Cultivating a Culture of Health Equity through Strengthening Public Health and a Community Organizing Partnership

State: MO Type: Promising Practice Year: 2016

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Addressing health equity, in particular structural inequities, requires resources and expertise often outside the capacity of most local health departments. To bridge the gap, the Kansas City Missouri Health Department (KCMOHD) developed a strong interdependent partnership with a community organizing entity and solidified their collaborative efforts with a Memorandum of Understanding (MOU). The mutually beneficial agreement has integrated public health and community organizing, fueled effective community engagement, resulting in a stronger culture of health that supports health equity, social justice, and economic dignity.

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Kansas City Health Department
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Cultivating a Culture of Health Equity through Strengthening Public Health and a Community Organizing Partnership
Kansas City, Missouri (KCMO) is the 37th most populated city in the nation and home to a diverse urban community on the Missouri-Kansas border (total population, 459,787). Population demographics have shown an even male to female ratio with an ever changing racial and ethnic landscape (59.5% White, 29.9% Black, 2.5% Asian, less than 1% American Indian/Alaska Native and Native Hawaiian/Other Pacific Islander, and 10% Hispanic/Latino 2010 U.S. Census Data); steady increases have been observed in both the Black and Hispanic populations. In 2000, KCMO faced the reality that the city’s longstanding geographic racial divide had created a significant health inequity across the community. Local statistics unveiled a startling 6.5 year difference in life expectancy between White and Black residents. In addition, a 13 year difference in life expectancy was identified across zip codes. Further investigation by KCMO Health Department (KCMOHD) officials exposed that social, economic and environmental factors attributed to approximately 47% of all deaths in KCMO; the pressing need for quality education, social support, employment opportunities, and living wages for all residents were thrust to the forefront of public health. To truly impact health outcomes for those with shorter life expectancies, KCMOHD had to first address city-wide health equity and social justice, an ambitious charge outside of the traditional role of a local health department. An aggressive response to health inequities was imperative. Success hinged on the KCMOHD’s ability to think and act innovatively through strategic selection of a collaborator with expertise in bridging the racial and economic divide. KCMOHD created a formalized partnership with a local community organizing group, Communities Creating Opportunity (CCO). The goal of establishing the MOU between KCMOHD and CCO was to ultimately improve the collective impact on community health outcomes, specifically increasing life expectancy and reducing inequities by race and zip code. The objectives established to meet this goal remained centered on social justice and health equity for all. These goals and objectives were met through the continual, collaborative efforts to share information and resources that helped each organization succeed in their respective sphere of influence. Efforts remain ongoing as KCMO continues to make strides in improving health equity, social justice, and health outcomes for all citizens. To date the partnership, fortified by the MOU has contributed to impressive progress in the following areas: Organizing a community event at Union Station with a panel of City Council members and the KCMOHD Director to discuss issues around health equity. In attendance were 1,100 community members and 100+ clergy leaders (2011) Increasing the number of banking institutions willing to provide small loans at reasonable interest rates (2012).  Increasing employment opportunities for people with a criminal history by removing the mandatory disclosure on city job applications and advocating on the passage of a state bill removing the prohibition of providing SNAP benefits to former felons (2013)  Achieving 70% voter approval rating to continue a city-wide property tax in support of illness and preventative health care for the indigent population of Kansas City (2013)  Advocating for Medicaid expansion in Missouri (2014 and ongoing) Engaging more than 1,000 individuals in viewing the Raising of America documentary in Kansas City and obtaining individual and agency commitments to support future initiatives to improve health outcomes for the city’s youth (2015) Ongoing work to increase the living wage in Kansas City; City approved, State preempted (2015) Initiatives adopted by the Mayor and City Council to support the increase in life expectancy and reduce zip code inequities were written into City of Kansas City Missouri's 5 year Business Plan and Budget (2015) While all elements of the collaboration could have theoretically, been achieved without the MOU process, it created a clear level of accountability for each agency in the partnership. The MOU, as a tool, clearly delineated roles and responsibilities leaving little question as to the expectations of each organization and ultimately resulted in more action and activity among the two partners. In addition, one-on-one relationship building, both internal between the organizations and external between the organization and key leaders in the community, has been a key factor that led to the success of this partnership. As a result of the KCMOHD-CCO collaboration and other multi-sector partnerships addressing community inequities, health outcomes for minority populations are beginning to improve. Over the past decade, life expectancy improved for everyone and the gap between White and Black residents was reduced from 6.5 years to 5 years. The two organizations will continue to work towards improving the overall health of Kansas City through community engagement around social justice and health equity issues. More information can be found on the KCMOHD website: http://kcmo.gov/health
In 2000, Kansas City, Missouri (KCMO) faced the reality that the city’s longstanding geographic racial divide had created a significant health inequity across the community. Local statistics unveiled a startling 6.5 year difference in life expectancy between White and Black residents, with a 13 year difference when broken down by zip code. Significantly higher rates of Cancer, Heart Disease and Homicide topped the list of causes. Fueling this great divide, was something much deeper than a medical model alone could solve. Further investigation by KCMOHD officials exposed that social, economic and environmental factors attributed to approximately 47% of all deaths in KCMO (based on Galea, et.al., American Journal of Public Health August 2011, Vol 101 no. 8). Social justice was largely absent leaving unjust advantage and privilege based on race, class, gender and other forms of difference to influence health outcomes. Health inequity flourished within the city, noted differences in population health status and mortality rates were systematic, patterned, unfair, unjust, and actionable. The pressing need for quality education, social support, employment opportunities, and living wages for all residents were being thrust to the forefront of public health. Operating primarily within the medical model side of the Bay Area Regional Health Inequities Initiative, A Framework for Health Equity, the department needed to move upstream towards the Socio-Ecological model side. To truly impact health outcomes for those with shorter life expediencies, they had to first address city-wide health equity and social justice, weighty issues outside the Health Department’s traditional sphere of influence. “We believe where you live shouldn’t determine how long you live. We’re not only concerned with keeping people from dying; we’re concerned with keeping them from becoming ill” - Dr. Rex Archer, Director, KCMOHD KCMO is home to a diverse urban community nestled on the Missouri-Kansas border with a total population of 459,787 people (59.5% White, 29.9% Black, 2.5% Asian, less than 1% American Indian/Alaska Native and Native Hawaiian/Other Pacific Islander, and 10% Hispanic/Latino; 2010 U.S. Census Data). Its expansive reach (315 square miles) across four counties ranks it as the 37th most populated city. While approximately one-fifth of the population lives below the poverty level, some populations are more afflicted by poverty than others; 30.5% of Kansas City’s Black population and 31.1% of the Hispanic population live in poverty compared to only 11.8% of the White population (2013 American Community Survey). The median household income for Blacks is over $20,000 lower than it is for Whites ($31,133 Black, $55,018 White). Unfortunately, Kansas City is infamous for its geographic isolation of minority populations, mostly in impoverished neighborhoods where poor health outcomes, neighborhood blight, drugs, gangs and violence are all too common. In 2000, an analysis of Census data landed Kansas City, Missouri as the 18th most segregated metropolitan area in the nation, a clear indication of its oppressive past and struggling present. In Kansas City, inequity abounds for both adults and children. According to data from KC Health Matters, 40.2 percent of Black children in Kansas City live below the poverty level, compared to 15.3 percent of White children in Kansas City. A report released (March 2014) by the U.S. Department of Education Office for Civil Rights identified Missouri as one of eleven states with higher gaps than the nation between the school suspension rates of Black students and White students for both boys and girls. To change the health outcomes for this population, the Health Department needed a shift in how they addressed and promoted public health city-wide. They turned to longtime partner, CCO, a grass-roots nonprofit organization focused on health access and equity, economic dignity, citizenship, and violence prevention across KCMO. CCO successfully utilizes community organizing techniques to create change in communities and is the largest data driven community engagement effort in the region. CCO employs the “one-to-one” relational conversation between organizations/organizers and everyday people by utilizing the evidence-based People Improving Communities through Organizing (PICO) - Community Organizing Model. The PICO – Community Organizing model provides intensive leadership training that teaches people how to use the tools of democracy to improve their communities. As a result organizations and movements are led by ordinary people who have learned to successfully use the levers of power to bring resources and political attention to their communities. The model utilizes research, action and relationships to influence public policy from the ground up by starting with local problems faced by families. Innovation exists within the KCMOHD-CCO partnership. The two organizations have utilized a common tool, a MOU, to creatively enhance and energize shared responsibilities around changing health outcomes by merging public health with community organizing. Through the establishment of an MOU, the two organizations adopted a community model as outlined by the Institute for Alternative Futures in thePublic Health Scenarios 2030 that focused on “Sea of Change for Health Equity” and “Community-Driven Heath and Equity”. This model promoted the following: Public health agency evolution into the chief health strategist role  Garnering of public support for opportunity, equity, and fairness in policies and economics Accelerating innovation in communities, alternative economics, and transformation through new technologies and the recognition of economic and social injustice Prior to the establishment of the MOU, KCMOHD and CCO operated as traditional community partners when specific issues emerged within the community, providing resources and collectively solving problems. Time and time again KCMOHD and CCO were appearing at the same community gatherings, taking up the same issues and advocating for the same change from different perspectives. This has been the traditional arrangement between public health and community organizing among health departments; touch and go partnerships that have not fully integrated shared values and shared resources. KCMOHD and CCO realized that formalizing a strong partnership and strategically working in tandem could create stronger more lasting change throughout the community. The use of an MOU with a community organizing agency has shifted the Health Department staff’s perception of health to adopt health equity as a primary influencer in changing community wide health outcomes. The KCMOHD adjusted their operational style to include community and leadership organizing around important key initiatives; CCO embraced the Health Department’s access to data, influential public relationships and focus on community health. As a result, social, economic, and health outcomes in KCMO are improving.The depth of collaboration between public health and community organizing and the use of an MOU KCMOHD and CCO is believed to be unique among health department organizational structures nationally. The framework of the relationship includes: • A shared vision: Creation of conditions for good health for all• A shared focus: Elimination of health inequities based on race, class, gender and power• Alignment: Between local public health agencies, faith based communities and others• A shared space: CCO is co-located in the Health Department, literally across the hall from the Health Department's Administrative Office• Shared outcomes and evaluation Partnerships between public health and community organizing agencies is a relatively new practice in public health climate that is shifting to include more health equity and social justice initiatives. The practice is not yet evidence based, however, the concept is being studied in depth by many institutional researchers. Most notably, is work conducted by Paul Speer, Associate Professor at Vanderbilt University. His research is in the area of community organizing, social power and community change with current work focused on studying organizational strategies for sustained civic engagement, organizational networks in violence prevention and the relationship between affordable housing and educational outcomes. Speer has published over 40 articles and chapters in a variety of journals including the American Journal of Community Psychology, Health Education & Behavior and the American Journal of Public Health. His work continues to support the union of public health and community organizing and demonstrates positive outcomes. In a recent scholarly work titled “Community Organizing: Practice, Research and Policy Implications”, published in Social Issues and Policy Review (2015), Speer encourages the development of community organizing/public health partnerships in the following ways: “Public-sector entities can sometimes find shared purposes with grassroots organizing groups. More generally, they can design policy-making processes that allow for increased engagement with grassroots groups. In addition, they can often support the local community institutions on which organizing depends. For nongovernmental organizations, community organizing groups should be considered as promising partners for community-driven health promotion and community development efforts. Community organizing also serves as a model for deeply democratic work oriented toward change in policies and systems.” The KCMOHD-CCO collaboration is a living, breathing and working model of what Speers’ research supports regarding community organizing and public health.
The goal of establishing the MOU between KCMOHD and CCO was to ultimately improve the collective impact on community health outcomes, specifically increasing life expectancy and reduce inequities by race and zip code. The objectives established to meet this goal remained centered on social justice and health equity for all. These goals and objectives were met through the continual collaborative efforts to address social determinants of health and share information and resources that helped each organization succeed in their respective sphere of influence. The KCMOHD-CCO partnership began in 2008 and was formalized through the MOU process for the first time in 2011 (see excerpt below). It emerged out of a natural progression of listening to each other, realizing shared values and determining that both agencies could better meet their individual goals and objectives by working together formally. The realization began when both KCMOHD and CCO noticed consistent similarities in the issues they supported and the community meetings that they attended. Wanting to learn more about the organization and how they could potentially help in the realm of public health, the HD Director attended a CCO Training in 2008 to learn more about the tactics that CCO employed to mobilize the community around important issues. Two years later CCO invited HD to join them at the first National Community Organizing and Public Health Exploratory Meeting (sponsored by the Kellogg Foundation-California Endowment) to learn how they could collectively grow and expand their partnership. By 2011, KCMOHD had included community organizing as part of the strategic map of internal operations and an MOU was created as a document that enabled both entities to track progress within the strategic framework and document how they we reengaging the community under domain four of the health accreditation standards. The result was a unique and powerful relationship that has promoted positive health outcomes for Kansas City. Since 2011, KCMOHD and CCO have collectively worked to change and/or influence community health. The scope of work as outlined in the MOU includes building capacity in the fields of public health through cross training, joint training, education, community engagement activities, leveraging resources (i.e. joint grant applications, housing both organizations in the same building, etc.) and sharing data and technology. The two organizations operate closely with a common agenda, engaging targeted communities through one-on-one relationship building (both internal between the organizations and external between the organizations and key leaders in the community), and collaborative priority setting. CCO was selected by KCMOHD to engage in this unique arrangement because of their ability to quickly mobilize people around important issues and command influence in spheres where Health Departments are traditionally limited. KCMOHD provides data and evidence needed to drive initiatives. The two agencies craft language that will lead the campaigns (i.e. “Ban the Box”), and CCO mobilizes the community in an educated, informed and peaceful way to strategically elicit change in policies and practices across the city and/or state. Both KCMOHD and CCO have spent the last 8 years mutually perfecting the relationship, building trust in each other and realizing the potential of what could be done by working together. Changes and input were and are continually welcomed on both sides of the arrangement. The collaboration has expanded beyond the two original partner agencies; KCMOHD works closely with community safety net providers and the University of Missouri-Kansas City to gather health related data, while CCO works with over 100 faith based leaders and their congregations gauging the pulse of the community, serving as a listening ear for upcoming issues and empowering everyday citizens to become change agents. As a result, community health and equity issues are addressed through broad-based involvement and participation: CCO, linking local residents and businesses into the movement and KCMOHD providing relationships and information from government, healthcare and academia. Once an issue is identified based on relevant data, information from CCO’s community presence and state/federal legislative priorities, the two agencies meet to discuss how it is impacting the health of the community. A strategy is developed, key players and influential community leaders are identified, a plan for influence around the issue is created using grass roots community organizing tactics, and data needs and information gaps are determined. Each agency then works both within their sphere of influence and together community-wide to create a movement that is stronger that either entity could achieve alone. The MOU acts as both a tool and a roadmap as the two agencies invest sufficient time and resources to achieve the intended health equity and social justice outcome within the targeted area/population. Some initiatives have taken longer than others and require additional resources over time to assure long-term change in health outcomes. The MOU with CCO enables KCMOHD to function as if it had its own community organizing division while experiencing tremendous cost savings from not having hired, trained and maintained its own community organizing division. The MOU process was easy to execute, requiring only the approval of each agencies governing board, and affordable with minimal costs associated with the execution of contracts and a pledged membership to CCO by KCMOHD. It is estimated that this process has saved KCMOHD upwards of $1.5 million to create the same level of influence and change as could be achieved with its own internal community organizing division. Below is an excerpt of the MOU language signed into effect by both KCMOHD and CCO. Mutual Goal: Integrating Public Health and OrganizingHaving worked together on many projects over the last few years, the two organizations recognize the need for additional changes within the organizing groups and public health agencies in order to embrace the “worldview” (the underlying systems that shape ideas, beliefs and values) focus on health equity, and incorporate new organizational strategies in order to achieve success. Goals of both organizations include working to build additional bridges between sectors and communities, and to bring forth from communities the importance of community power. It will be an opportunity to learn a new way to organize in locations consistently without knowledge of their “power” to influence change that brings about improvement in health care and resources through sustainable policy, systems, environmental changes, new practices, increased economic opportunities, etc. The Health Department /CCO collaboration represents a strategic alliance that works together to define a new narrative, as “organized” public health, as they develop an arena of power to improve the quality of health for all metro Kansas Citians, with an emphasis on creating a culture of health equity and economic dignity. We have added to the Institute of Medicine’s 1988 statement about public health… “Public Health is what we do collectively, as a society, through organized actions to assure the conditions in which all people can be healthy”. Thus, together this collaboration of the Kansas City Health Department and CCO is a necessary partnership. The basic framework for the collaboration centers around five key areas: A shared vision: Creation of conditions for good health for all A shared focus: Elimination of health inequities based on race, class, gender and power Alignment: Between local public health agencies, faith based communities and others A shared space: CCO is co-located in the Health Department, literally across the hall from the Health Department's Administrative Office Shared outcomes and evaluation Partnership Collaboration Objectives: Operational IntegrationPublic Health and Community Organizing Build on the ongoing strategic and relationally driven effort to integrate key public health activities with the arts and practice of community organizing for long-term increase in healthy life expectancy within our Kansas City metro. Public health increasingly is recognizing the need to work upstream, on root causes impacting the health and vitality of residents. Community organizing, specifically congregation based community organizing, is increasingly operating from a power building orientation of shaping the debate and influencing ideology within issue campaigns, which allows for greater collaboration. Problem: Inequities in life expectancy are dramatic. In Kansas City, Missouri there is a 13 year life expectancy difference between a 64130 zip code and that North of the river. Caucasian women live twenty years longer than African American men. There is a five times difference in infant mortality in these zip codes. We keep throwing more money at illness care expecting different results. Instead, we have joined together to design and support strategic investments in system change so that prevention policies, innovative programs, and funding increases will progress at a faster rate. In so doing we want to decrease the rates of people getting sick. Collaborative Ideas (PH= Kansas City, MO Public Health). Note: The following categories are presented where they “best fit” with the understanding that some items actually belong to more than one category. I. Building Capacity in the Fields of Public Health and Community Organizing. A. Cross Training (PH and CCO) (CCO and PH): New Employee Orientation led by PH and attended by CCO and PH staff—occurs quarterly, all CCO staff will attend in 2013. CCO director consults with PH director on how to most effectively integrate root causes as compared to clinical public health initiatives in the orientation. CCO introduces new employees to our offices, larger staff team, & organizing priorities as part of the department visits during mid-day orientation.  PH senior/key staff attends PICO National Leadership Training—occurs twice per year in January and July—2 per year Metro Leadership training attendance by PH—larger # determined by cross section of people employed by Health Dept. who attend CCO congregations, also individuals at PH who gravitate toward organizing as health department is organized as an institution  Clergy leadership engagement CCO trains PH in neighborhood canvassing and VAN in targeted zip codes with low life expectancy B. Joint training: Metro Leadership training for CCO and PH together to build teams and connections, i.e. utilize leadership team trainings/Local Organizing Committee trainings to design approaches for congregations and health department divisions and/or programs (Communicable Disease, Environmental Health Division of Administration, Maternal Child…) Higher level training for leadership of other area health departments led by Eva and Rex and key staff that have been involved to date. Prioritizing: Johnson County, Lougene Marsh and Wyandotte County, Joe Connors. C: PH funding community organizing D: Joint grant applications: Generating target list by September? 2013 Integrating public health and organizing outcomes in key grants, being explicit about evaluation costs E. Data and Technology: KCMO PH has data and technology that we don’t have. i.e. flip chart power points to advance visual structures and mapping Design surveys together that we can use optical scanning PH technology for Translation equipment and computer/digital labs F: PH members of congregations not yet CCO members— Help advance the engagement and utilize match list Help establish infrastructure for collaboration.  Develop funding resources for collaboration. II. Engaging Target Communities A. One on one relationship building: PH tracks 1-1’s of top 50 low-wage workers, tracking how many one to ones conducting and how many. –Expectation launched in February, 2013, waiting for measurement tool, Sharepoint. Joint meeting between PH and CCO on evaluative measures and how they align, using Dr. Paul Speer, Vanderbilt University. First work session, June 17th.  PH gives CCO a list of top/key 24 leaders to conduct 1-1’s with over next 6 months as we are launching Building a Healthier Heartland.—List due by end of June, 2013 B. Representation on each other’s advisory, governing bodies: PH Health Commission or PH Working group representation (names generated from CCO and vetted by Mayor) CCO board position either from at-large roles or as a formally aligned institution C. Collaborative priority setting: Health Commission committee has CCO present when determining priorities around theme and particular issue Discuss options: lead, support, research/plan for next year, opt out, endorse only D. Mutual increase in legitimacy, reinforce each other’s credentialing, i.e. testifying at critical hearings: Congregational tool kits that credential KCPH and CTG  Data analysis reports that can be unveiled to press through white papers, demonstrations Press, etc.  E. PH liaisons to local organizing committee: Need to run CCO’s congregational list by PH employees to see intersection and encourage participation. F. PH training of local organizing committee:a. Connect public health issues, when relevant, to organizing campaigns G. Internships and Organizing Academy: Recruit PH interns into joint effort Joint grant writing: Dr. Laura Lacy Hahn, Dean at School of Nursing at UMKC and co-chair of health commission.  Recruit professionals into the field of public health and organizing, i.e. designing an Public Health and Organizing Academy given twice per year that recruits by scholarship or payment high level individuals who want training and would be positioned to enter into public health and organizing profession post academy. H. PH assisting CO inside the walls (and outside) Serve as bridge between sectors Cross collaborate with additional public health professionals and organizers Help educate the public Develop tracking and provide regular presentation of data (including social indicators, and linkages to other sources. Support HIAs Help build networks of power with community organizers I. CO assisting PH outside the walls (and inside) City Council and partner power building—over next two years co-strategize movement in KCMO council, violence prevention circles and politics around it. Serve as bridge between sectors Organize healthy healing conversations Build grassroots base for health equity and community transformations  Help educate the public Build networks of power and leadership  Help establish infrastructure for collaboration. Cross collaborate with other public health entities. Regularly present data to community. Mobilize around policy issues. Develop funding resources for collaboration. III. Achieving Health Impact Outcomes A. Co-locate and discern ways CO can engage population at PH: i.e. Voter Registration for walk ins Issue promotion within the building C. Breakthrough Campaigns: Match CCO issue priorities and Health Commission priorities and chose a HIA priority each year Create the story that is magnified national attention to promote the integration of public health and organizing V. Communication. Both parties agree to communicate regularly and not less frequently than monthly regarding any issues or problems that may arise in order to keep side up-to-date on issues that impact this understanding, and to resolve any problems that may arise. VI. Compensation. No financial resources will be exchanged between KCMOHD and CCO as part of this Memorandum of Understanding. VII. Confidentiality. With respect to this Agreement and any information supplied in connection with this Agreement, both KCMOHD and CCO agree to (1) protect such information as confidential in a reasonable and appropriate manner or in accordance with applicable professional standards and laws; (2) use such confidential information only to perform its obligations under this Agreement; and (3) reproduce such confidential information only as required to perform its obligations under this Agreement or as required by the Missouri Sunshine Law. VIII. Assignment. No party hereto shall have the right to assign this Agreement to any other person or firm without the prior written consent of the other party. IX. Notices. All notices shall be sent postage prepaid to the intended party at the address set forth below (unless notification of a change of address is given in writing) and two (2) business days following the date of mailing shall be deemed the date notice is given. X. Partner Termination. This Agreement shall automatically renew for successive one (1) year terms and either party may terminate this agreement by providing thirty (30) days written notice. XI. Severability. Should any part, term, or provision of this Agreement be declared to be invalid, void, or unenforceable, all remaining parts, terms, and provisions hereof shall remain in full force and effect, and shall in no way be invalidated, impaired, or affected thereby.
The KCMHOD-CCO collaboration has supported initiatives and achieved impressive outcomes at both the city and state level. Among the notable accomplishments that the partnership has influenced include: Organizing a community event at Union Station with a panel of City Council members and the KCMOHD Director to discuss issues around health equity. In attendance were 1,100 community members and 100+ clergy leaders (2011) Increasing the number of banking institutions willing to provide small loans at reasonable interest rates (2012).  Increasing employment opportunities for people with a criminal history by removing the mandatory disclosure on city job applications and advocating on the passage of a state bill removing the prohibition of providing SNAP benefits to former felons (2013)  Achieving 70% voter approval rating to continue a city-wide property tax in support of illness and preventative health care for the indigent population of Kansas City (2013) Legislative progress toward increasing eligibility for Medicaid and Medicaid expansion in Missouri (2014 and ongoing) Engaging more than 1,000 individuals who have attended the screening of Raising of America documentary in Kansas City and have made commitments to support future initiatives to improve health outcomes for the city’s youth (2015) Ongoing work to increase the living wage in Kansas City; By a 12 to 1 vote the outgoing City Council voted to increase the living wage. The vote was ratified again by the incoming Council, also by a 12 to 1 vote. The State preempted, and a state wide ballot initiative is now being pursued (2015) Initiatives to support the increase in life expectancy and reduce zip code inequalities was unanimously approved to be included in Kansas City’s 5 year Business Plan and Budget (2015) All the above mentioned items highlight some of the efforts that are paying off. Over the past decade, life expectancy improved for everyone and the gap between white and African-American residents was reduced from 6.5 years to 5 years. KCMOHD and CCO are continually evaluating the MOU from each perspective and making adjustments to fit the needs of their standalone entity. As the relationship has progressed, changes and adjustments have been made to create a stronger working environment. As an example, in 2012 CCO and KCMOHD co-located within the same building to increase and improve communication and working relationships across the two groups. This made joint trainings, cross trainings, agency education and day-to-day communication easier and more fluid. In addition, co-location provided cost-savings for both, an advantage lauded by the leadership of both non-profit organizations, critical in a city with stiff competition for philanthropic dollars. As the model progresses the two agencies have turned to the Community Engagement Continuum (Principles of Community Engagement, 2nd Edition) as a barometer in formally measuring the strength and effectiveness of community engagement outcomes as a result of the MOU. In addition, KCMOHD is currently using the Bay Area Regional Health Inequities Tool Kit to assess the progress of the collaboration. Since the evaluation is not yet complete, no changes have been made to the process or arrangement date. Results of both assessments will guide modifications to the MOU and evolution of the partnership, identifying weaknesses and gaps and enhancing the most effective methods. The KCMOHD and CCO are currently assisting the Clay County Missouri Health Department in developing a similar program on a smaller scale to help determine best practices in smaller locations with fewer community organizing resources. As the program develops, the specifics of replicating this model will emerge. Lessons learned will further be applied to the KCMOHD-CCO model for continual growth. What began with limited community involvement has progressed to sharing information with communication flowing both to and from the community throughout the entire process; from development to solution, KCMOHD and CCO continue to work toward shared leadership with a strong bidirectional relationship that allows for final decision making to occur at the community level. As they perfect their relationship to true shared leadership within the community, broader health outcomes affecting the broader community will be realized. Although there has been no independent evaluation conducted the formalized written MOU, automatically serves as an evaluation tool for both partners; each uses the document to conduct ongoing evaluation of the effort. To date, all but one of the extensive, collaborative ideas identified in the MOU have been implemented with one partial exception, a joint, annual HIA priority has not been identified each year, since the adoption of the MOU. (see item a. below) III. Achieving Health Impact Outcomes      C. Breakthrough Campaigns:          a. Match CCO issue priorities and Health Commission priorities and chose a HIA priority each year KCMOHD’s use of a formal, written MOU between public health and a community organizing agency has merited attention from nationally recognized funders and research entities. Over the past year, this partnership was presented to the Robert Wood Johnson Foundation and the University of Wisconsin – Population Health Institute in Kansas City’s Culture of Health Prize proposal. Both agencies stand behind this collaboration and indicate that it was highly influential in their decision to award Kansas City with a 2015 Robert Wood Johnson Foundation – Culture of Health Prize. “The collaborative efforts of the Kansas City Missouri Health Department and Communities Creating Opportunity are working to influence change in health equity across Kansas City. Their efforts are purposeful and address the root causes of disparity through a broad, peaceful and positive approach. They excelled in all six of our prize criteria.”       - Carrie Carroll, Researcher – University of Wisconsin – Population Health Institute More information about the award and the video created by the Robert Wood Johnson Foundation can be found at: http://www.rwjf.org/en/library/articles-and-news/2015/10/coh-prize-kansas-city-mo.html  
Sustaining the KCMOHD-CCO collaboration is relatively seamless, a highly desired attribute in any partnership. The heavy-lifting completed, successes have been documented and trust is firmly established. To maintain the successful partnership, the two entities must continue to agree to work together in the capacity that they have currently achieved, be willing to evaluate the practice and adjust elements to ensure mutual benefit as the arrangement progresses. For the KCMOHD, it is hard to consider operating without the help of CCO. While all elements of the collaboration could have been achieved without the formal MOU process, the MOU created a clear level of accountability for each agency in the partnership. Each entity accepted the responsibilities that came with the formalized and strategic work. The MOU, as a tool, clearly delineated roles and responsibilities leaving little question as to the expectations of each organization. Beyond the importance of creating a formalized MOU, the KCMOHD learned that the document is only as good as the spirit under which it is executed. Willingness to work together, trust each other and operate outside of ego driven political agendas was imperative to success. To assist in driving the collaborative effort that supported the written MOU structure, the KCMOHD meets one-on-one with every CCO staff member to better understand and work across organizations. The collaboration, implemented using the unique MOU as a tool to move the partnership forward, is rooted in the key elements of NACCHO’s focus on programs demonstrating innovation and responsiveness. No formal cost/benefit analysis was conducted on this arrangement; however, as mentioned previously, it is estimated that utilizing an established local community organizing agency saved KCMOHD upwards of $1.5 million in costs associated with creating and operating its own community organizing division. The successful work done through the MOU by the partners to improve resources for health initiatives provide additional revenues and cost savings for the community. For example, the efforts of KCMOHD and CCO assisted achieving a 70% voter approval for a property tax in Kansas City, providing an additional $15 million in annual support for health services to uninsured and underinsured residents.
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