Development Of The Community Health Improvement

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Morbidity and Mortality Weekly ReportSupplement / Vol. 65 / No. 2February 26, 2016Development of the Community HealthImprovement Navigator Database of InterventionsU.S. Department of Health and Human ServicesCenters for Disease Control and Prevention

scussion.6Limitations.7Conclusion.7References.8The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),U.S. Department of Health and Human Services, Atlanta, GA 30329-4027.Suggested citation: [Author names; first three, then et al., if more than six.] [Title]. MMWR Suppl 2016;65(Suppl-#):[inclusive page numbers].Centers for Disease Control and PreventionThomas R. Frieden, MD, MPH, DirectorHarold W. Jaffe, MD, MA, Associate Director for ScienceJoanne Cono, MD, ScM, Director, Office of Science QualityChesley L. Richards, MD, MPH, Deputy Director for Public Health Scientific ServicesMichael F. Iademarco, MD, MPH, Director, Center for Surveillance, Epidemiology, and Laboratory ServicesMMWR Editorial and Production Staff (Serials)Sonja A. Rasmussen, MD, MS, Editor-in-ChiefCharlotte K. Kent, PhD, MPH, Executive EditorChristine G. Casey, MD, EditorTeresa F. Rutledge, Managing EditorDavid C. Johnson, Lead Technical Writer-EditorCatherine B. Lansdowne, MS, Project EditorMartha F. Boyd, Lead Visual Information SpecialistMaureen A. Leahy, Julia C. Martinroe,Stephen R. Spriggs, Moua Yang, Tong Yang,Visual Information SpecialistsQuang M. Doan, MBA, Phyllis H. King,Teresa C. Moreland, Terraye M. Starr,Information Technology SpecialistsMMWR Editorial BoardTimothy F. Jones, MD, ChairmanMatthew L. Boulton, MD, MPHVirginia A. Caine, MDKatherine Lyon Daniel, PhDJonathan E. Fielding, MD, MPH, MBADavid W. Fleming, MDWilliam E. Halperin, MD, DrPH, MPHKing K. Holmes, MD, PhDRobin Ikeda, MD, MPHRima F. Khabbaz, MDPhyllis Meadows, PhD, MSN, RNJewel Mullen, MD, MPH, MPAJeff Niederdeppe, PhDPatricia Quinlisk, MD, MPHPatrick L. Remington, MD, MPHCarlos Roig, MS, MAWilliam L. Roper, MD, MPHWilliam Schaffner, MD

SupplementDevelopment of the Community Health Improvement NavigatorDatabase of InterventionsBrita Roy, MD1Joel Stanojevich, MPH2Paul Stange, MPH3Nafisa Jiwani, MPH3Raymond King, PhD4Denise Koo, MD31Yale University School of Medicine, New Haven, Connecticut2Center for Global Health, CDC, Atlanta, Georgia3Office of Associate Director for Policy, CDC, Atlanta, Georgia4National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GeorgiaCorresponding author: Brita Roy, MD, Department of Internal Medicine, Yale University School of Medicine. Telephone: 203-785-5564;E-mail: [email protected] the passage of the Patient Protection and Affordable Care Act, the requirements for hospitals to achieve tax-exempt status includeperforming a triennial community health needs assessment and developing a plan to address identified needs. To address community healthneeds, multisector collaborative efforts to improve both health care and non–health care determinants of health outcomes have been themost effective and sustainable. In 2015, CDC released the Community Health Improvement Navigator to facilitate the developmentof these efforts. This report describes the development of the database of interventions included in the Community Health ImprovementNavigator. The database of interventions allows the user to easily search for multisector, collaborative, evidence-based interventions toaddress the underlying causes of the greatest morbidity and mortality in the United States: tobacco use and exposure, physical inactivity,unhealthy diet, high cholesterol, high blood pressure, diabetes, and obesity.BackgroundPopulation-level health outcomes in the United States,including life expectancy and infant mortality rates, lag behindthose of other countries in the Organisation for EconomicCo-operation and Development, despite spending the greatestpercentage of its gross domestic product on health care (1–5).To attenuate this gap, health care payment models are shiftingaway from rewarding volume of service and toward rewardingvalue based on health outcomes (6,7). However, focusing onclinical improvements alone is unlikely to substantially improvepopulation health outcomes (8). During the 20th century, mostcauses of and contributing factors to morbidity and mortalitywithin the United States shifted from infectious to chronic (9).The underlying causes of these chronic illnesses are associatedwith complex social, behavioral, and environmental factors (10).Various models describe the determinants of health outcomes,each emphasizing the relative contribution of health care andother factors (e.g., health behaviors and socioeconomic factors)to health outcomes and the interdependence of these factors(10–15). These models indicate that health care accounts for10%–20% of health outcomes, whereas socioeconomic factorsaccount for up to 40% (11). This underscores the importanceof collaboration between health systems and non–health caresectors to prevent disease and improve community healthoutcomes (16–21). Non–health care partners might includepublic health, businesses, the local government, communitymembers, and community-based organizations. These sectorscan work together with health systems to create sustainedchanges that address the root causes of disease, includingsocioeconomic factors, the physical environment, healthbehaviors, and clinical care (22). Simultaneous interventions inmultiple areas, both within and outside the health care system,have the greatest sustained improvements in community andpopulation health ( infographic.pdf ). For example, in Maine, collaborationamong health systems, the public health field, and multiplecommunity organizations resulted in a multicomponentstrategy to improve and maintain control of cardiovascularrisk factors for hypertension, hyperlipidemia, and tobacco useover a 40-year period (23).Policies in the United States are beginning to reinforce thesefindings. To be eligible for tax-exempt status, also known as501(c)(3) status, hospitals must meet requirements establishedby the Internal Revenue Service (IRS). Before passage of PatientProtection and Affordable Care Act (ACA) in March 2010, manyhospitals met the IRS requirements for tax-exempt status throughincreasing access to medical care to those without insurance orby making clinical care for indigent patients more efficient (24).US Department of Health and Human Services/Centers for Disease Control and PreventionMMWR / February 26, 2016 / Vol. 65 / No. 21

SupplementAlthough beneficial, these efforts did not address the root causesof disease. For example, although a tax-exempt hospital mighthave provided free diabetes medications and medical care fordiabetic patients without insurance, if the hospital did not alsoaddress the underlying causes of type 2 diabetes (e.g., access tohealthy foods and safe locations for physical activity), diabetesrelated outcomes among these patients might not have improvedsubstantially or might have worsened.There are new requirements for nonprofit hospitals tomaintain their tax-exempt status. With the passage of ACAregulations, tax-exempt hospitals are provided incentivesto create and sustain multisector collaborations to addressunderlying causes of disease. Every 3 years, tax-exempthospitals must conduct a community health needs assessmentand develop an implementation plan to address identifiedneeds. These needs assessments are required to solicit inputfrom government public health officials (25). In addition, theACA regulation allows for joint implementation strategies andinput from other community members, including health careconsumers and advocates, community-based organizations,academic experts, school districts, health care providers, andneighboring hospitals. The regulation requires a description ofthe community health needs assessment process, communitiesserved by the organization, and how the activities promote thehealth of the communities served by the organization. Suchcollaborative interventions have the added benefit of betterpreparing hospitals for imminent value-based payment models(26), and, most importantly, for improving the overall healthof their communities.To ensure short- and long-term success, IRS allowshospital administrators and their partners to seek multisector,collaborative, evidence-based interventions to addressthe priority health needs identified in their communities(18,27). For example, to reduce rates of childhood obesity ina community, a hospital and its community partners mightbenefit from finding ways to coach families about healthyeating, increase access to healthy foods, and create safe placesto walk and play. Accordingly, in addition to increasing timeavailable for clinicians to counsel families on the importanceof healthy food choices and preparation, partnerships mightinclude collaboration with school superintendents and localgrocers or farmers markets to increase children’s access tofresh fruits and vegetables in school meals and throughschool gardens. Another partnership could involve the USDepartment of Transportation creating safe places to walk bybuilding sidewalks and enlisting crossing guards to increase thefeasibility and safety of walking school-bus programs, programsin which adults walk students to school along a specific route(28–30). Together, changes such as these are likely to have a2MMWR / February 26, 2016 / Vol. 65 / No. 2substantial, long-lasting impact in the community and reducefuture health care costs (10,18,27).No easily accessible, comprehensive inventory exists thatis designed for hospitals to identify effective evidence-basedmultisector strategies to improve community health. Thisreport describes an online tool intended to support this typeof collaboration: the CDC Community Health ImprovementNavigator (CHI Navigator). The CHI Navigator providesresources that describe the necessity of collaborative approachesto improve community health, offers tools reviewed by expertsto establish and maintain effective collaborations, and assistsusers in finding effective interventions to improve communityhealth and well-being. This report focuses on the developmentof a critical component of the CHI Navigator: the databaseof evidence-based interventions (available at The conceptual framework and methodsused in the development of the database of interventions aredescribed in detail. Hospital administrators can use the CHINavigator’s database of interventions to select and implementevidence-based interventions that have been effective in similarcommunities with similar collaborators to develop plans toaddress problems identified in the triennial community healthneeds assessment, in alignment with the IRS requirements fortax-exempt status.MethodsIn 2015, CDC released the CHI Navigator, a freelyavailable website that supports hospitals, public health, andother community stakeholders in their work to improve thehealth of their communities. The CHI Navigator includesan easily understandable visual representation of the reasonsfor working collaboratively with non–health care sectors toimprove health ( navinfographic.pdf ), describes hospital-specific examples ofsuccessful collaborative interventions, and provides resourcesand tools to support the process of long-term collaborationand community health improvement. The CHI Navigatorguides the user through steps of community action adaptedfrom the University of Wisconsin Population Health InstituteCounty Health Rankings and Roadmaps site (11): 1) assessneeds and resources, 2) focus on what is important, 3) chooseeffective policies and programs, 4) act on what is important,and 5) evaluate actions.As part of step 3, CDC developed the CHI Navigatordatabase of interventions so that the user can identifyevidence-based interventions to address the risk factors forthe causes of the most substantial morbidity and mortalityin the United States: tobacco use and exposure, physicalUS Department of Health and Human Services/Centers for Disease Control and Prevention

Supplementinactivity, unhealthy diet, high cholesterol, high blood pressure,diabetes, and obesity (26). The goal is to assist hospitals andtheir associated health care organizations and communitypartners in identifying relevant interventions that they canadapt to have the greatest collective impact on improvingtheir community’s health and well-being. Accordingly, theCHI Navigator database of interventions guides hospitalsand their affiliated health systems and community partnersin identifying multisector collaborative interventions in thefour action areas: 1) socioeconomic factors, 2) the physicalenvironment, 3) health behaviors, and 4) clinical care.Development of the Database ofInterventionsIn 2014, CDC convened a team to create the CHI Navigatordatabase of interventions; members included two physicians,four public health researchers and program developers, andlater in the process, web designers. This CDC team beganby scanning available online resources to identify evidencebased interventions to improve community health (Selectionof Source Databases) and established partnerships withorganizations that had created sources that would be includedin the CHI Navigator database of interventions. Then the teamidentified multisector collaborative interventions addressingat least one of the causes of greatest morbidity and mortalityin the United States, listed previously (Identification ofInterventions). Finally, the interventions were organized intocategories to help users search for adaptable interventions(Creation of Sorting Filters).Selection of Source DatabasesThe CDC team developed a comprehensive, queriabledatabase of evidence-based interventions that address thefollowing modifiable causes of the greatest morbidity andmortality in the United States: smoking, hypertension,hyperlipidemia, obesity, poor diet, and inactivity (31). Existingdatabases of interventions were identified that met the followinginclusion criteria at the time of development (August 2014):the database had to be free; be accessible online; be navigableusing easily accessible, predefined filters or table of contents;be fully developed and complete; provide evidence ratingswith clearly defined methods; provide source informationand references to the original studies; clearly define outcomesassessed that are related to the conditions of interest; includeinterventions requiring cross-sector collaboration betweentwo or more sectors (e.g., health care and public health); andinclude interventions not already covered in other databasesin the CHI Navigator (iteratively performed, with The Guideto Community Preventive Services [The Community Guide] asthe first database included).Identification of InterventionsSelected databases provided two distinct types of entries:1) summary recommendations based on systematic reviewor synthesis of current evidence from multiple studies andother evidence-based sources (i.e., reviews) or 2) scientificevaluation of the efficacy of an int

Michael F. Iademarco, MD, MPH, Director, Center for Surveillance, Epidemiology, and Laboratory Services MMWR Editorial and Production Staff (Serials) Son