PARTNERSHIPS: Case Reports
Over the past few decades, Ohio has consistently fallen near the bottom of America's health rankings, with significant disparities and inequities for many health outcomes by race, income, and geography. In December 2014, Ohio received a grant that catalyzed efforts to address these challenges. The federal Center for Medicare & Medicaid Innovation awarded Ohio a 4-year $75 million State Innovation Models test grant, which required a population health plan. The plan objectives were (1) to make recommendations about population health planning and infrastructure in Ohio and (2) to align health priorities among public health and health care. With a population of 11 million residing in 88 counties with more than 100 local health departments (LHDs) and multiple health care systems across the state, developing a coordinated population health planning infrastructure was imperative. Ohio's new statutory requirement for mandatory public health accreditation for all LHDs by 2020 added significant momentum to these efforts. Public Health Accreditation Board (PHAB) Standards and Measures provided the necessary framework for this process.
The Planning Process
The Ohio Department of Health (ODH) and the Governor's Office of Health Transformation contracted with the Health Policy Institute of Ohio (HPIO), a nonprofit organization that provides independent analysis for policy makers (Table). HPIO convened a broad-based Population Health Planning Advisory Group as well as a subgroup of LHDs, hospitals, and allied professions. Planning began with a comprehensive review of data across a range of health domains. Creating strategic alignment between the State Health Improvement Plan (SHIP), county-level Community Health Improvement Plans (CHIPs), and hospital Internal Revenue Code (IRC) requirements was an important objective in the process. To that end, HPIO constructed a crosswalk describing the range of community health priorities that emerged from the CHIPs.1 Overall, there were many similarities among the top health priorities identified in CHIPs from across the state. This crosswalk served as a basis for the development of a menu of statewide priorities that LHDs could choose from to demonstrate alignment with the SHIP toward improving the collective health status of Ohioans. The next key challenge was synchronization of timelines in the context of PHAB and IRC requirements for tax-exempt charitable hospitals. PHAB Standards 1.1 and 5.2 require local and state health departments to develop health assessments (SHA, CHAs) and health improvement plans (SHIP, CHIPs) within a 5-year period. The IRC requires tax-exempt hospitals to conduct a community health needs assessment (CHNA) and adopt an implementation strategy (IS) every 3 years. Many LHDs were already well established in a 5-year cycle for their CHA/CHIP, and others were working to establish a planning cycle to sync with the 2020 accreditation mandate. Reconciliation of these time frames was critical for the successful alignment of population health planning in Ohio.
The report of this work was released in January 2016.2 Four major recommendations emerged: align health priorities across clinical medicine and public health; align planning timelines for conducting health status assessments; develop an allocation approach for community benefit funding; and ensure transparency and accessibility of health assessments and improvement plans. The ODH was charged with developing a guidance document to assist communities with the implementation of these recommendations. Legislation was passed by the Ohio General Assembly in July 2016 for those recommendations where consensus could be achieved.3 All LHDs and tax-exempt hospitals are now required by statute to submit assessments and plans to the state on an established cycle. Tax-exempt hospitals are also required to submit their Schedule H annually, and the state must make all plans, assessments, and schedules available online.
Improving Population Health Planning in Ohio: Guidance for Aligning State and Local Efforts was released in January 2017.4 The guidance document was informed by PHAB Standards and Measures, the Patient Protection and Affordable Care Act, research on best practices, and input from stakeholders. Highlights of the guidance document include the following:
- LHDs and tax-exempt hospitals should be the lead partners in the assessment and planning process. Planning should include a broad range of community partners as required by PHAB Measure 1.1.1 for LHDs and outlined in 26 CFR 1.501(r)-3 for hospitals.
- The MAPP (Mobilizing for Action Through Planning and Partnerships) framework should be used by communities across the state. This framework is recognized by PHAB in Measure 5.2.1, and hospitals can adapt the framework to meet their federal requirements.
- Local community planning should align with the SHA and SHIP by selecting at least 2 priority areas from the SHIP to include in their collaborative CHIP and IS planning process. All planning should be guided by data, with an emphasis on decreasing health disparities and achieving health equity.
The guidance document provides a timeline and details on synchronization toward a common 3-year planning cycle by 2023, while still adhering to respective PHAB and IRC requirements.
In reflecting on Ohio's population health work, our team has identified several essential components that may be valuable for communities to consider in their planning processes.
- A champion that has clout to lead a diverse statewide coalition was identified. The Governor's Office of Health Transformation was critical to the design and implementation process, working to ensure all the diverse partners participated and stayed at the table, while shepherding the statutory changes through the legislative process. This vision and visible leadership at the top was essential.
- The key partners were well represented, and those parties directly affected by the recommendations had a specific forum for vetting their concerns toward developing consensus during the planning process and legislative phase.
- A neutral and knowledgeable partner gathered data, facilitated meetings, and prepared the report (HPIO).
- Legislation was proposed and ultimately passed on those issues where consensus was achieved. In ensuring accountability, partners agreed to create a state-level repository for tracking progress and aggregating data to ensure the desired outcomes of alignment and common health priorities are met.
- Notably, PHAB Standards and Measures served as the foundation for the SHA/SHIP and CHA/CHIP alignment. And, because so many LHDs are pursuing accreditation, they are more actively engaging their community partners and looking for opportunities to improve their work on population health issues. Accreditation requirements provided a strong framework on which to advance the population health planning infrastructure in Ohio.
The state biennial budget that was passed in June 2017 sets aside $3.5 million to assist LHDs that choose to merge or form shared service models such as a Council of Governments. Portions of the funds can be used to hire an accreditation coordinator, pay accreditation fees, or fund other accreditation-related work or technical assistance. Another portion is earmarked to provide a base level of resources to LHDs to support activities toward aligning their community health assessments with local health care systems. To that end, the state budget also provides up to $1 million to assist LHDs in transitioning from a 5-year planning process to a 3-year frequency consistent with IRC requirements. The budget also includes funds to double the existing state subsidy as an incentive for those LHDs that have achieved PHAB accreditation.
Ohio has a rollout of planning alignment among state and local public health and hospitals that concludes in 2023. Our next step is to provide technical assistance and facilitated discussion among LHD and hospital leaders to develop common metrics and a model for collaboration on the CHA/CHIP and hospital CHNA/IS, leading to a shared needs assessment process by 2020. Ohio is confident that this supportive approach toward alignment provides a foundation to improve population health outcomes in our state.
2. Health Policy Institute of Ohio (HPIO) for the Ohio Governor's Office of Health Transformation, Ohio Department of Health and Ohio Department of Medicaid. Improving population health planning in Ohio. http://www.healthpolicyohio.org/populationhealth
. Published January 2016. Accessed July 21, 2017.