A New Approach to Collaboration: More Alignment between Health Systems and Community Organizations

Updated: May 26

While Community Health Needs Assessment (CHNA) has become common (and often mandatory) among community-based organizations, local government, and large hospital systems, aligning health-system and community-level efforts to improve population well-being is an ongoing challenge.

In many cases, this is because different data are collected -- health systems examine patient-level data, whereas communities are more focused on social determinants of health -- and it’s difficult to establish clear links between community needs (up-stream) and clinical health outcomes (down-stream).

It’s important that communities and health systems align efforts to fully address today’s toughest health issues. It's clear that improving well-being requires health systems to step outside of their traditionally siloed work to partner with community organizations, local government, and invested individuals and collaboratives to assess needs and coordinate improvement efforts. Unfortunately, that’s easier said than done. Stakeholders in community-clinical partnerships often face:

  • Differences in understanding of identified community needs and areas for improvement

  • No clear way to see the “big picture”; too much data to make sense of it all

  • Difficulty establishing clear links between community needs (up-stream) and clinical challenges (down-stream)

  • Lack of knowledge about successful community/clinical strategies and interventions to model

A New Approach

Solving these challenges requires a new approach that combines improved quantitative data analysis with a repository of implementation strategies, and uses technology to provide a simple, proactive tool. We have developed IP3 | Assess, a web-based application that we believe will dramatically change the way communities and health systems work together to measure, identify, and align interventions to simultaneously address clinic-level and community-level needs. IP3 | Assess integrates advances in analysis and technology to support collaboration, and simplifies the common four step process to identify needs and adopt corresponding interventions to address those needs:

  • Understand and prioritize the clinical and community health needs within a community.

  • Identify areas where clinical and community priorities most strongly overlap and/or are most in need of improvement, and where there is a complementary mix of upstream and downstream strategies/interventions.

  • Discover evidence-based strategies that involve community-clinical partnerships to effectively address identified priorities.

  • Align partners and stakeholders around broader efforts and specific strategies that address identified priorities, including shareable data reports that reflect the differing priorities and interest of all partners.

Solution Summary

IP3 | Assess integrates three advances to support the approach described above:

1. Direct comparison of data not traditionally comparable: Z-Score analysis provides a statistically rigorous method through which indicators can be compared, even if they have different units and collection methods. It also leverages a flexible benchmarking system that improves relevance for local communities and health systems. For example, see how your community’s relative score for active transportation compares to is relative score for cardiovascular disease

2. See and showcase the “big picture”: Data frameworks organize indicators into categories that make sense and are easily tied to action. They make it easier to identify and prioritize overlapping community and clinical needs to align intervention efforts. For example, a health system may use a chronic-disease-burden framework, while a community-based organization may view the same data through the “Vital Conditions” framework. Both might identify obesity as an important area of focus, but for different reasons; it is a significant clinical health issue, but also associated with Basic Needs for Health and Safety, and Transportation.

3. Seamless integration with Community Commons for Information Exchange: We just launched a brand new set of tools and resources over on Community Commons, where our goal is to provide every community access to the best, relevant evidence-based interventions, tied to specific, local needs. Content on the Commons is organized across topics, measures, and frameworks, and makes it easier to find and model ways communities and health systems can coordinate strategies to increase well-being.

These three components build upon state-of-the-art mapping, visualization, and reporting tools in the IP3 | Assess application. Partners can move from Understanding to Discovery and through Alignment to Coordinated Action in one seamless user experience. Want to schedule a demo of IP3 | Assess to learn more? Get in touch.




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