at least one partner that fell into that category; one CHA could reference multiple partners of the same partner type. Local health departments included 7.3 types of partnerships on average, whereas state health departments partnered with 5.4. The mean number among CHAs/CHIPs in smaller jurisdictions was 7.5, whereas the mean for larger jurisdictions was 6.9.
This diversity of sectors is also reflected in the sources of the data incorporated in the CHAs/CHIPs. The most common data sources were US Census (94.9%), Behavioral Risk Factor Surveillance System (BRFSS)/Youth Behavioral Risk Factor Surveillance System (YBRFSS) (80.4%), and County Health Rankings (60.1%) (data not shown). However, many of the CHAs/CHIPs also referenced state or local specific data sources such as those related to education, crime, and transportation.
From the CHIPs, 2444 objectives were extracted. The average number of objectives per CHIP was 15.1. All objectives were coded with a broad area and 94.1% were also coded with an LHI.
The Healthy People 2020 goals were launched in December 2, 2010,24 and have been adopted by many health departments. Nearly all (88.6%) of CHA/CHIP documents explicitly referenced the Healthy People 2020 goals in their documentation. The objectives categorized by LHI are illustrated in Table 2. In total, 89.9% of health departments had at least one objective that addressed the LHI nutrition, physical activity, and obesity. More than three-fourths (76.6%) addressed access to health services. Tobacco and substance use was also an important consideration for health departments, and more than 40% of them had an objective addressing each of those issues.
The objectives were also categorized into the broad areas from the PHAB reaccreditation population health outcomes reporting framework. Results of that analysis are shown in Table 3 (no indicators were categorized under the broad area of genetics, and it is omitted from the table). Two of the broad areas were represented in more than 80% of the CHIPs: preventive health care (85.4%) and individual behavior (82.3%).
The LHI and broad area analysis was also conducted by health department type and jurisdiction size. In almost all cases, a larger percentage of CHIPs from state and large health departments included at least one indicator in each category compared with local health departments and small health departments. Among the few exceptions is that the broad area of social environment was more prominent among local health departments (48.6%) than among state health departments (30.0%). There are differences in the average number of objectives by health department type, with state CHIPs including on average 27.5 objectives and local health departments containing 13.7. Larger health departments had a slightly higher average number of objectives than small health departments (15.9 and 14.2, respectively).
Table 4 shows the topics from the reaccreditation framework that were addressed by at least 10% of the CHAs/CHIPs, organized by broad area. While the LHI for nutrition, physical activity, and obesity does not have an equivalent broad area, it is represented in topics under the individual behavior broad area, including physical activity/inactivity levels (43.0%) and healthy eating patterns (38.0%). It is also represented under the health-related quality-of-life broad area as obesity (55.1%), under the physical environment broad area as access to healthy foods (50.0%), and access to exercise opportunities/public transportation and community walkability (42.4%). Mental health also appears in topics under several different broad areas, including the preventive health care broad area of access to mental health providers (36.7%) and the health-related quality-of-life category of mental health (21.5%). Suicide was also considered in the CHIPs and is the leading mortality topic (18.4%). Additional topics of note include tobacco use (43.7%) and opioid and prescription drug abuse (13.3%).
This study demonstrates that accredited health departments are engaged in cross-sector collaborations to address a wide array of public health issues. Not only do nearly all (99.0%) of the CHAs/CHIPs include representation from hospitals and health care organizations, but also a broad array of other types of partners are included, especially education and service organizations. Notably, nearly three-fourths of the CHAs/CHIPs included business representation. Other sectors are also involved; for example, law enforcement was included as a partner in nearly half of the CHAs and transportation data were incorporated in the CHAs. While this is not unexpected, given the emphasis in PHAB's requirements on engaging diverse partners to collaboratively understand community health needs and assets, this study provides confirmation that PHAB-accredited health departments are engaging in the type of cross-sector collaboration encouraged in the Culture of Health.25
Smaller health departments were especially likely to engage a broad array of partners. Nearly all the partner organization types were more commonly included in the CHAs of jurisdictions under 100 000 than in larger ones. This finding is consistent with past research indicating that partnerships may play a particularly important role in helping small health departments offset other capacity limitations.26 , 27 It may also suggest that relying on strong local partnerships might be a helpful strategy to help smaller health departments achieve accreditation.
This study also builds understanding about the health objectives included in CHIPs. Findings are consistent with previous studies that have found nutrition/obesity/physical activity, access to medical care (particularly mental health services), and substance abuse as common priorities in improvement planning.15 , 28 , 29 Accredited health departments and their communities are tracking outcomes that focus on a range of determinants of health. In addition to access to health care and preventive services, they are monitoring—and planning actions to address—individual behaviors and the social and physical environments. This multipronged approach is important in moving the needle in population health.
While this study contributes to our understanding of partnerships and health outcomes of interest to accredited health departments, there are several limitations. First, several outcomes could have been coded to multiple LHIs and broad areas/topics. For example, an outcome about access to oral health care could have been coded to both oral health and access to health services. Efforts were taken, including the use of a codebook and the review by the research team, to ensure that similar outcomes were coded consistently in this study. However, different choices in the guidelines for coding outcomes would have led to differences in the results. Second, the CHA/CHIP documentation that was used for this study was submitted to PHAB as part of the accreditation process. In some instances, the health departments submitted multiple documents to illustrate how they demonstrated their conformity with the specific components of the CHA and CHIP measures. Because the analysts were not always reviewing a single, comprehensive CHIP, it is possible that some health departments are tracking additional outcomes through their CHIP process that were not captured in this study. Third, the limited number of small health departments in the study makes it difficult to draw conclusions about differences between health departments of different sizes. Finally, because these were documents provided by the first approximately 160 accredited health departments, they are not representative of CHAs/CHIPs from all health departments nationally. These findings represent early adopters of accreditation and should not be generalized beyond that.
Additional research could build on findings from this analysis. As more health departments are accredited, it will be possible to make more robust comparisons by health department size or type. It would also be appropriate to further explore how accredited health departments are using their CHAs/CHIPs to address health equity. The reaccreditation requirements document for population health outcomes reporting indicates that health departments may track measures that are specific to certain subpopulations in an effort to better understand potential inequities. Given that many of the CHIPs did address social determinants of health, it will be interesting to explore if the way health departments are monitoring health outcomes allows them to measure progress in improving health equity.
This study sheds light on ways accredited health departments work collaboratively to improve the health of their communities. Strengthening partnerships and increasing the understanding of community needs, assets, and inequities are among the short-term outcomes of accreditation that are believed to contribute to eventual improvements in community health status, as articulated in the accreditation system logic model.30 , 31 This study begins to tell the story of how accreditation contributes to improved community health by documenting the partnerships and health priorities of accredited health departments. The field will learn more as PHAB begins to collect population health outcomes through reaccreditation.
Implications for Policy & Practice
- Accredited health departments engage with diverse partners in their community health assessment and improvement planning processes. These collaborations may be particularly important for small health departments that achieve accreditation.
- Accredited health departments are monitoring outcomes related to multiple determinants of health—preventive health services, individual behavior, and social and physical environments. This may be a productive strategy for improving community health.
- Nearly all accredited health departments report working with health care partners. By working closely together in planning for improvement of the health status of the population they jointly serve, health departments and health systems have the potential to address many of the multiple determinants of health.
- Follow-up studies, using the population health outcomes reported as part of reaccreditation, have the potential to expand our understanding of accreditation and its impact.
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