Coalitions for Impacting the Health of a Community: The Summit County,Ohio,Experience

Introduction

C ommunity coalitions are mechanisms that are increasingly utilized to address complex health issues at the local level. As collaborative partnerships of diverse members who work toward a common goal, coalitions afford communities the opportunity to combine and leverage resources from multiple and diverse sources. These collaborations enable greater breadth of scope and depth of responses to intractable problems that impact the health of communities. In addition to leveraging and increasing access to resources, coalitions offer many other advantages that make collaboration an asset for individuals, organizations, and communities. By mobilizing relevant resources around a specific goal, coalitions offer the opportunity to coordinate services and limit duplication of parallel or competing efforts. The inherent diverse membership also offers avenues to develop and increase public support for issues, actions, or needs and gives individual organizations the opportunity to impact the community on a larger scale. ^1,2

Framework for population health success

In order to be effective in coordinating a diverse multitude of services across sectors, coalitions such as these need a shared frame for envisioning and acting to improve community health. Thomas Frieden, MD, MPH, Director of the US Centers for Disease Control and Prevention, developed an inclusive conceptual framework to describe the differential level of impact of health-oriented interventions. ¹⁹ Taking an expansive view of population health determinants, the Health Impact Pyramid accommodates both biomedical and social determinants of health. Depicted as a 5-tier pyramid (Fig. 1), this framework symbolizes how interventions have the potential for varying degrees of population impact. At the bottom of the pyramid, with the greatest potential for impact, are socioeconomic factors and contextual/environmental factors. Interventions at these levels require the least individual effort and affect the greatest change in population health. Examples of interventions at the socioeconomic level include improving education and reducing poverty. At the level of changing the context, interventions are aimed at altering the environment so that individuals' default decisions become healthier. Such an intervention might be adding fluoride to water or improving the air quality. Because changes at these levels do not require individual-level behavior change, they impact a large number of people. In the middle level are 1-time protective interventions such as immunizations and cancer screenings. These occur at a limited point in time but have the potential to impact health in the long term. The top 2 tiers are counseling and education, and clinical care interventions, which require the most individual effort and affect the least change in population health. Although interventions at these levels are intended to change behavior and improve health, they are limited by “lack of access, erratic and unpredictable adherence, and imperfect effectiveness.” ¹⁹

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FIG. 1.

Health Impact Pyramid. ¹⁹

In order to have the maximal impact on population health, communities must coordinate interventions at each level of the Health Impact Pyramid. ¹⁹ Communities should be flexible so as to identify the most effective interventions for different health issues in a given context. Each community has a unique set of barriers and assets that impact health issues and mediate the effectiveness of interventions in particular ways. Taking a context-specific approach to understanding the issues, assets, and barriers, along with improving awareness and communication among stakeholders, can improve health outcomes. The Health Impact Pyramid framework can be used by communities to facilitate the assessment of each issue as well as the unique barriers and assets relevant to a given problem.

Methods

In Summit County, Ohio, the authors have used the Health Impact Pyramid framework in the context of the Wellness Council to facilitate strategic planning, program review, and implementation directives at the community level. With the collaboration of the partners in the Wellness Council, the network was utilized to undertake surveillance of the landscape of health and wellness efforts in the community. The purpose of undertaking the surveillance was to determine the types of programs currently available, identify gaps in programming, and determine how resources might best be utilized and leveraged to create maximum impact. Taking into account the Health Impact Pyramid framework for improving population health and the Healthy People 2020 topic areas, the authors surveyed, mapped, and framed their current programming efforts onto the Health Impact Pyramid. ^19,20

Results

A total of 41 distinct programs were identified from the completed interviews. Programs were defined as a set of centrally coordinated activities with a singular goal. In some instances, separate programs within organizations were grouped together as a single distinct program for this purpose. The authors chose to group these cases for reasons relating to parsimony and interpretability. As an example, one of the regional health systems conducts regularly changing classes and seminars on a variety of topics within the community. Although these multiple classes each targeted different health topics, given their temporary and transitory nature, they were grouped as 1 ongoing program within that organization. Of the 41 programs identified, 12 programs were directed at children from birth to 18 years of age; 15 were directed at adults up to age 64; and 14 had no age specifications. None were directly targeted at adults age 65 and older, though there are efforts that address this age group through more broadly focused programs.

For the second step, the level of intervention was classified within each program according to the Health Impact Pyramid. For each program, a primary level of intervention was identified, followed by secondary and tertiary emphases as appropriate (Table 2). The primary level was decided by considering the definitions of programs at each level and determining the focus of the majority of programming efforts. ¹⁹ For example, the school health programs included multipronged strategies to address the health and wellness of students, using education, counseling, clinical care, and advocacy for systems change to improve health. Clinical care interventions were identified as the primary level for these programs because the majority of program resources (ie, time, effort, outcome evaluation) were spent on the clinical care level of intervention. Eighteen of the 41 programs employed interventions at more than 1 level of the Health Impact Pyramid; 11 programs used 2 levels, and the remaining 7 identified programming at 3 or more levels of the Health Impact Pyramid.

Results of program coding onto the Health Impact Pyramid level can be seen in Figure 2. The majority of programs (n=27) relied on interventions at the counseling and education level. Programs such as the Nutrition and Physical Activity Self-Assessment for Child Care program within SCHD were within day-care centers in the community to improve the nutrition and physical activity levels of young children and were classified at this level of the Health Impact Pyramid. Six programs relied primarily on clinical care interventions. An example of this kind of programming included The University of Akron Nurse-Managed Health Clinic and Akron Community Health Resources (a local Federally Qualified Health Center) that provide clinical services to uninsured and underinsured people within the community. Two programs relied on 1-time protective interventions: smoking cessation programs offered through SCHD and The Pink Ribbon Project that provides breast and cervical cancer screenings for underserved women. Five programs relied primarily on interventions at the changing the context level, such as the Akron-Canton Regional Foodbank's work within the community to make healthy and safe food widely available to vulnerable members of the community. Only 1 program was identified with primary interventions at the socioeconomic factors level—the Summit 2010 program, offered through SCHD to impact social and economic determinants of health by improving educational outcomes and economic stability of residents within the community. Programs' secondary and tertiary levels of intervention also are indicated in Table 2.

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FIG. 2.

Local Akron, Ohio programs by Health Impact Pyramid level of intervention. ¹⁹ ABIA, Austen BioInnovation Institute in Akron; AHA, American Heart Association; NAP SACC, Nutritional and Physical Activity Self-Assessment for Child Care; SCPH, Summit County Public Health; WIC, Women, Infants, and Children.

In the third stage of the analysis, programs were mapped to the Healthy People 2020 Topic Areas. ²⁰ The majority of programs discussed in the interviews addressed more than 1 Healthy People 2020 topic area and all programs were mapped using 1 or more of these topics. Of the 42 Healthy People 2020 topics, 22, or slightly more than half, were currently addressed by programs in the community. It also was determined that the majority of programs within the community corresponded to the “nutrition and weight status” topic area. A listing of all topic areas by Health Impact Pyramid level can be found in Table 2. Many of the topic areas (n=20) were represented at the counseling and education level of the Health Impact Pyramid. Twelve of the Healthy People 2020 topics were addressed with interventions at the contextual level, and 11 were addressed with interventions at the clinical care level. Six of the Healthy People 2020 topics were addressed at the socioeconomic factors level and 2 at the long-lasting protective intervention level.

The final step in the analysis involved integrating this information to understand the community's current response to 4 identified key health issues: diabetes, heart disease and stroke, mental health and mental disorders, and tobacco. Although these 4 areas correspond to Healthy People 2020 topic areas, they are interrelated issues and therefore the authors considered them more broadly. For example, all programs within the diabetes category that targeted diabetes, nutrition and weight status, and physical activity were included. Efforts beyond the programs analyzed also were examined to identify any additional activities that fell within each of the 4 health issues. For example, the authors included a greater emphasis on existing traditional medicine-based programs and considered programs not currently involved with the Wellness Council.

The results of this analysis identified areas where programming could be enhanced to meet current needs. For example, in the area of prevention of diabetes and heart disease, there are more than 50% fewer programs at the lower 2 levels of the Health Impact Pyramid compared to the top 2 levels. There is an opportunity to have a greater impact on population health by increasing programmatic efforts at these levels. By disseminating the results of this surveillance to the community, the authors are working with stakeholders across multiple sectors to strategically plan future interventions, limit duplication, leverage resources, and increase collaboration to maximize effects. In addition, they are engaged in a community-wide effort to address these issues. ²¹

Discussion

Overall, the results of this surveillance provided a foundation of understanding to build and to achieve the goal of improving the health of the community by using resources most efficiently and effectively. The first main finding of the surveillance was that the majority of health and wellness programs in the community focused at the top tiers of the Health Impact Pyramid. Although interventions at these levels (eg, counseling, education, clinical care) are essential tools of health improvement, the concentration of programs at this level represented a disproportionate use of valuable resources with little population health impact. The dispersion of programs across the levels of the Health Impact Pyramid forms an inverted pyramid with fewer programs on the bottom and more programs at the top tiers. This means that greater resources are used to affect smaller amounts of change in population health. A challenge now recognized and faced by the community is how to tip the balance of the pyramid and redistribute the emphasis of programming to the bottom of the Health Impact Pyramid. This does not mean eradicating important and effective counseling and education programs, but rather greater movement toward affecting the determinants of health.

The Wellness Council, in light of these results, is serving as a forum for program leaders to connect with others across institutions, and for intervention leaders to innovate for collaborative and coordination efforts. This strategy allows for optimizing the impact of current programming efforts rather than implementing new initiatives, which require greater resources, time, and effort. It is clear from the results that the entire community must give greater consideration to supporting interventions at the bottom tiers of the Health Impact Pyramid.

A further area of growth identified through the surveillance is how to identify and include programs from Healthy People 2020 topic areas not currently represented in Wellness Council and to include organizations working in those areas within Wellness Council. To have the greatest positive impact on the community, stakeholders in the community recognized that all interests must be represented at the coalition, and have moved forward to utilize community connections to reach out to and understand the efforts of programs in those topic areas.

Through the examination of the key health issues, the Wellness Council has begun to identify how responsibility for impacting these important health outcomes can be shared at the community level. Given the prevalence of diabetes, heart disease and stroke, mental and behavioral health, and tobacco use, and the implications each of these issues has for health outcomes, the community must come together to make changes for maximum impact. For example, the key programs that provide prevention and treatment of diabetes at each level of the Health Impact Pyramid were identified. Program leaders have assembled to plan a strategy for how best to coordinate and implement existing and needed services in this area. Given the unique health needs, assets and barriers in the community, the Wellness Council is working to plan an informed local approach to address each of these issues broadly and efficiently.

Another example of the success of the Wellness Council coalition is a program, entitled Personalized Educational and Experiential Modules for Diabetes Self-Management, that was conducted that utilized a community-wide collaboration with the aim of reducing the impact of chronic disease while empowering patients and reducing costs. Based on the results reported earlier referencing conducting the surveillance and gap analysis for diabetes, a need for a community-wide group self-management program for individuals living with diabetes was identified. This innovative pilot was supported by the GAR Foundation and brought together professionals from the medical, public health, and social sciences fields, as well as individuals from nonprofits and faith-based and community organizations for a community health approach to combat the chronic disease epidemic. This initial program focused on diabetes self-management, which ultimately empowered participants to change their behaviors and take increased control over their disease. Participants were recruited from 3 sites, and included participants with private pay insurance, public insurance, and no insurance. From this innovative pilot, significant results included decreases in blood glucose and low-density lipoprotein cholesterol levels, weight loss (ie, total participant weight loss of 115.1 pounds), ²² decreased body mass (ie, 22.8 point body mass index decrease), ²² and decreased emergency department visits for diabetes-related issues. This was a promising evidence-based intervention that was well received by participants. Recommendations from The Community Guide ²³ were used for the design and implementation of the program. The program involved a multidisciplinary team to design, deliver, and implement all of the educational and experiential components. Recognition of the success of this pilot was as a second place winner of the I'm Your Community Guide! ²³ Additionally, this was a high-impact solution to the increasing prevalence of diabetes, which contributed to the participants' improved disease self-management and increased self-efficacy.

Moreover, the American Cancer Society highlighted the work as a successful national model for prevention efforts. The American Cancer Society has the responsibility to report to the US Congress on the “…cross-cutting approaches that communities are taking to improve the health and well-being of their residents.” ²⁴ Only 18 were showcased from the entire nation; the program described herein was the only one from Ohio. ²⁴ In addition, the Centers for Disease Control and Prevention has highlighted the Summit County collaboration efforts. ²⁵

Another example of the inclusion of this successful broad-based coalition is the involvement of the Wellness Council in the local Accountable Care Community (ACC) initiative. ^21,26,27 The ACC initiative brings together the more than 60 members of the Wellness Council of Summit County, already described. The ACC initiative is a collaborative, multi-institutional approach that emphasizes a shared responsibility for the health of the entire community while avoiding the expenditure of resources on overlapping programs and services. The ACC is impacting the range of determinants of health and making community efforts more efficient by strengthening links between existing programs, capitalizing on resources, and creating novel solutions to chronic health issues. ^26,27 The ACC areas of focus are spectrum-wide, namely health promotion and disease prevention, access to care and services, and health care delivery. In response to the health needs of the local community and the goals set by Healthy People 2020, the ACC initiative focuses efforts on chronic conditions including diabetes, obesity, asthma, and hypertension. The ACC initiative not only increases community wellness and quality of life by focusing on these chronic diseases, but also lowers health care costs, increases productivity, maintains or increases quality, and enhances the patient experience. ^26,27 These metrics are aligned with the Triple Aim of the Institute for Healthcare Improvement. ²⁸

The ACC goes beyond the Accountable Care Organization concept called for in the Patient Protection and Affordable Care Act, as it integrates not only medical care delivery systems, but also encompasses local health systems, community stakeholders, educational institutions, social service and faith-based organizations, and philanthropic organizations. The focus is on the health outcomes of the entire local community instead of a select few. It integrates area assets into a shared responsibility framework among regional entities to enable improvement in population health, to close gaps in health care delivery, and to measure impact as innovative health strategies are implemented. ²⁷ Through the creation and implementation of the ACC, a sustainable health model has been developed for the community of Summit County, Ohio, that is lessening the burden of disease and achieving a level of success that can be replicated by communities nationwide.

Conclusions

A coalition-based surveillance approach was used to identify the programmatic level and potential impact of current clinical, public health, social service, and educational initiatives being implemented to improve the health of the Summit County community. This approach allowed the recognition and identification of gaps by level of intervention within local community-wide initiatives, mapped to the Healthy People 2020 topic areas. Using the Health Impact Pyramid to depict gaps in topic areas and levels of intervention offered a concrete method to convene community stakeholders around a shared vision, understanding, and plan of action. By integrating this information with community-specific data on medical care and public health promotion, access to care and services, delivery of health care, personal health outcomes, and environmental conditions, the level of wellness programming was identified in a priori areas targeted to have the maximum impact on the health of the community.

The results of this surveillance were shared with the Wellness Council as well as the wider community to facilitate improved collaboration, coordination of programs, leveraging of resources, and to catalyze development and growth of programs in underrepresented areas. The discussion stimulated by the presentation of these results has now resulted in forward movement toward addressing programming gaps and better coordination of programs across intervention levels and topic areas. The authors recommend that other communities attempting to facilitate community-wide planning for health and wellness use this approach.

With the strength of this broad-based coalition, a multisector community partnership, a culture of collaboration, shared standards for evaluation, and a shared framework for impacting health, the health of the population can be transformed. Through this community coalition and surveillance analysis, important changes in the health and well-being of the population are catalyzed. As has been demonstrated in Summit County, Ohio, which has been recognized as a national model of success, communities can benefit from such multisector oversight coalitions that jointly share the strategy, responsibility, and shared accountability for improving population health and, ultimately, positively impact the health of their populations.