View All In: Data for Community Health – past & present in a full screen map
Addressing Healthcare’s Blindside in Albuquerque’s South Side (AHBASS) targets the low-income Southeast Heights and South Valley neighborhoods in Albuquerque, New Mexico. Bernalillo County, which encompasses metro Albuquerque, is characterized by both extreme poverty and wealth, with disadvantaged neighborhoods displaying markedly worse health outcomes than wealthier ones. AHBASS’s vision is to reshape the community to promote healthy eating, active living, and education that can lead to job opportunities. They have created a membership rewards program that incentivizes healthy behaviors and keeps participants engaged through events, email, texts, and an app. AHBASS hopes to use this program to connect people with the services they need, track their movement between programs, and provide wellness rewards for participation.
In 2015, the Irvington Health Department, local organizations and community stakeholders determined that a more effective approach to improving the quality of life for residents involved the formation of the Irvington Health Coalition. As a Coalition, members aimed to utilize data to support the development of future initiatives, which would target the primary health concerns within the Township. Due to the fact that large scale data specific to Irvington Township was not readily available, the Coalition mainly utilized data associated with Essex County. Preliminary research collected from resources associated with County Health Rankings and existing public data, indicated that the prevalence of environmental hazards, obesity, teenage pregnancy, sexually transmitted infections, unemployment, and low family and social support are primary areas of local concern. These concerns will be addressed as outlined in the Blueprint for Action.
All Chicago Making Homelessness History, a not-for-profit organization dedicated to ending homelessness across Chicago, and the University of Illinois Hospital and Health Sciences System (UI Health) are partnering to engage in the CHP Program. The team will work to improve care coordination for Chicago residents who are housing insecure or homeless by integrating data from UI Health’s electronic health records with information about housing status from the Homeless Management Information System managed by All Chicago. UI Health and All Chicago anticipate that these efforts will lead the way for greater integration of housing, health, and human services delivery systems at a national level.
All Children Thrive (PHIL)
Long Beach, CA
The City of Long Beach is embarking on an initiative to see all children living in our city have the resources and opportunity to thrive. The City of Long Beach Department of Health & Human Services will be leading this work with key partners including: The Children’s Clinic, Building Healthy Communities Long Beach, Long Beach Alliance for Children with Asthma, SAFE Long Beach Violence Prevention Plan, and other City of Long Beach departments of Finance and Libraries. This team will address social determinants of health utilizing an equity lens, authentic community engagement, and partnerships that support collective impact, focusing on children ages 0-8 and their parents. The goals of All Children Thrive will be determined and agreed on by the residents, parents, and families of Long Beach, through a series of community dialogues to take place in the Spring of 2018.
The Allegheny County Health Department (ACHD) is forming the Allegheny Data Sharing Alliance for Health—a connected data warehouse that combines data from multiple sectors to create a more complete picture of the factors impacting the cardiovascular health of the county’s 1.2 million residents. The collaboration will merge existing data sets from five sectors: public health, human services, economic development, healthcare, and transportation. Once amassed, the data will be exported to a modeling platform, the Framework for Reconstructing Epidemic Dynamics (FRED). Ultimately, a geographically accurate model of the complex distribution of cardiovascular disease risk factors in the county will enable the community to test the potential impact of various interventions.
St. Paul, MN
Altair, with Lutheran Social Service of Minnesota as fiscal sponsor and lead member, envisions an e-Health infrastructure that fully integrates primary care (including supplemental mobile health services), behavioral health, and social services to improve the quality of life of people with disabilities in the Twin Cities. The project is bringing behavioral health providers into a state certified Health Information Exchange (HIE), enabling care teams to proactively assess the behavioral health needs of people with disabilities within a Minnesota Accountable Care Organization (ACO).
American Diabetes Association – Colorado Area (Connecting Communities and Care)
Address prediabetes using the Prevent Diabetes STAT (Screen, Test, Act Today) program in collaboration with the American Diabetes Association (ADA) – Colorado Area and Kaiser Permanente Colorado (KPC). The collaboration will create strong networks where patients at KPC are linked to community-based resources through the ADA – Colorado Area’s Latino Initiatives programs.
Avondale Children Thrive (BUILD 2.0)
Arguably one of the greatest health issues facing Cincinnati, and most especially Avondale, is the community’s high rates of pre-term birth and infant mortality. Avondale Children Thrive (ACT) reflects a cross-sector collaboration to address the social determinants of children’s health, and specifically, on those interventions that address maternal and child health early on. Partners seek to create an environment in which Avondale children, aged zero to six, are able to thrive related to a variety of factors, such as education, community engagement, safety, employment, and health. The program employs an innovative health champion model, drawn from, and for, the community and employs a door-to-door strategy—leveraging trust built as housing providers and neighbors.
Baltimore City Health Department (PHNCI)
Since launching “Baltimarket” in 2010, the Baltimore City Health Department (BCHD) has been a leader in utilizing grocery delivery as a food desert solution. After developing the Virtual Supermarket, a successful model for group-based online grocery ordering and delivery to low-income communities, BCHD pushed for federal policy change. In January 2017, the USDA selected seven retailers to pilot online SNAP acceptance, three of which are in Maryland. With its PHNCI grant, BCHD is working to increase access to healthy food by supporting the implementation of the USDA’s online SNAP pilot in Baltimore, providing support for residents and grocers as well as advocacy for program policies and processes that maximize accessibility of online grocery ordering and delivery. The project will create a train-the-trainer learning network that will develop tools to support implementation of online SNAP orders in community sites such as libraries, schools, recreation centers, and the facilities of community-based partners.
The Baltimore City Health Department (BCHD)—working with a collaborative that includes the Mayor’s Office, CRISP (Maryland’s HIE), community-based organizations and nonprofits, and faculty at Johns Hopkins and the University of Maryland—is leading a city-wide effort to reduce falls among residents age 65 and older. B’FRIEND is creating a real-time data surveillance system that will track fall-related emergency department visits and hospitalizations. The project is also integrating core medical data with other health, housing, environmental and social service data related to fall risks. Data analyses will be used to align community programs, direct place-based interventions, develop new interventions, and inform a public health campaign.
Believe in a Healthy Newark (NJHI)
The Believe in a Healthy Newark (BHN) Initiative will develop Impact Teams that will focus on three areas of health relevant to the Initiative’s target population – the residents of the South and West Wards of Newark. These three areas include: Healthy Homes, Adverse Childhood Experiences, and Food and Fitness. BHN will utilize a collective impact approach that will allow them to identify common measures, develop common interventions, and use assessments of their success to modify and strengthen their initiatives. These areas closely align with the interests and expertise of steering committee members, and it is expected that this work will result in demonstrable improvements of certain health measures enumerated in the County Health Rankings data for Essex County.
Boyle Heights, CA
The Boyle Heights Accountable Community for Health is housed at The Wellness Center at Historic General Hospital, a collaborative partnership model facilitated by the LAC+USC Medical Center Foundation and in continuous operation since 2014. The partnership includes 15 distinct nonprofit community-based organizations with collocated offices at The Wellness Center (TWC). Collectively, we provide no cost health and wellness services to Los Angeles’ most vulnerable residents, helping them navigate to resources that remove barriers to care and build personal resiliency to achieve and maintain good health. TWC serves families and the community as a whole through intergenerational and community programs that promote advocacy and build capacity. Our services respond to the needs of our client population; we coordinate responses around trauma-informed care and mental health, chronic disease management and prevention, pain and mobility, healthcare access and legal services, and food and housing insecurity. Through the CACHI Accelerator opportunity, we are honing our collaborative model and strengthening our community presence as a trust center and center of excellence for trauma-informed services, as we respond to the wellness needs of our neighbors in Boyle Heights and the larger Los Angeles community.
Bridging Health and Safety in Near Northside (BUILD 2.0)
Residents of the Near Northside neighborhood are caught in a cycle of poor health. They face multiple stressors including health disparities, environmental challenges, and public/personal safety threats. This partnership will take steps to address and amend several of these upstream health and safety issues, including: creating safe public spaces, engaging residents in identifying hot spots and creating policy changes to address them; making improvements to the built environment, such as sidewalks, crosswalks, truck routes, lighting, and wayfinding; ensuring healthy homes through assessments, remediation, and repair; and utilizing technology to collect, analyze, and share data.
Bronx Healthy Buildings Program (BUILD 1.0)
Bronx, New York City
The Bronx Healthy Buildings Program aims to reduce asthma-related hospital visits and address the social determinants of health through education, organizing, work force development, and building upgrades. Using several data sources, the Program will pinpoint distressed buildings that are drivers for high rate emergency room visits. Energy audits, building inspections, and tenant organizing will identify needed repairs and opportunities for energy efficiency improvements. The Program will secure funds for local contractors to complete the work. Additionally, the program will recruit, train, and hire tenant leaders to be Community Health Workers; they will be responsible for the education of other tenants on behavioral interventions and asthma self-management practices. Finally, the Program will evaluate the health benefits and cost savings to the healthcare system after the implementation of this project.
BUILD Health Aurora (BUILD 2.0)
The Aurora BUILD Health Challenge responds to psychosocial, developmental, and family well-being needs identified through screenings and interventions delivered in community settings. The partnership creates a continuum of early childhood mental health supports delivered in a local WIC office, primary care clinics, and other community settings to address the upstream needs of families with young children and enhance social emotional well-being. Community Health Workers (CHW) and early childhood mental health specialists collaborate to identify family needs and provide resources for prevention, health promotion, and interventions. The partnership is focused on developing and implementing the necessary agency, community, and systems-level changes to provide a continuum of care.
BUILD Health Mobility (BUILD 2.0)
New Orleans, LA
This collaboration brings new and unique data assets to local policy and planning decisions related to mobility and marks an unprecedented opportunity to influence the New Orleans built environment and policy landscape. By building and leveraging a distinctive, integrated health equity data system (HEDS), this effort addresses persistent mobility barriers that underlay disparities in chronic disease rates in the Claiborne Corridor. Using HEDS to collect and integrate clinical, social, and community infrastructure data, this team will provide focused, geographically specific analyses to inform efforts to promote population health and equity—and ultimately inform policy recommendations, such as: optimal bus routes, opportunities for streetscape interventions for accessibility and walkability, and innovation of Medicaid transportation.
Get Healthy Camden is a working group of the Camden Collaborative Initiative, and a coalition of partners from multiple sectors aimed at integrating health into community development planning, “complete streets” transportation projects, sustainability initiatives, and more. Based on the County Health Rankings, Get Healthy Camden’s Blueprint for Action is a three-point plan to improve health outcomes in Camden by addressing community health and wellness, equitable change and sustainability, and improving environmental conditions that impact walkability and bikability. The Blueprint includes goals such as instituting healthy food and beverage options at three major employers, and expanding the Camden Night Gardens event to attract more trail users.
Cape May, NJ
Local organizations and community stakeholders from Cape May County’s health, education, business and not-for-profit sectors determined that a more effective approach to advancing health in the Cape May community involved the formation of the Cape Regional Wellness Alliance. The Alliance identified Adverse Childhood Experiences (ACES) as a community health priority, and its Blueprint focuses on promoting resiliency among youth. Among the strategies outlined in the Alliance’s plan is collecting data that correlates known trauma occurrences for children up to 18 years old, such as parental separation, hunger and substance abuse in the home to quantify previously undisclosed cases of ACES. By integrating this data from medical, education and law enforcement partners, the Alliance intends to develop and implement a comprehensive community education campaign in the Cape May County communities of Lower Township, Middle Township, Wildwood and Woodbine. Scroll down to access Cape Regional Wellness Alliance’s Blueprint.
The North Jersey Health Collaborative envisions improved health equity within Morristown’s census tract 435. Partners within this coalition represent public health, social services, and other community organizations. North Jersey Health Collaborative conducted a needs assessment that determined substance abuse is a key health factor impacting neighbors in census tract 435. This Blueprint for Action also proposes ideas to improve the area’s built environment as well as involve more residents and youth in civic engagement opportunities, with a goal of shifting the perceptions regarding neighborhood safety and sense of community.
Asbury Park, NJ
Led by Meadowlink, five coalition members is participating in a year-long Boundary Spanning Leadership Institute delivered by the Center for Creative Leadership. This team of five coalition members representing sectors including healthcare, community residents, social services, business, public safety and education, is sharing the skills and tools from this Institute with their full coalition to strengthen the coalition’s capacity to make long-term change in their community. The team also includes a community coalition coach who is deeply rooted in the community and acts as an advisor to the team and the larger coalition as they embark on creating a Culture of Health in Asbury Park. The coalition has developed a blueprint for action, outlining its work and timeline for the remaining three years of grant funding. Scroll past the first two videos to access the link to the blueprint.
Building a Healthy and Resilient Liberty City (BUILD 1.0)
Liberty City, FL
Working collaboratively with Liberty City neighborhood leaders, the Florida Institute for Health Innovation, Miami Children’s Initiative, Jackson Health Systems and the Florida Department of Health in Miami-Dade County will address crime and violence in Liberty City as barriers to community health. Miami Children’s Initiative will use its “block-by-block” strategy, working directly with Liberty City residents, and together with Catalyst Miami, will leverage its Parent Leadership Training to build community capacity for resident-driven action. Health care, public health and community leaders will work together to identify and address root causes of crime-driven health outcomes, leverage community and health resources, and strategically plan for improved public safety, using evidence-based and community-designed crime prevention and restorative justice interventions.
Building Bridges to Health (NJHI)
Boud Brook and South Bound Brook, NJ
Local organizations and community stakeholders from Bound Brook’s and South Bound Brook’s health, education, business and not-for-profit sectors determined that a more effective approach to advancing health in their communities involved the formation of the Building Bridges to Health coalition. While the annual County Health Rankings point to Somerset County as one of the top three healthiest counties in New Jersey, the Coalition found that county-level statistics do not accurately reflect the characteristics, health factors and health outcomes of the smaller communities of Bound Brook and South Bound Brook. Surveying community members to inform its Blueprint, the Coalition identified that addressing the built environment, and particularly access to transportation, presents an opportunity to impact community health. The Coalition’s Blueprint also outlines next steps for expanded school-based programming, and partnering with trusted local organizations to develop programming for children, families and older adults that promotes wellness.
BUILDing Health and Equity in East Portland (BUILD 1.0)
East Portland, OR
BUILDing Health and Equity in East Portland, Oregon, is a historically underserved area of Portland with low levels of educational attainment and high rates of poverty. Population growth has outpaced the development of food access, affordable housing, and other vital elements of urban infrastructure, resulting in health inequities and social disparities. These barriers to health have resulted in high rates of chronic diseases, including diabetes, cardiovascular disease, asthma, and obesity. BUILD will aim to end the cycle of toxic stress, reduce chronic disease and its causes, promote health equity, and reduce disparities. The partnership is connecting governmental, community, and business stakeholders to invest in the infrastructure of East Portland, improve health equity, and reduce health disparities in the region.
Building Uplifted Families (BUILD 2.0)
Charlotte, NC, was last among 50 U.S. cities in upward mobility because of inter-generational poverty, low educational attainment, and health disparities. This project aims to improve mobility by addressing disparities, enhancing local capacity, advancing partnerships, and improving preventative healthcare access. In addition, workforce training and mentoring to improve earning potential, reduce use of high-cost services, and reinforce family stability will also be a focus.
Care AC (NJHI)
Atlantic City, NJ
The CARE AC coalition surveyed more than three dozen civic and community organizations to identify pressing issues that are barriers to health in Atlantic City. The responses included a lack of safe play spaces, negative community perception, and resource connectivity at health care visits. In their Blueprint for Action, CARE AC proposes offering mini-grants as the model that will build a healthier community. The Blueprint highlights plans to launch a fruit and vegetable prescription program among local health care providers and secure a “Playful City USA” designation for the city in 2017 to address the health behaviors, the socioeconomic factors, and the physical environment challenging Atlantic City. CARE AC’s partners include AtlantiCare, the Boys and Girls Club of Atlantic City, Stockton University, Jewish Family Services, CASA for Children, the Community Food Bank of NJ, and the Atlantic City Tourism District.
Chandler Park Healthy Neighborhood Strategy (BUILD 1.0)
The Eastside Community Network (ECN), in coordination with St. John Providence Health System – Community Health Investment Corporation and Detroit Department of Health and Wellness Promotion, aims to enhance both the social and urban infrastructure in the 48213 zip code in east Detroit. Through greater engagement of residents, the three groups seek to further improve upon the recent progress made in Chandler Park — an established community initiative with similar goals. The BUILD Health Challenge Grant will allow the collaborating partners behind the “Healthy Neighborhood Strategy” initiative to accelerate their efforts to restore the areas around the park – clustering education, recreation, conservation, and green infrastructure around a community gathering space to improve safety, make it easier for residents to stay active, and rebuild a cohesive neighborhood.
The Chicago Department of Public Health (CDPH) with its partner at the University of Chicago’s Center for Data Science and Public Policy created a predictive model that helps identify young children at risk of being lead poisoned in homes with lead paint. The model provides an opportunity to prevent lead paint exposure through proactive home lead inspections and blood testing at an earlier age. The predictive model combines data from multiple sectors including public health, census, buildings and the county assessor’s office to create realtime interfaces that identify where at-risk children live. CDPH housing inspectors will be alerted to inspect the homes of at-risk children for lead paint hazards either through an application or by physicians at community health centers through electronic health records (EHR).
The Children’s Comprehensive Care Clinic is a not-for-profit organization dedicated to finding innovative approaches to pediatric health challenges. With the support of the CHP program, the Children’s Comprehensive Care Clinic will work with its partners to improve care for families of children with medical and behavioral complexity throughout multiple counties in the Austin, Texas area. Through collaboration among multiple sectors including health care, social services, community-based organizations, and education, they will build and provide a patient-controlled common technology platform. The effort aims to bring together individuals and entities involved in the care of a child, with the patient and family at the center, and anticipates developing a sustainable, integrated, participatory health care data ecosystem.
The Cincinnati Children’s Hospital Medical Center (CCHMC) is a not-for-profit organization working to improve child health and transform delivery of care through fully integrated, globally recognized research, education and innovation. In an effort to identify hot spots of poor child health and to understand the underlying social determinants of health, they will work with the CHP Program to reduce inpatient hospitalizations for pediatric patients with the use of electronic health records and geographic information systems in its community. The use of data across sectors will improve CCHMC and its partners’ ability to identify and address root causes of poor health outcomes within the community. CCHMC anticipates that work undertaken during CHP will translate to other Cincinnati neighborhoods in the future.
City of Longmont (Connecting Communities and Care)
Implement education programs and activities that can increase Longmont’s community capacity to identify signs of people who are struggling with mental health issues in order to intervene earlier and connect individuals to resources.
Cleveland Healthy Home Data Collaborative (BUILD 2.0)
The Cleveland Healthy Home Data Collaborative (CHHDC) is a new healthy housing data system. The initiative is grounded in neighborhood community engagement that enables physicians, public health officials, and the public to easily access collaborative, useful information to address health disparities—with a focus on asthma and lead poisoning. Geocoded housing data relevant to determinants of health is analyzed and prioritized to provide risk-stratified, place-based information. Value-added data from multi-sector sources is used for identifying lead-safe housing, determining patient risk for asthma, supporting public policy, and targeting public health programs.
Collaborative Cottage Grove (BUILD 2.0)
Collaborative Cottage Grove’s Community-Centered Health program is committed to the transformation of health, equitable community development, and inclusion of cultural diversity. The partners are leaders in changing housing systems to align health and housing. They are not only mapping asthma hospital visits and housing condition data to identify communities in need of support, but they are also developing an electronic referral system to link families with asthma education and housing assessments, and developing funding for remediation and rehabilitation. Cottage Grove aims to foster healthy, resident-led communities by integrating community empowerment with environmental changes and high-quality, onsite, primary and behavioral health care. These efforts will ultimately create a positive and measurable impact on hospital emergency visits and health disparities in the community.
Colorado Black Health Collaborative (Connecting Communities and Care)
Building on existing referral systems, this program aims to link black patients from clinical sites in metro Denver to vetted community resources to improve cardiovascular health.
Colorado Coalition for the Homeless (Connecting Communities and Care)
Provide recovery-focused transitional housing to homeless individuals with co-occurring mental illness and substance use disorders. Fort Lyon Supportive Residential Community College Network provides college level courses and vocational certification/classes in partnership with Otero Junior College and Lamar Community College.
The environment in which people live, work, and learn has a profound impact on health, but policies and programs that shape environments generally fall outside the jurisdiction of health agencies. The Colorado Department of Public Health & Environment (CDPHE) is implementing a “health in all policies” (HiAP) approach to address equity across sectors and lead to sustained improvements in the social determinants of health. With its PHNCI grant, CDPHE is advancing its HiAP approach by delivering a community leadership coaching model and a meaningful community engagement workshop to government leaders, with the goal of increasing capacity for collaboration among them. In addition, CDPHE will form a Colorado equity alliance comprised of 20 multidisciplinary partners working on “winwin” initiatives; harness the power of data to decrease inequities; leverage state dollars to support local policy change and spur cross-disciplinary networks by hosting a statewide Equity Summit.
Colorado Springs Fire Department (Connecting Communities and Care)
Colorado Springs, CO
Enable the Community Assistance Referral and Education Services (CARES) behavioral health team to continue finding emergency services super-utilizers appropriate community resources for their ongoing health through increasing the team’s caseload by 60 patients. With this support, CARES could provide much needed additional services for the 76 percent of CARES EMS users with behavioral health complaints.
Santa Maria, CA
The Dignity Health Foundation, a not-for-profit organization that aims to improve screening and treatment for postpartum depression by engaging pediatricians, obstetricians, mothers’ primary care providers, and others key stakeholders in health care, has joined the CHP program. To address the link between maternal and child health by reducing stigma and increasing screening and treatment of postpartum depression, they will foster a collaboration between the Marion Regional Medical Center and a number of Community Partners serving the Santa Maria Valley in southern California. With support from the CHP Program, the Dignity Health Foundation will develop a postpartum depression toolkit, which would include a directory for web-based resources, and processes for data sharing and training materials for community health workers, that can be shared with other health systems.
DuPage County Health Department (PHNCI)
The large population of individuals with mental illness in the nation’s criminal justice system, and their risk of recidivism, is an ongoing public health challenge. To reduce their numbers and minimize their risk of recidivism, the DuPage County Health Department (DCHD) is partnering with the DuPage County Sheriff’s Office to implement the DuPage County Post-Crisis Response Team (PCRT) project. DCHD is using its PHNCI grant to advance strategies such as cross-sector teams comprised of a mental health clinician and a DuPage County sheriff’s deputy to conduct follow-up visits with individuals with potential mental health issues who have previously encountered law enforcement and link them to the appropriate care. PCRT’s Sequential Intercept Mapping workshop is also examining opportunities for data collection and analysis created by the unique partnership of DCHD and the DuPage County Sheriff’s Office, including standardizing Uniform Crime Reporting codes used to document mental health-related calls to law enforcement.
East5ide Unified (BUILD 1.0)
Five neighborhoods (Cole, Clayton, Five Points, Whittier, and Skyland) in Denver, CO, have deep community roots strong social ties, and valuable assets to support children, but issues including racism, economic and educational inequalities have hindered their ability to achieve their full potential. By building and strengthening relationships and partnerships needed to increase community cohesion and connectivity, East5ide Unified is building a network of support systems and community-wide commitment to level the playing field for young children before they start school.
Santa Clara County, CA
With the leadership of Santa Clara County Public Health Department, the PEACE Partnership is coordinating organizations from multiple sectors to implement interventions and strategies to build healthier environments and address violence, trauma and the linked health challenges. The PEACE Partnership works to prevent violence and trauma, build on community strengths and cultural assets, and foster community resiliency. The San Jose Mayor’s Gang Prevention Task Force has been working for decades to reduce violence in the community. Building on their progress, PEACE Partnership has enabled leaders from multiple sectors to move forward the initiative and more effectively integrate how the health system leaders can contribute to addressing trauma as part of the Task Force’s ongoing efforts. This is just one example of how the ACH model promotes a more sustainable health infrastructure — allowing these institutions to work together to address violence and trauma.
Engaging the Community in New Approaches to Healthy Housing (ECNAHH) is set in Cleveland, Ohio, one of the poorest cities in the country. A large amount of the community has substandard, unhealthy, and unsafe housing, which contributes significantly to health conditions such as lead poisoning, asthma, and chronic obstructive pulmonary disease (COPD). These factors have an outsized impact on poor, minority, and vulnerable populations. ECNAHH seeks to improve asthma and lead poisoning outcomes related to unhealthy housing, as well as COPD and injury prevention. By focusing on prevention-based housing maintenance, integrated with strategically targeted home interventions, ECNAHH aims to reduce health hazards in the home.
Essential Access Health (CHP)
Los Angeles, CA
Essential Access Health (EAH) champions and promotes quality sexual and reproductive health care for all. EAH achieves its mission through an umbrella of services, including clinic support initiatives, advanced clinical research, provider training, patient education, advocacy and consumer awareness, and data-driven performance measurement and quality improvement. EAHwill contribute their expertise in data aggregation, technical assistance, and performance measurement and data dissemination. EAH staff is experienced in processing large quantities of data, as well as creating and maintaining data reports from different electronic health records systems. They use these data to populate web-based dashboards where participating agencies can view their performance on a core set of measures and get recommendations on possible corrective actions to improve their results.
St. Louis, MO
FLOURISH seeks to achieve large-scale, lasting improvements in the health and well-being of babies and families by impacting entrenched systems that may not be considered traditionally health-related, but are critical to the helping mothers and babies thrive—specifically, transportation. In the area of maternal/infant health, access to medical appointments and consistent medical care is key to healthier outcomes and addressing racial disparities in infant mortality. This project engages new, cross-sector partners in managed care, Metro Transit, medical transportation, and policy advocacy to improve transportation access for two high need zip codes, thereby disrupting the interdependent systems that hinder families’ access to fresh foods, health care, employment, and social services.
Food for Health: Coordinating Care Across Sectors to Improve Care among Vulnerable Populations (DASH)
The Parkland Center for Clinical Innovation, the Parkland Health and Hospital System, and the North Texas Food Bank and its partner agencies are leveraging the Dallas Information Exchange Portal to improve the diet and nutrition of patients who experience food insecurity and have been diagnosed with chronic diseases like hypertension and diabetes. The project will improve multi-sector care coordination by providing hunger relief agencies with a real-time, electronic one-page summary of clients’ medical and social history so that case workers can recommend appropriate nutritional choices and facilitate chronic disease self-management. Relevant information will also be shared with health care providers at Parkland to enhance their understanding of patients’ needs.
Forward, Franklin (BUILD 2.0)
Franklin Borough, New Jersey, resembles many rural communities. Once the thriving “Fluorescent Mineral Capital of the World,” Franklin now faces steep economic and health disparities. The Forward, Franklin Initiative is addressing these disparities by rebuilding a sense of community and pursuing two upstream, integrated goals: 1) Increasing sense of community via a process of “re-imagining” town identity and enhancing public spaces to facilitate social connection; and 2) establishing a local, data-informed, cross-sectoral, resident and organizational partnership (the Forward Franklin Alliance; FFA). Fueled by local data, the FFA directs grant strategies, while working to systematically change the role residents have in decision-making and transforming health of community members long-term.
Fresno County, CA
FCHIP is a structured and enduring platform where people and organizations are working collectively across sectors to build a culture of health and equity to improve the well-being of all residents in Fresno County. We are shaping and implementing policies, systems and environments that produce measurable improvements in health through collaboration, alignment, and leveraged resources.
Garrett County Health Department (PHNCI)
Innovation and Appalachia are two words not often associated with one another because technology has traditionally lagged in that part of the country. However, Garrett County Health Department’s (GCHD) recent development of the Garrett County Planning Tool, a digital community planning experience, has empowered thousands of historically unrepresented individuals to participate in community planning. The tool is revolutionizing the way the community develops a comprehensive Community Health Improvement Plan and is the first to successfully engage over 25% of the entire county population, from teens to senior citizens. The tool balances what people most care about with the most current data, making sustainable changes possible. With its PHNCI grant, GCHD aims to customize the tool for use by other communities by developing a Universal Community Planning Tool through the development of a manager plug-in that installs inherited open-source libraries, ensuring future, low-cost updates with minimal overhead.
The Greater Detroit Area Health Council (GDAHC) is a not-for-profit organization that has extensive knowledge of data analysis, and performance measurement and data dissemination. GDAHC currently works as one of seven initiatives across the country focused on the use of electronic health records and supporting data to identify population-level issues, such as antibiotic use for viral infections and appropriate screening for Vitamin D deficiencies, with a goal to improve quality, health, and efficiency. They are dedicated to transparency in data sharing, and have successfully launched a system of multi-payer data measurement and public reporting of physician performance on their website (myCareCompare.org). In addition, they successfully provide aggregated individual physical level data to physician organizations to guide quality improvement.
Harris County BUILD Health Partnership (BUILD 1.0)
North Pasadena, TX
The Harris County BUILD Health Partnership is working to alleviate the impact of food insecurity and increase access to healthy food in Pasadena, Texas by launching a new food system that is healthy, sustainable, affordable, accessible, and community-informed. Programs and services address all stages of the food system (production, distribution, and consumption) to improve access to local fresh produce while also closing the gap in upstream factors of workforce and educational opportunity.
Healing South Stockton (PHIL)
San Joaquin County, CA
As part of the larger South Stockton Promise Zone, Healing South Stockton ACH coordinates multiple sectors to implement interventions and strategies to build stronger, accessible, culturally-competent support systems that address the underlying causes of trauma. South Stockton Promise Zone has been working to improve the overall health, educational, and economic outcomes of South Stockton neighborhoods that have been underfunded and underserved for decades. Healing South Stockton is one section of this collaborative that has ensured all of the domains of work in the Promise Zone (issues in housing, health, employment, education, and public safety) have been incorporated into plans for reducing trauma and improving overall health outcomes. This collaboration has played a key role in aligning efforts across the work and eliminating silos between partnerships.
The Druid Heights Community Development Corporation (DHCDC), in coordination with the R. Adams Cowley Shock Trauma Center at the University of Maryland Medical Center and the Baltimore City Health Department, aims to reduce trauma and stress induced by poverty, violence, and the lack of a cohesive community. Solutions promote trauma-informed care and focus on the community. Furthermore, the program seeks to address the sources of such trauma and stress through a combination of preventative measures and data analysis. The collaboration will follow a public health approach to youth violence prevention, using several tactics, including providing case management to pregnant women, teaching literacy and responsible parenting techniques, preventive policing, alternative discipline in community schools, and improved trauma care in community schools
Health Forward / Salud Adelante (BUILD 1.0)
Health Forward/Salud Adelante is working to improve the health and well-being of Cook County Health and Hospital System’s most vulnerable patients. By integrating legal care into health care, they are striving to reduce the negative effects of the social determinants of health on low-income residents. The project is using a data-driven approach to address barriers to health care access, facilitate attorney involvement in immigration advocacy to improve well-being, and equip the community with the tools to decrease health-harming legal issues.
Health Solutions (Connecting Communities and Care)
Expand our Behavioral Health Treatment Court for incarcerated individuals by increasing therapeutic programs within the Pueblo County jail and a Suboxone outpatient clinic. The program provides Moral Reconation Therapy and the evidence-based curriculum “Thinking for a Change.”
Healthier Perth Amboy (NJHI)
Perth Amboy, NJ
In 2016, local organizations and community stakeholders from Perth Amboy’s health, education, business and not-for-profit sectors determined that a more effective approach to advancing health in their community involved establishing the Healthier Perth Amboy Consortium as part of the Middlesex County East Health and Human Services Consortium. Healthier Perth Amboy’s Blueprint details the Coalition’s plan to build a healthier community using strategies that establish workplace wellness, healthy school environments, and access to healthy foods. The Coalition’s goals also include fostering an economic climate that is conducive to a healthy community by investing in local businesses and stabilizing housing costs. Scroll down to access Healthier Perth Amboy’s Blueprint.
Healthy Hill Initiative (BUILD 1.0)
HAPHousing and its partners seek to capitalize on the current resources available in Old Hill, improving the existing structures that are underutilized, and expand upon those that are successful. The BUILD Health grant will be used primarily to assess the most pressing needs and the immediate course of action. To this end, Healthy Hill is bringing together community residents and champions from six sectors: food justice, housing and neighborhood revitalization, youth engagement and education, workforce and job training, public safety, and public health / health care / health data. The Healthy Hill Initiative will expand upon and accelerate several efforts currently under way in Old Hill: housing remediation to address asthma, re-purposing vacant parcels as community green space, community gardens to engage youth leaders and provide fresh food, substance abuse prevention coalitions and more.
Healthy Homes Des Moines (BUILD 2.0)
Des Moines, IA
Healthy Homes Des Moines (HHDSM) focuses on mitigating housing’s effects on asthma-impaired children. Its goal is to move upstream in asthma control—addressing environmental factors that make control harder and traditional treatments less effective. The project also builds institutional support for ensuring healthy living environments for asthma-impaired children elsewhere in Iowa by using data to make the case for the cost effectiveness of upstream interventions, securing third-party funding, adding legal resources for tenants, and involving family support professionals in household environment improvement.
Healthy Homes East Bank (BUILD 1.0)
Des Moines, IA
HeaHealthy Homes Des Moines aims to reduce asthma-related hospital visits by improving the social, economic, and environmental factors that have the greatest impact on respiratory health. Healthy Homes Des Moines strives to take an upstream approach to asthma by improving indoor air quality and promoting preventive self-care through health education. Healthy Homes Des Moines will employ implement a three-pronged strategy: (1) Determine households in need of remediation through data collection and referrals from area hospitals and schools; (2) Coordinate health inspectors to identify health risk factors in the home and engage contractors to make needed repairs ; and (3) Develop asthma prevention programs to be implemented by public health professionals with subject matter expertise.
Healthy Ontario Initiative (BUILD 1.0)
The Healthy Ontario Initiative is working to increase wellness among Ontario residents who face health disparities as a result of a number of economic, social, and language barriers. Specifically, it seeks to lower the rate at which adults are diagnosed as overweight or obese. To reduce barriers to health, the Healthy Ontario Initiative began its work by creating a data platform that defines Key Performance Indicators, establishes baseline metrics, and tracks progress over time. It uses body mass index metrics to measure how successfully the rate at which adults are diagnosed as overweight or obese has declined. Next, they created health hubs, which include two city parks with community centers, two family health centers, a community garden, four places of worship, and an elementary school.
In Orange, residents, resources, and learning communities are isolated from each other. Featuring Orange Public Schools, Montclair State University, Drew University, the Hispanic Business Association, Urban Essex Smart Growth, and the Police Athletic League as partners, the Healthy Orange coalition posits that “in a healthy city, everybody is learning all the time.” The Blueprint for Action emphasizes providing resources for lifelong education or addressing obstacles to it, through creating community schools that open their doors to the neighborhoods, supporting the development of babies through play, and implementing an adult school. A significant grant to revitalize a 15-block area of the Heart of Orange, is proposed model to help improve community health outcomes. Healthy Orange also identifies an opportunity in anti-violence initiatives led by the Orange Interfaith Council, as the County Health Rankings already indicate a decrease in violent crime within Essex County.
Healthy Plainfield (NJHI)
In 2016, local organizations and community stakeholders from Plainfield’s public, not for profit, health, education and business sectors determined that a more effective approach to improving health outcomes for the community involved the formation of the Healthy Plainfield coalition. The Coalition identified employment opportunities, income, access to clinical care and the built environment as community health priorities. Healthy Plainfield determined its work would focus on connecting and aligning community resources to address educational attainment. The Coalition’s strategies include expanding workforce development programs, as well as community- and school district-based General Equivalency Diploma (GED) and English as a Second Language (ESL) programs. Healthy Plainfield’s Blueprint indicates obesity and access to clinical care are its other key focus areas for building a healthier community. Scroll down to access Heathy Plainfield’s Blueprint.
San Gabriel Valley, CA
The Healthy San Gabriel Valley Initiative (HSGV) is an effort to create a synergistic effect across sectors and organizations in the San Gabriel Valley, which include health care, education, government, business, faith-based and non-profit, as well as community stakeholders. HSGV embraces the many assets of the region and partners to address our most complex social issues across sectors. Our goals are to advocate by developing a shared inclusive voice for the SGV for resources to improve the health of the region, support local efforts to create positive change that improves the health of individuals and communities, advance positive systems change in the SGV by being a resource for local cities/communities and aligning with county-wide health improvement strategies and develop a regional communication network in the SGV to share best practices, resources and data to create a healthier region.
Focusing on the intersection of pediatric health and housing conditions law, the Healthy Together Medical-Legal Partnership for Improving Asthma in Southeast DC is a nationally-replicable model that leverages primary and emergency medical expertise, legal support, and funding from Managed Care Organizations, to find real solutions to asthma prevalence and morbidity in low-income neighborhoods of Southeast DC. The BUILD Health Challenge allows partners to target substandard housing conditions at the heart of asthma health disparities among children in DC’s lowest-income neighborhoods.
Home Preservation Initiative for Healthy Living (BUILD 2.0)
The Home Preservation Initiative (HPI) for Healthy Living seeks to improve asthma outcomes related to unhealthy housing in five neighborhoods in West Philadelphia. By combining home repairs and community health worker home visits, HPI aims to significantly reduce emergency department visits and hospitalizations due to pediatric asthma. For these primarily African-American communities, substandard housing, unemployment, low wages and a lack of education are barriers to the overall health and well-being of residents. Using outcome data, the collaboration will show health care cost savings, aiming to make a strong case for Medicaid reimbursement for home repairs.
Hope Rising (PHIL)
Lake County, CA
Hope Rising is an Accountable Community for Health collaborative. The organization’s Governing Board and Leadership Team consist of CEO-level executives and program directors and coordinators from health systems, Medicaid payer organizations, behavioral health organizations, criminal justice, education, elected officials, housing, long term care, payers, public health department, providers, philanthropy, county agencies, non-profit organizations, elected officials, workforce development and community members. We have partnered for many years on a wide variety of health improvement initiatives, and Hope Rising formalizes those partnerships in order to improve the health and wellness of Lake County. Hope Rising operates through four program areas, identified through the collaboratively-developed Community Health Needs Assessment. The four goals are health, economic development, education and healthy environment.
Humboldt County, CA
The complex health and social issues Humboldt County faces cannot be solved by one organization or through one initiative alone. By bringing together diverse organizations and individuals under a common vision and agenda, Humboldt County stakeholders can achieve improved health of all residents through the manifestation of an Accountable Care for Health (ACH) model. This model allows stakeholders to align multiple initiatives that address the health of the whole population while closing the gap for vulnerable populations and communities. The Humboldt Community Health Trust includes cross-sector participation from 18 industry leaders and will initially focus on addressing issues related to substance use disorder.
Imperial County, CA
With leadership from the Local Health Authority Commission and the Imperial County Public Health Department acting as the backbone, the ACH convenes multiple sectors to implement strategies that will help to build healthier environments and address the underlying factors that affect asthma management. For years, local organizations conducting in-home asthma education and environmental trigger remediation have sought out cyclical, grant-based funding to support their work. The ACH is working with these partners to strengthen the evidence base of their programs, improve their communication and linkage to the clinical sector, and measure a return on their efforts that will help to justify their great need in the community. This is just one example of how the Imperial County ACH is strengthening and better aligning solutions to reduce asthma hospitalizations and missed school attendance.
Increasing Access to Behavioral Health Screening and Support in Aurora (IABHSSA) aims to create a community in which all children have the opportunity to reach their full potential. Through universal psychosocial, developmental, and maternal wellbeing screenings, they are identifying and addressing underlying needs before children experience long-term negative consequences. IABHSSA is using the Child Health Clinic at Children’s Hospital Colorado and the local WIC clinic as pilot sites for an innovative feedback loop system centered on community-based Community Health Workers (CHWs) who conduct psychosocial screenings in families with young children. This pilot will increase the number of psychosocial screenings conducted, create response protocols based on real-time community feedback, and build a sustainable system of coordinated care.
Jewish Family Service of Colorado (Connecting Communities and Care)
Wheat Ridge, CO
Address mental health for seniors through outreach, counseling, care management and activities in the city of Wheat Ridge.
The Kansas Public Health Systems Group (PHSG), a partnership representing public health practice, academia, government, and charitable organizations, has explored options for implementing the foundational public health services (FPHS) since 2015, with significant progress. PHSG’s grant will go toward building on these efforts by engaging cross-sector partners to determine the feasibility of applying the model in a rural, decentralized state; planning, piloting, and documenting the evolution of the FPHS model from an emerging practice to a prevailing practice; and evaluating the use of crossjurisdictional sharing for specific FPHS components. This project includes developing a state modernization roadmap for the FPHS model; creating a performance management system with measures for each component of the Kansas FPHS model to increase efficiency, effectiveness, accountability and adaptability to other communities using similar FPHS models; and supporting a local pilot project using the roadmap and performance management system to develop a local FPHS implementation manual.
Connecting data across health and housing has the potential to improve the health of residents living in low-income housing in King County. For the first time, Public Health – Seattle & King County is partnering with local housing authorities to link housing data with Medicaid claims records. The result is de-identified data that can provide key information about the health issues facing residents. This information can then be used to develop prevention programs—such as the use of community health workers—to address specific health needs of the resident community. This approach is part of King County’s Accountable Community of Health—a regional partnership committed to working in new ways to improve health and health care.
Live Healthy Bridgeton (NJHI)
In 2016, local organizations and community stakeholders from Bridgeton’s public, not for profit, health, education and business sectors determined that a more effective approach to improving health outcomes for the community involved the formation of the Live Healthy Bridgeton coalition. The Coalition identified that the departure of major industries and the challenge to attract or create new industries in the last 40 years has resulted in areas such as employment, educational opportunities and the physical environment becoming community health priorities. Live Healthy Bridgeton’s Blueprint for Action outlines a plan to engage new partners to promote workforce development among the city’s youth and increase access to green spaces through collaborations with Cumberland County and school district partners. Scroll down to access Live Healthy Bridgeton’s Blueprint.
Live Healthy Napa County (PHIL)
Napa County, CA
Live Healthy Napa County (LHNC) is a public-private partnership focused on eliminating health inequities in Napa County so that all Napa County residents have the opportunity to achieve their optimal level of health and wellbeing. The current work of the LHNC ACH centers on improving access to healthy, nutritious food through a collective impact effort aimed at systems and policy change. Food insecurity is a root cause of obesity and related chronic diseases. LHNC partners believe that addressing upstream factors that lead to health inequities is critical to our efforts to reduce the impacts of chronic disease on population health in Napa County.
New Orleans, LA
The Crescent City Participant Community (CCPC) is administered by the Louisiana Public Health Institute with joint leadership from the City of New Orleans Health and Police Departments, the City of New Orleans Homeless Court, Metropolitan Human Services District, the Orleans Parish Forensic Mental Health Coalition, the Orleans Parish Sheriff’s Office, and the Partnership for Achieving Total Health, Inc. Through its collaboration with the CHP National Program Office, the CCPC will be working to use health information technology to share management and coordinate care among participant entities – aggregating data from electronic health records, proprietary and public community-level records, public health information, and the Greater New Orleans Health Information Exchange. The CCPC aims to identify and intervene for the severe and persistently mentally ill and other vulnerable people that are high-utilizers of the criminal justice system, emergency departments, emergency medical or crisis response services, psychiatric facilities, and social services agencies.
HealthInfoNet (HIN), a nonprofit that serves as the statewide health information exchange (HIE), is leveraging the HIE and a real-time predictive analytics system to integrate electronic health record and social determinant data across three critical access hospitals, seven federally qualified health centers, and two Community Action Agencies (CAAs) in Maine. The HIE and predictive modeling programs will be deployed to identify the most complex, high-risk patients so that care management teams can connect them to appropriate community services. In particular, the project team is identifying the most appropriate datasets related to social determinants of health to incorporate within the HIE.
Merced County, CA
The Merced County Department of Public Health is leading this collaboration to develop a coordinated system of interventions and strategies that address fundamental conditions that lead to cardiovascular disease, diabetes, and associated depression. A series of surveys and meetings were held to engage residents to inform the development of solutions that best serve their needs. In response, local leaders are moving forward with a multi-pronged approach that is based on medical and clinic services; improving living environments by making it easier for people to engage in exercise; more effective referral programs; and incorporating community health workers to more successfully educate and share information with residents on how to access resources. Recognizing that low-income communities of color do not often seek out and utilize mental health services, local leaders are recruiting community ambassadors who can engage residents as peers to reduce fears and stigma related to behavioral health.
The nonprofit Minneapolis Heart Institute Foundation works to improve the cardiovascular health of individuals and communities through innovative research and education, and is well-versed in cross-sector collaboration.They will share lessons learned during the development, implementation, and evaluation of Hearts Beat Back: The Heart of New Ulm Project – a 10-year community-based initiative to reduce heart attacks in New Ulm, Minnesota. They successfully collaborated with partners in various sectors to utilize data from electronic health records, community health screenings, community needs assessments, and environmental assessments to make health-conscious changes throughout New Ulm. They are committed to sharing their experiences and best practices with other communities throughout and beyond Minnesota.
Minnesota Department of Health (PHNCI)
To address the root causes of health inequities, public health practice must shift from an emphasis on the consequences of health inequities to the social conditions that create them. The Minnesota Department of Health (MDH) is utilizing its PHNCI grant to convene a learning community to help six local health departments (LHDs) transform the way they do business to advance health equity. The learning community will focus on three practices: aligning programs and resources with the organizational commitment to health equity; working in true partnership with the community; and working at the policy level on the social conditions that affect health. Through structure and support for risk-taking and mutual learning, this project will facilitate rapid, collective progress toward a common goal. Moreover, the project will give MDH and its national partners an in-depth look at innovation so that emerging health equity practices become prevailing practices in public health.
Mt. St. Rafael Hospital Clinic (Connecting Communities and Care)
Connect with community-based organizations to improve the health of the diabetic population. This project will link current resources and expand them to effectively target diabetic health in the local community.
Hunterdon County, NJ
Building on the Hunterdon County Partnership for Health’s work to advance health in Hunterdon County, the Blueprint by the cross-sector Healthy Hunterdon: Motivating Culture Change for a Healthier Tomorrow coalition focuses on healthier weight as a mechanism for impacting community health. The Partnership has identified opportunities to advance their work in the areas of access and transportation, mental health and healthy behaviors. Regarding healthy behaviors, the Partnership’s goals include partnering with Hunterdon County Chamber of Commerce to implement a worksite wellness strategy that builds a Culture of Health where people working in Hunterdon County are supported in adopting healthier behaviors. Scroll down to access Healthy Hunterdon’s Blueprint.
Local organizations and community stakeholders from Greater Freehold’s health, education, business and not-for-profit sectors determined that a more effective approach to advancing health in their community involved the formation of the Neighborhood Connections to Health coalition. The Greater Freehold area includes the Borough of Freehold, Freehold Township, Howell Township, Farmingdale Borough, Manalpan Township and Englishtown Borough. Neighborhood Connections to Health conducted focus groups and analyzed health status indicators to develop its Blueprint for improving health outcomes in its underserved communities. The Coalition’s action plan outlines steps for identifying streetscape design opportunities and strategies such as the NJ Safe Routes to School and Complete Streets approaches for addressing the physical environment to promote health and wellness in Greater Freehold. Engaging new community partners fostering collaboration to increase access to healthy foods and reduce the incidence of elevated blood lead levels in children are additional health priorities addressed in the Blueprint. Scroll down to access Neighborhood Connections to Health’s Blueprint.
Neighborhood Tabulation Areas: Enhancing Community Health Improvement Capacity in NYC Through Shared Information at the Small Area Level (DASH)
New York, NY
The New York City Department of Health and Mental Hygiene (NYC DOHMH) and its partners are creating a comprehensive dataset that encompasses small area health profiles that will reflect the impact of social, economic, and other factors on community health outcomes. Project analysts are geocoding and analyzing newly obtained and existing data from multiple sectors at the Neighborhood Tabulation Area (NTA) level (approximately 30,000 residents), increasing granularity to help identify and refine specific health needs. The NTA-level profiles will enable enhanced analysis, monitoring, and planning to promote the health of all New Yorkers and reduce health disparities in high-need communities.
New Brunswick Healthy Housing Collaborative (BUILD 2.0)
New Brunswick, NJ
The New Brunswick collaborative is a multi-sector coalition of organizations and community members dedicated to ensuring that all New Brunswick residents live in safe homes that facilitate healthy living. Through an extensive network, partners implement healthy housing assessments, consumer trainings, lead and asthma testing, and environmental changes that produce safer and healthier home environments; provide opportunities for healthier lifestyle and behavior change; and advocate for housing policies that promote community health and well-being.
The North Coast Health Information Network, a not-for-profit health information exchange has partnered with the Humboldt County Department of Health and Human Services Social Service (DHHS-SS); through the CHP program, they will work to reduce emergency department utilization by the indigent, high-need, super-utilizer population by 15 percent over the course of their participation in the CHP program. In order to do so, they will build an interface between the DHHS-SS Homeless Management Information System and North Coast’s health information exchange to share data from electronic health records, and public and private records, social services case managers will receive alerts about clients’ health center/hospital visits for follow-up care coordination. The organization will aim to decrease emergency department utilization by 25 percent over time and expand the data exchange to other programs and social service organizations.
Northwest Colorado Community Health Partnership (Connecting Communities and Care)
Steamboat Springs, CO
Supporting residents of a five county region in achieving their best mental health through development of a community-wide behavioral health strategy, widely offered Mental Health First Aid courses, and development of prescribing protocols for providers to reduce prescription drug use and resulting addiction, ultimately resulting in systems change and community standards around prescribing.
The One Northside Center for Lifting Up everyBody (The Club), improves health by addressing the social determinants of individual and community well-being. This partnership focuses on highly vulnerable populations that are dual eligible for Medicaid and Medicare, low income and often chronically ill. Building off priorities in the resident driven One Northside Consensus plan, the Club connects residents with integrated supports through outreach workers, a centralized wellness center, and enhanced data collection for tracking health outcomes.
In 2016, the cross-sector Passaic County Food Policy Council determined four focus areas for improving community health in Southern Passaic County, which includes the City of Paterson, the City of Passaic, Clifton, Haledon and Prospect Park: economic opportunity, community safety, healthy food access and access to clinical care. Noting that food access is a growing need in Southern Passaic County, the Council’s goals include implementing or expanding school breakfast and summer meals programs as well as introducing healthy food procurement practices in local institutions. Additional strategies the Council has identified for its work include land banking, streetscape design, a food business incubator and vocational training for adults. Scroll down to access the coalition’s Blueprint.
Pima County Health Department (PHCNI)
Mothers in Arizona Moving Ahead (MAMA) is a pilot project focused on individual and systems-level changes that improve health outcomes and financial stability for mothers and children living in poverty. A joint project of Pima County’s Health and the Community Services Employment and Training Departments, MAMA enables low-income mothers to become partners, not just patients, and to identify the system changes needed in practice and policy to achieve greater equity and to provide more responsive care for people living in poverty. In a time of uncertain funding, this model is designed to be PHNCI Innovation Grant Program Project Overviews Page 3 of 3 lean and replicable by harnessing strong community collaboration and a volunteer base. Pima County Health Department is using its PHNCI grant to ensure that this model will build social capital across economic class as it engages and educates new sectors of the community for a deeper understanding of poverty while increasing political will to undertake lasting community change.
Project ACCESS (BUILD 1.0)
Colorado Springs, CO
Project ACCESS (Assessment and Community Collaboration to Engage and Strengthen Southeast Colorado Springs) is working to reduce barriers that cause inequities in order to improve socioeconomic conditions and social cohesion in Southeast Colorado Springs. They empower community residents to change policies and practices that impact community conditions to improve health outcomes for current and future generations. Their goals include gathering current and collected data and research, engaging community members, and mobilizing the community.
El Paso County, CO
Project Detour is a cross-sector collaboration that grew from the community’s commitment to interrupting patterns of addiction and incarceration in El Paso County, Colorado. The project is led by community partners united to disrupt and treat the cycle of addiction. Qualifying participants possess a combination of underlying addiction issues, homelessness, criminal justice system involvement, and a need for medical and social detox services. This effort positively impacts its participants and the community by reducing criminal justice system recidivism, opiate and narcotic dependence, negative interactions with the community at large, and repeated detox unit stays.
The Providence Center for Outcomes Research and Education is a not-for-profit health policy research shop committed to improving community health. Their CHP project will be based in a multi-county region in Southwest Washington State, and will bring together diverse sectors including academia, education, housing, health care, and criminal justice. With the support of the CHP Program, their team will build a shared data system that will aggregate public records, insurance claims, and public health data for community-based population health management.
Prowers United / Big Timbers Health Alliance (Connecting Communities and Care)
Prowers County, CO
Bring together collaborators from health care, community-based organizations and residents through a formalized collaboration to address high rates of obesity in Prowers County.
Raising of America Partnership Boulder County (BUILD 2.0)
Thriving children in healthy environments set the foundation for an equitable community. Yet the families of Lafayette, Colorado are lacking many of the fundamental economic and social supports necessary for raising healthy children in secure environments. To address these issues, this collaborative is fostering inclusion and engagement to create conditions for young children and their families to help them reach their full potential. This project supports a sustainable pathway for engaging families, encourages leadership and involvement, and creates a bridge between health care and community health—all with the intention of improving family-friendly policies and early childhood development.
Covington & Gallatin Counties, KY
This collaborative is working together to pass tobacco free policies and reduce tobacco use in two Northern Kentucky communities: Covington and Gallatin County. The project will improve data-driven decision making while softening residents’ perceptions about tobacco-free environments. The short-term impacts include healthier residents, increased use of data to plan and evaluate complex health programs, and collaboration across sectors to address health problems in Northern Kentucky. The desired long-term impact is that fewer people will face tobacco-related chronic illnesses, such as heart disease, lung problems, and cancer. And those exposed to secondhand smoke will have improved outcomes and fewer children will start smoking. In addition, the resident tax burden from smoking ($1,168 per household) will decrease. The ultimate goal of the grant is to see a 2% reduction in the adult smoking rate in Covington and a 1% reduction in Gallatin County by August 2019.
Riverside County, CA
The vision of the Riverside County Accountable Community for Health Coalition is to establish one or more ACHs to monitor and address the most important health outcomes and their causes at both the community and health care system levels, and to develop and sustain an integrated network of community and clinic resources to prevent and control the most pressing issues, beginning with obesity and diabetes. Our goals are to: 1) determine the extent and distribution of risk and facilitative factors for obesity and diabetes at the personal (obesity, diet, exercise), social (networks, culture, language), and environmental (impediments and resources) levels, 2) develop an ACH coalition with a governance structure inclusive of all relevant segments of the community, 3) carry out a strategic and integrated set of projects each year for prevention and control of obesity and diabetes, 4) work with local governments, health care systems, school districts, health coalitions and others to translate effective programming into public and institutional policy and practice, 5) monitor and document progress toward targeted objectives and outcomes, and 6) develop a structure and mechanism for sustained financial and community support to assure continuation of a vital ACH.
The Live Healthy Salem County Coalition is a partnership of organizations and agencies from the public, not for profit, and private sectors, whose focus is on improving health outcomes in Salem County. The Coalition’s mission is to inspire residents of Salem County to live healthy, productive lives by enhancing opportunities that lead to a sustained culture of wellness. The United Way of Salem County is the lead agency and the Senator Walter Rand Institute for Public Affairs at Rutgers University-Camden is the neutral convener (facilitating meetings and providing research and technical support). The Live Healthy Salem County Coalition worked collectively to: assess the strengths and weaknesses of the current systems affecting health in the county; develop a plan of action that will address the identified health needs of Salem County residents. The combined effort of the partners culminated with the development of a Blueprint for Action, addressing mental and behavioral health, substance abuse, and chronic disease and obesity as priority areas of need in the community.
San Diego County, CA
With Be There San Diego acting as the backbone, the San Diego ACH is taking a dual approach to create ideal cardiovascular health across the entire lifespan — establishing a countywide table for planning and coordination, while simultaneously implementing a tailored network of solutions in local communities of high need like Southeastern San Diego. In these communities, the ACH works with local leaders and organizations to catalyze current efforts promoting heart health. While collaboration among various agencies is certainly not new in San Diego, the ACH is helping the region become more connected and prevention-oriented. A new and exciting aspect of the ACH is the establishment of a local Wellness Fund that weaves together a variety of funding streams and financing approaches to both sustain the ACH and invest in strategies needed to improve community health.
San Diego Health Connect (CHP)
San Diego, CA
The San Diego Health Connect (SDHC) is a Health Information Exchange (HIE) that successfully designed and implemented a regional health information organization in the San Diego and Imperial Counties. As a part of the CHP Program, they will partner with Be There San Diego (BTSD), a multi-stakeholder collaborative experienced in improving population health with a focus on cardiovascular disease. With extensive expertise in technical infrastructure and data exchange, SDHC is an active trading partner with The Sequoia Project, a national HIE, and has partnered with San Diego County Health and Human Services to facilitate automated, electronic transmittal of relevant patient data for monitoring public health and delivering services where needed. In addition, their patient indexing system allows them to positively identify 95 percent of the region’s adult population, and their standards in naming and information records have increased patient matching to over 95 percent. BTSD, in turn, excels in sharing and comparing data in a collaborative learning environment to identify and promote best practices and improve health outcomes.
San Luis Valley Behavioral Health Group (Connecting Communities and Care)
Work collaboratively with health care systems and community agencies to improve access and effectiveness of our current health care delivery system with a targeted focus towards substance-abusing pregnant women in the San Luis Valley.
San Pablo Area Revitalization Collaborative (BUILD 1.0)
The San Pablo Revitalization Collaborative (SPARC) will reduce health disparities rooted in historic divestment, institutional racism, and physical decline. The project seeks to restore residential pride in the community in four areas: (1) Health: Prevent and control high blood pressure among residents in order to reduce emergency room and hospitalization rates of at-risk populations; (2) Community and Housing: Target blighted hot spots and transform them into safe, open spaces created by residents for residents; increase the number of affordable housing sites and reduce the number of residents who have to move due to rising rents; (3) Economy: Create a vibrant business corridor by supporting local businesses and entrepreneurs; implement job training and asset building programs; and (4) Partnership: Recruit more leaders and raise the funds needed to implement work and track the Collaborative’s impact.
Seattle Chinatown-International District Healthy (BUILD 1.0)
Seattle Chinatown — International District Healthy Community focuses on the Chinatown-International District (CID), which has been the first American home for many immigrants from Asia and the Pacific since Seattle was founded. The statistics for many key health indicators — including frequent mental distress, obesity, unemployment, and violence — are in the worst quartile in the county. InterIm CDA, Swedish Medical Center, Public Health Seattle & King County will work with key partners to identify specific upstream solutions with promise or that have evidence of improving the quality of life for these residents while maintaining unique community assets. By utilizing bilingual advocates and health educators, this project aims to provide development in the economic, housing, and wellness sectors.
Servicios de La Raza (Connecting Communities and Care)
Create a strong referral network and link the community to prevention efforts in diabetes and obesity.
Since its 2013 formation, the Shaping Elizabeth coalition has focused on health equity. The partners have since identified opportunities to build a Culture of Health specifically in Bayway, Elizabethport, and Midtown. By addressing the health behaviors facilitating high rates of chronic disease in these communities, Shaping Elizabeth intends to improve health outcomes for youth and adults. The coalition’s Blueprint for Action emphasizes goals of diabetes reduction, HIV-prevention, and expanding its Mobile Market program to improve residents’ access to healthy foods.
Sonoma County, CA
Through the leadership of Sonoma County Health Action, the ACH model is bringing many different sectors together to create a portfolio of interventions to reduce preventable heart attacks and strokes. Local leaders are prioritizing populations and neighborhoods within Sonoma County that experience the greatest disparities. Community partners are screening and providing coordinated services for these populations. Local health providers are working together to guarantee high-quality care for the prevention and management of cardiovascular disease for all. The ACH also enables residents and organizations to bring their voices to the table and engage in new and deeper ways to improve the health of their communities.
Jersey City, NJ
Community safety and education are focus areas that the Partnership for a Healthier Jersey City is emphasizing in its efforts to build a healthier community in Jersey City. Referencing a 2013 Community Health Needs Assessment compiled by Jersey City Medical Center, the coalition has identified a goal of recruiting more residents of underserved areas to pursue health careers. The partnership’s Blueprint for Action proposes that Jersey City’s current low ranking regarding the number of primary care providers available to residents is a significant socioeconomic opportunity toward reducing health disparities for all Jersey City residents. The Blueprint for Action also identifies the potential of Jersey City becoming the most pedestrian and bike-friendly major city in the state, through the shared resources of the City of Jersey City, the Jersey City Parks Coalition, and BikeJC. Core members of this multi-sector coalition include the Jersey City Housing Authority and the Jersey City Department of Health & Human Services.
Only through true empowerment can communities most impacted by health inequities take ownership of their health. Since many communities with low civic engagement have been historically disempowered, the Tacoma-Pierce County Health Department (TPCHD) aims to create a hyper-local and authentic civic engagement opportunity with visible results. To achieve this goal, TPCHD sees participatory budgeting as an innovative, democratic process in which community members directly decide how to spend part of a public budget. The process gives community members the authority and resources to respond rapidly and directly to the root causes of their health problems, reduce the scale and duration of problems, and improve feelings of connectedness and well-being by participating. TPCHD is using its grant to initiate multiple projects that directly reflect community health priorities by implementing a participatory budgeting process focused on two schools in one of TPCHD’s highest-need communities, East Side Tacoma.
Toms River, NJ
Local organizations and community stakeholders from Toms River’s health, education, business and not-for-profit sectors determined that a more effective approach to advancing health in their community involved establishing the Toms River Family Health & Support Coalition. In working to identify the greatest health impact areas in the community, the leadership team has prioritized four critical areas of focus: Nutritious Food Connections, Senior Isolation, Substance Abuse and Youth Emotional Wellness. The Coalition’s Blueprint details key community partners and strategies to advance its mission to “make Toms River the healthiest community in New Jersey.” Scroll down to access the coalition’s Blueprint.
Research has shown that breastfed infants have lower incidence of infectious and chronic diseases and breastfeeding mothers experience increased child spacing, decreased risk of type 2 diabetes, and decreased risk of breast and ovarian cancers. And Healthy People 2020 set a target of 81.9% of infants ever breastfed and 60.6% of infants breastfeeding at 6 months. Yet in Mississippi, the breastfeeding rates remain the lowest in the nation, with only 52% of mothers initiating breastfeeding and 23.9% breastfeeding at 6 months (2016 CDC Breastfeeding Report). This collaboration seeks to not only address upstream barriers to breastfeeding, but also to transform the culture surrounding breastfeeding in Mississippi in order to increase breastfeeding initiation and duration, decrease infant mortality and childhood obesity, and improve birth spacing.
New Jersey’s capital city has made strides toward health equity, earning the community a finalist placement in the Robert Wood Johnson Foundation’s 2016 Culture of Health Prize. Partners such as the YMCA of Trenton, The College of NJ–Trenton, the Trenton Health Team Community Advisory Board, Friendship Baptist Church, Isles, the City of Trenton, and the Trenton Neighborhood Restoration Campaign have united as the Healthy Trenton coalition, building the capacity to extend and expand the community’s transformation. The Blueprint for Action offers a strategy for streamlining resources and conversations. In 2015, the Trenton Health Team updated a county-level Community Health Needs Assessment. Their findings note that Trenton residents are more concerned about immediate barriers to health, such as safety and food access, than longer-term health issues such as chronic disease. External perceptions of Trenton and diminishing neighborhood cohesion also exacerbate the issue of health equity. An essential framework within the Healthy Trenton coalition’s Blueprint is to incorporate health considerations into the city’s Master Plan for the first time ever.
This collaborative initiated a “Safe & Healthy Corridor” along Brunswick Avenue, coordinating and building on existing and planned activities to improve the environment within that section of Trenton’s North Ward. The goal was to create a public space where people feel safe—where residents and visitors are comfortable walking, biking, exercising, and interacting with others—thereby improving physical and mental health and generating a sense of community well-being. Aligning with the City’s Trenton250 Master Plan, current aims include city revitalization and development of green spaces, and fostering nutrition and active living in local schools and corner stores.
Tri-County Health Network (Connecting Communities and Care)
Improve the rural region’s health and decrease the burden of diabetes and heart disease by promoting healthy behaviors and chronic disease self-management. Funding will help expand existing community-based programming and evidence-based services that promote prevention and self-management, increasing the number of people served and resulting in better overall health of our community.
University Hospitals Rainbow Babies & Children’s Hospital is a full-service children’s hospital and pediatric academic medical center – a not-for-profit organization that uses advanced treatments and innovations to deliver pediatric specialty services for 740,000 patient encounters, annually. With the support of the CHP Program, they will work to prevent and manage the childhood asthma disease burden in target neighborhoods in Cleveland, Ohio. Fostering partnerships among the health care, public health, housing, social services, environment, and criminal justice sectors, the organization will use data from electronic health records, and public and private records, and Medicaid claims to integrate existing pediatric longitudinal social, environmental, educational, and clinical data. Through this work, they anticipate the ability to create an accountable care community to collectively improve the health and wellness of these Cleveland neighborhoods.
University of Chicago (PHNCI)
To help government officials improve the match between where public funds for health and health‐ related social services are sent within the city of Chicago, and where the need for those services is most acute, the Chicago Department of Public Health (CDPH), in collaboration with the University of Chicago’s Center for Spatial Data Science and School of Social Service Administration, is developing a scalable, open‐source spatial analytic framework and web‐based tool. With their PHNCI grant, project leaders aim to enhance the project’s ability to meet two key strategies of CDPH’s Healthy Chicago 2.0 initiative: analyze geographic access to health and human services and address gaps in care; and increase capacity and availability of health and human services by maximizing the impact of existing resources. The project will offer a replicable framework and tool for jurisdictions beyond Chicago to analyze and improve their own distributions of public funds for health and health‐related social services.
The University of Chicago Medicine will provide expertise in data integration to the CHP Program. As the anchor health care institution on the south side of Chicago, they convened and collaborated with community partners to address critical health issues in their communities. Through their Medical Home Connection program, they leveraged partnerships with community health centers to use consistent messaging when educating emergency department utilizers on the value of using medical homes for ongoing care. Patient Advocates scheduled follow up medical home visits for patients who were discharged from the emergency room. Through an electronic portal they sent real-time information to the health centers informing them of the patients emergency room visit and follow up appointment. The program successfully increased the average show rate to follow up appointments from 35 percent to 60 percent. With the adoption of an electronic patient information portal integrated with the electronic information system, the program expanded. With the use of data from multiple sources the collaborating partners have implemented several additional population health management programs.
Using a Connected Information System to Enable Spontaneous, Shared Community Treatment of Adults with Severe Mental Illness (DASH)
San Antonio, TX
On behalf of the Community Medical Directors Roundtable, the Center for Health Care Services (CHCS) is leading a multi-sector effort to create a connected information system that integrates physical and behavioral health care data into Healthcare Access San Antonio (HASA), a regional health information exchange (HIE). The system will enable critical sectors—including law enforcement, hospitals, and homelessness services providers—to rapidly identify people in crisis and notify CHCS staff through real-time HASA alerts. This will allow behavioral health providers to intervene earlier and prevent inappropriate hospitalization or incarceration. Furthermore, when a patient arrives in the emergency department exhibiting psychiatric symptoms, HASA participating organizations will be able to access an individualized Community Treatment Plan to help direct the patient’s course of care.
The Vanderbilt University Department of Health Policy is committed to bringing together a broad group of health policy scholars devoted to developing health policy solutions. Through the CHP program, they aim to decrease infant mortality rates by developing a data-sharing network to study predictors of infant mortality and identify at-risk mothers and infants. With shared data from various sectors, the organization will be able to aggregate and analyze disparate data that will allow real-time identification of at-risk pregnant women and referral to specific and appropriate interventions. By engaging new community partners and including additional data, they anticipate improving their predictive model until they can correctly place 95 percent of prior years’ infant deaths into the highest tercile of risk.
The Vermont Child Health Improvement Program (VCHIP) of the University of Vermont College of Medicine’s Department of Pediatrics is a population-based maternal and child health services research and quality improvement program. Through its participation in the Community Health Peer Learning Program, VCHIP will create an electronic shared plan of care (e-SPoC) for families with children and youth with special health care needs. This family-centered system will aim to simplify the management of each child’s multiple systems of care into adulthood through information from electronic health records as well as data on economic, environmental, and social determinants of health.
Sacramento County, CA
Health Education Council, backbone organization for Sacramento Accountable Community for Health Initiative (SACHI), convened leaders from health care, public health, local government, and community based organizations to determine the health and geographic focus us SACHI. A review of data revealed West Sacramento’s rate of heart disease and hypertension presenting in the Emergency Department (ED) is 23-25% higher than average for Yolo County and 70% higher than CA average; rates of heart disease and hypertension in hospital admissions is 52% – 66% higher than Yolo County and 25% higher than CA. After thoughtful discourse, the SACHI Leadership will focus efforts in West Sacramento to reduce rates of heart disease and related conditions by improving access to care, reducing risk, and prioritizing prevention. Over an 18-month period, SACHI Leadership Team and Stakeholders will convene to identify a shared vision and understanding of heart disease in West Sacramento and develop shared goals with a commitment to working together to reduce and prevent it. In addition, we plan to cultivate leadership to serve as champions from multiple organizations and levels of organization governance, engage partners and develop community engagement strategies to hear from community members and understand the impacted systems, and develop strategies focused on modifiable behaviors and access.
The White Earth Reservation Tribal Council is expanding implementation of WECARE (White Earth Coordination, Assessment, Resource and Education), a care coordination database system that provides an efficient and effective way to link families on or near the reservation to the services they need. The project is using RiteTrack software to improve care coordination, enabling connections between primary care, home health, education, early childhood programs, and human services in an accountable care-like organization. Clients complete a universal intake assessment indicating their interest in a wide range of community services, creating an electronic alert referral for appropriate programs to address the social determinants of health.
Youth-Driven Healthy South Los Angeles (BUILD 1.0)
Los Angeles, CA
Youth-Driven Healthy South Los Angeles (YDHLA) focuses on the Los Angeles neighborhoods of Central Alameda and South Central. These neighborhoods have extremely limited access to healthy foods and are surrounded by polluted, vacant city land. Social, economic, and environmental factors have contributed to high levels of obesity, diabetes, and other cardiovascular complications. YDHLA aims to improve obesity, diabetes and cardiovascular disease. Partnering with California Hospital Medical Center and the Los Angeles County Department of Public Health, the National Health Foundation seeks to create an inviting community with healthy food. Additionally, they seek to engage the youth, demonstrate to them that change is possible and rely on their leadership.