Health Improvement Planning Beyond the Office: Working in the Clouds

State: AZ Type: Promising Practice Year: 2014

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The Maricopa County Department of Public Health serves the third largest local public health jurisdiction in the U.S. and is located in Phoenix, Arizona. Historically speaking, the department was “siloed” by an array of smaller, grant-funded programs, many of which targeted overlapping populations. Limited inter-office communications led to uncoordinated efforts which ultimately could not meet the needs of the community at the population level. To address this tall challenge, four cross-departmental working groups dubbed “clouds,” were created to enhance communication, foster inter-office projects, and promote efficiency within the department and among community-based partners. The overarching goal of this novel cloud approach is to create a conceptual framework that both improves MCDPH’s internal operations and increases the department’s ability to impact the community’s health status.

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Maricopa County Department of Public Health
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Health Improvement Planning Beyond the Office: Working in the Clouds
The Maricopa County Department of Public Health serves the third largest local public health jurisdiction in the U.S. and is located in Phoenix, Arizona. Historically speaking, the department was “siloed” by an array of smaller, grant-funded programs, many of which targeted overlapping populations. Limited inter-office communications led to uncoordinated efforts which ultimately could not meet the needs of the community at the population level. To address this tall challenge, four cross-departmental working groups dubbed “clouds,” were created to enhance communication, foster inter-office projects, and promote efficiency within the department and among community-based partners. The overarching goal of this novel cloud approach is to create a conceptual framework that both improves MCDPH’s internal operations and increases the department’s ability to impact the community’s health status.The 18-month Community Health Improvement Planning cycle officially kicked off in January of 2013, when inter-office groups and community-based stakeholders began to meet in the four clouds and develop objectives. Specific objectives were formed based on the general strategies chosen at a large community stakeholders meeting in June 2012. Within each of the four cloud groups, subgroups formed to address specific issues to influence the five priority health issues (obesity, diabetes, cardiovascular disease, lung cancer, and access to health care). Each subgroup developed an 18-month SMART objective by which to measure progress. Although process monitoring and data collection is ongoing throughout the process, at the end of the 18-month cycle, each specific objective will be evaluated for outcome. The five-year Community Health Assessment cycle will evaluate the CHIP’s ultimate impact. The 78 objectives created are systematically evaluated through the use of implementation worksheets. Each cloud subgroup submits an implementation worksheet on a quarterly basis, which includes the team objective, purpose of the initiative, individual implementation activities with responsible parties and deadlines, and specific measures by which to gauge progress. This format makes it extremely easy for the evaluation team to conduct process evaluations. An evaluation snapshot of CHIP and cloud-related activities was conducted in June 2013 showing that 23 of the 79 proposed objectives had already been completed by this six-month point. Of the original 79 stated objectives, four had to be modified due to feasibility. An additional three objectives were removed because it was discovered fairly soon in the action cycle that the activity was not feasible. Please see the narrative portion of this application for specific examples. The cloud structure allows for greater efficiency and less redundancy across the department. Many collaborative projects have been executed in a short frame of time, such as coordinated responses to federal offices that would not have occurred easily before this department-wide effort. Furthermore, in the past, it would be common for several staff persons from different offices at MCDPH to arrive at the same community-based event, and be surprised to see one another. Now, with coordinated communications through regular meetings and SharePoint, one office can volunteer to take information to events for several programs, and is more aware of how these programs work with the increased level of interaction between offices. Working within the clouds is supporting a culture change within the organization. As mentioned previously, the CHIP plan is on an 18-month cycle with the first cycle set to end in June 2014. The cloud structure outcomes will be evaluated at the end of each cycle, and the actual public health impact assessed upon completion of MCDPH’s next comprehensive community health assessment.
The Maricopa County Department of Public Health (MCDPH) serves the third largest local public health jurisdiction in the U.S., with more than 3.8 million residents according to the 2010 census. Maricopa County encompasses over 9,200 square miles, roughly the size of the state of Massachusetts, and is composed of a mix of urban, suburban, and rural areas including the whole or parts of five sovereign American Indian Reservations. Home to the major metropolitan cities of Phoenix, Scottsdale, and Mesa, Maricopa County serves as the state’s major geopolitical and economic center. County residents are demographically diverse, with over 29% of residents identifying as Hispanic or Latino and more than 22% of residents over the age of 55. Poverty in Maricopa County is slightly higher than the national average, with nearly 11% of families living at or below the Federal Poverty Level.In 2011, the Maricopa County Department of Public Health (MCDPH) partnered with the Arizona Department of Health Services (ADHS) to facilitate Maricopa County’s first-ever community health assessment (CHA) and determine the community’s greatest health needs. The 18-month process was a collaborative, community-driven effort that engaged more than 1,000 residents, health professionals, and community partners. Utilizing the Mobilizing through Planning and Partnership (MAPP) framework, four comprehensive assessments were conducted: the Local Public Health System Assessment, Community Themes and Strengths, Forces of Change, and a comprehensive Community Health Status Report. Through this systematic assessment and data collection process, five community health priorities emerged. Each area of health was selected by rationally applying systematic and data-driven processes. Not only were these areas supported by the data, but they reflected the voices of community members and public health professionals. The public health strategic health priorities are: obesity, diabetes, cardiovascular disease, lung cancer, and access to health care. After the strategic health priorities were identified and vetted, the real challenge was apparent: how does one of the largest and least funded public health jurisdictions address complex issues such as these at the population level? According to NACCHO in 2010, Maricopa County receives only $12.63 in public health funding per capita, compared to $60 per capita nationally, or $65 per capita for jurisdictions over the size of two million. To create a Community Health Improvement Plan (CHIP) that will improve the entire community’s health status and actually have an impact on these five strategic priorities, a new approach was needed. In the past, the department was “siloed” by an array of smaller, grant-funded programs, many of which targeted overlapping populations. Limited inter-office communications led to uncoordinated efforts which ultimately could not meet the needs of the community at the population level. In order to better coordinate public health efforts throughout the county’s 52 school districts, representatives from each of the department’s school-based efforts began to meet on a monthly basis. This led to sharing of school contacts, consolidating communications, and the development of a website specific to school-based programs. The initial success of this effort led to the model’s replication targeted at each of the National Prevention Strategy’s four public domains: community, health care, worksites, and education, where the original “schools” group was expanded to also include early childhood venues and post-secondary institutions. These four cross-departmental working groups were dubbed “clouds,” in reference to the concept of cloud computing. Not only does this cloud structure enhance communication, foster inter-office projects, and promote efficiency, but the model has been duplicated to coordinate community-based partners external to the health department. Each cloud group, internally and externally, has each of the following roles filled by a health department staff person: a cloud leader, a policy expert, an evaluator, and an epidemiologist to support data needs. The entire concept is supported by a Strategic Initiatives Coordinator from the Office of Community Empowerment and a Stakeholder Communications Coordinator from the Public Information Office.This innovative practice does not currently boast scientific evidence or peer reviews to support its effectiveness; however, many practices that have earned the evidence-based classification through the Community Guide do rely on coalitions for their effectiveness. While not an exact replication of coalitions, the cloud structure does have many similarities to a coalition-based approach, by convening stakeholders, facilitating communication, and promoting objective-driven interdisciplinary work groups. Furthermore, the objectives developed by working groups within the cloud structure are rooted in evidence based strategies. This process is explained in detail in the following section.
Global Immunization|Nutrition, Physical Activity, and Obesity|Tobacco
The overarching goal of this novel cloud approach is to create a conceptual framework that both improves MCDPH’s internal operations and increases the department’s ability to impact the community’s health status.The cloud structure planning began in June of 2012, and the program’s official launch took place in January of 2013. June 2012 marked the end of the CHA cycle when the strategic health priorities and vetting cycle were presented to a group of 100 community stakeholders who had participated in various ways throughout the assessment process. At this same meeting, community action plan strategies were chosen by the community-based stakeholders group. Meeting participants selected the strategies from a list of evidence-based approaches to address poor nutrition, physical inactivity, tobacco use, and barriers to health care (to affect the five health priorities). The list was generated from MCDPH’s internally created database which houses over 800 strategies reviewed for their level of scientific evidence through the Community Guide, Centers for Disease Control and Prevention, Cochrane Library, Institute of Medicine, and other reputable sources. The 18-month CHIP cycle officially kicked off in January of 2013, when inter-office groups and community-based stakeholders began to meet in the four clouds and develop their objectives. Specific objectives were formed based on the general strategies chosen at the June 2012 meeting. Within each of the four cloud groups, subgroups formed to address specific issues to influence the five priority health issues (obesity, diabetes, cardiovascular disease, lung cancer, and access to health care). Each subgroup developed a specific 18-month SMART objective by which to measure progress. Although process monitoring and data collection is ongoing throughout the process, at the end of the 18-month cycle, each objective will be evaluated for outcome. The five-year Community Health Assessment cycle will evaluate the CHIP’s impact. The following four objectives are examples taken from the 79 objectives created from both the internal and partner cloud groups: By June 30, 2014, the Office of Epidemiology in association with the education cloud will draft guidelines pertaining to the prevention of animal and insect-borne disease threats in Maricopa County for the school wellness guidebook. By June 30, 2014, the Office of Health Promotion and Education in association with the community cloud will increase the number of website hits on FindHelpPhoenix.org by users in Maricopa County by 300% over baseline. By June 30, 2014, the Data Team health care cloud partner subgroup will offer data users in Maricopa County health-related data from a centralized system updated annually by working collaboratively MCPDH and qualitative/quantitative data experts. By June 30, 2014, the Empowerment Through Policy worksites cloud partner subgroup will increase the number of existing worksites with comprehensive wellness policies by five. Cloud groups internal to MCDPH meet monthly, and the external partner clouds meet quarterly. Each quarter the self-selected work groups fill out an implementation plan form for that particular quarter to specify the activities that will be conducted during the three-month period to reach the 18-month objective as well as assign deadlines and individuals responsible for conducting or overseeing each activity. This format allows for creativity and self-directed work, while providing accountability and structure for process monitoring and evaluation. The community partners gain numerous benefits by participating in the cloud groups. In a time when all community-based agencies have limited resources available to carry out their mission, it is quite advantageous to be connected to such a large group of other agencies working to support mutual goals. Participants have indicated that networking is one of the greatest assets of cloud participation. In addition, technical assistance services are offered by the health department to support the participating partners, many of which the agencies may not have the internal capacity or expertise to employ. Examples of these services include provision of epidemiological data for program planning or grant applications, program evaluation technical assistance, and policy development support. As of October 2013, more than 60 agencies have been engaged through the cloud structure forming the Health Improvement Partnership of Maricopa County (HIPMC). Cloud leaders agreed that the external group should have branding separate from MCDPH, since it is truly a community effort, and not government-specific. A total annual budget of $116,251 is used to fund infrastructure and support materials including two staff positions, space and refreshments at meetings, and costs related to branding and marketing. The majority of the program budget goes to two full-time staff positions responsible for coordinating the effort. A Strategic Initiatives Coordinator position serves to oversee the entire cloud structure. The person in this role takes care of planning meetings, creating agendas, facilitating the leadership team and also serves as a content expert. The Strategic Initiatives Coordinator is responsible for being aware of all cloud activities, both among staff internal to MCDPH and the partner groups, making connections, and serving as the main contact person for all cloud participants. The midpoint in salary range for this position is $47,861. The other critical staff role which makes the project possible is the Stakeholder Communications Coordinator from the Public Information Office. The person in this role ensures that all marketing and branding is consistent, coordinates communication with graphic designers to create quality products, supports the SharePoint site which facilitates communication among MCDPH staff cloud members, and oversees all communications with external partners through multimedia and the monthly newsletter. The midpoint salary range for the Stakeholder Communications Coordinator is $58,490. The remainder of staff positions who contribute to the project (such as each of the four Cloud Leaders, Evaluators, Policy Analysts, and Epidemiologists) support the initiative in-kind, as policy, systems, and environmental public health work fits into their positions’ existing scopes of work.While there are no direct costs associated with the internal staff cloud meetings, the quarterly partner meetings do have a small cost associated for venue space and refreshments. Three of the quarterly meetings are held onsite at MCDPH, so there is no fee for meeting space. Clouds meet separately, and the four meetings are spread throughout the course of two days with healthy snacks, water, and coffee provided for meeting participants at the cost of $300 per quarter. Once per year, the partner clouds meet together for a celebration meeting. When all four clouds meet simultaneously more space is needed. The venue, lunch, and small incentives (such as flash drives or pens) total $1,500. The remaining budget allotment is for multimedia and branding. Constant Contact licensing was purchased at the cost of $600 annually. A graphic designer created a logo branding HIPMC, a banner displaying the name of the partnership for use on websites and media materials, and an infographic which demonstrates the interrelationship between the four cloud sectors, the five health priorities, and four protective factors. These branding pieces cost a total of $4,500. Finally, a short video which tells the story of the interplay between the five health priorities and social determinants of health was adapted from a similar project in Canada for $2,100. While many of the media related costs are one-time purchases, the budget will be rolled over from year to year to sustain new efforts and ideas. The marketing and branding items can be found at the following two websites: http://www.hipmc.orghttp://maricopahealthmatters.org
As mentioned previously, the CHIP plan is on an 18-month cycle with the first cycle set to end in June 2014. The cloud structure outcomes will be evaluated at the end of each cycle, and the actual impact assessed upon completion of MCDPH’s next comprehensive community health assessment.An evaluation snapshot of CHIP and cloud-related activities was conducted in June 2013 showing that 23 of the 79 proposed objectives had already been completed by this six-month point. Of the original 79 stated objectives, four had to be modified due to feasibility. An additional three objectives were removed because it was discovered fairly soon in the action cycle that the activity was not feasible. In reference to the four CHIP objectives used as examples in the previous section, the evaluation snapshot revealed the following insights: “By June 30, 2014, the Office of Epidemiology in association with the education cloud will draft guidelines pertaining to the prevention of animal and insect-borne disease threats in Maricopa County for the school wellness guidebook.” This objective is well under way. As of June 30, 2013, the Office of Epidemiology had developed the format for which all vector-borne guidelines will appear in the school wellness guidebook. The education cloud group internally reviewed and provided feedback on the proposed format, and the responsible parties have continued to develop the information accordingly. “By June 30, 2014, the Office of Health Promotion and Education in association with the community cloud will increase the number of website hits on FindHelpPhoenix.org by users in Maricopa County by 300% over baseline.” Even though this objective was intended for completion by June 30, 2014, the Office of Health Promotion and Education actually achieved the objective by June 30, 2013. A new objective is in development to continue the FindHelpPhoenix.org efforts within the community cloud. “By June 30, 2014, the Data Team health care cloud partner subgroup will offer data users in Maricopa County health-related data from a centralized system updated annually by working collaboratively MCPDH and qualitative/quantitative data experts.” This team quickly made strides in selecting an online site where the information will be housed, and a local foundation is working collaboratively with the state health department to augment the Behavioral Risk Factor Surveillance Survey to redirect funding and gather more useful, relevant data with a larger sample size in future years. “By June 30, 2014, the Empowerment Through Policy subgroup in the worksites cloud will increase the number of existing worksites with comprehensive wellness policies by five.” This particular group is also making strides towards achieving the goal by the stated date. At the point of the June 2013 evaluation, the Empowerment Through Policy group was in the process of reviewing existing information on worksite-based wellness policies, employee survey data, and evidence-based approaches for use in worksites. All objectives are systematically evaluated through the use of quarterly implementation worksheets. Each cloud subgroup submits an implementation worksheet on a quarterly basis, which includes the team objective, purpose of the initiative, individual implementation activities with responsible parties and deadlines, and specific measures by which to gauge progress. This format makes it extremely easy for the evaluation team to conduct process evaluations. In the case of some objectives, outcome evaluations are also possible, such as the community cloud example listed previously. Other objectives, such as the worksite cloud objective referenced above, will not have a complete outcome evaluation until the end of the 18-month cycle. Many of the positive outcomes generated from the cloud structure are related to improved interoffice communication at MCPDH, as programs that would not typically interact are able to make referrals. One such example is that the Dental Sealant Program from the Office of Oral Health increased the number of program delivery sites through the Parent Ambassador Program, which is housed in the Office of Public Health Policy.In another example, two separate letters were compiled to address public comment opportunities from the federal government offices responsible for nutritional standards in schools (USDA), as well as physical activity opportunities in communities (Surgeon General’s Office and the CDC). Rather than each office submitting ideas separately, our Office of Physical Activity and Nutrition worked with the Office of Public Health Policy, Oral Health, and Health Promotion and Education to draft a comment letter. These products were stronger, more balanced, and thorough due to this collaboration. The Director and Health Officer of MCDPH reviewed, edited, and submitted the document on behalf of our entire department. The cloud structure offered a platform in which facilitating the process was natural and cohesive. In a similar example, the Office of Performance Improvement collaborated with the Office of Epidemiology to submit feedback on the Internal Revenue Service’s hospital-required Community Health Needs Assessments. This type of teamwork did not happen prior to the cloud structure.  
This practice has already revealed dramatic insight in terms of how to facilitate large groups to achieve multiple goals. The team learned early on that even though all parties share the same goal of creating a healthier community, this shared interest alone is not sufficient enough to ensure accountability and consistency among partners. For example, several attendees who were present for a meeting early on in the process did not return after they learned that there may be expectations of participants in between quarterly meetings.This issue was addressed by outlining the framework of expectations for those participating in the CHIP process. The organizations who actively align with HIPMC are the partners who are active in their cloud working groups. These partners receive the highest level of support and facilitation, as well as expedited responses to technical assistance requests. Other organizations are more defined as ‘contributors’-- those that have shared interests, and attend meetings, but do not take part in the work groups. All partners benefit from being a part of the HIPMC network, including shared branding and access to over one hundred local organizations. Engaging both partner types concurrently, albeit differently, allows those who cannot fully invest time in the work groups are still able to participate. MCDPH has found that a much greater number of partners are willing to be involved when they can determine their own expectations for engagement. As referenced in the evaluation section, the cloud structure allows for greater efficiency and less redundancy across the department. Many collaborative projects have been executed in a short frame of time, such as coordinated responses to federal offices that would not have occurred easily before this department-wide effort. Furthermore, in the past, it would be common for several staff persons from different offices at MCDPH to arrive at the same community-based event, and be surprised to see one another. Now, with coordinated communications through regular meetings and SharePoint, one office can volunteer to take information to events for several programs, and is more aware of how these programs work with the increased level of interaction between offices. Working within the clouds is supporting a culture change within the organization. The health department is committed to maintaining the cloud structure. Both cloud support positions (Strategic Initiatives Coordinator and Stakeholder Communications Coordinator) are County-funded, unlike 75% of MCDPH positions which are grant-funded. This is intentional, as department leadership is committed to reaching the goals and outcomes expected by the cloud platform. Other than these two positions, the effort is largely an improved infrastructure, which is in the process of being institutionalized by MCDPH. Furthermore, as the cloud goals align with accreditation goals, and public health accreditation and maintenance is a major priority for department leadership, it is advantageous to imbed this communication structure further into each office’s mission department-wide.
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