People, Policy, and Place: A Model for Organizational Transformation from Health Disparities to Health Equity

State: TX Type: Promising Practice Year: 2016

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Harris County, Texas is one of the fastest growing and diverse areas facing a multitude of upstream challenges. Being the 3rd largest populous county in the United States with over 4 million people, we have 19% poverty, 78% HS graduation, and 11 zip codes on a pollution watch list. All are correlated with poor health (Kinder Institute, 2014); some are avoidable, unnecessary, and reversible (health inequities). HCPHES prioritized the elimination of health inequities in its 2013 Strategic Plan. This required moving from an “improvisational” health equity approach to one that’s coordinated, systemic, and institutionalized (NACCHO, 2009). In the two years since, HCPHES has adopted an official approach to improving health inequity (the 4 Es: Economics, Education, Environment, and Engagement), established a senior-level health equity position, and assessed staff and programs for health equity. We are now launching high-impact health equity community initiatives that operationalize improvements in the 4 Es. These efforts were the result of a comprehensive evidence-based health equity strategy (our proposed practice) replicable to other health departments for use in their institutional journeys to health equity.

 

 

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Harris County Public Health and Environmental Services
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People, Policy, and Place: A Model for Organizational Transformation from Health Disparities to Health Equity
Harris County Public Health and Environmental Services (HCPHES) is the county health department for Harris County, Texas – the third most populous county in the United States – providing comprehensive public health services to the community through an annual budget of over $80 million and a workforce of over 700 public health professionals. The HCPHES jurisdiction includes approximately 2.2 million people within Harris County’s unincorporated areas and 33 municipalities located in Harris County, Texas. For certain public health services, such as mosquito control, Ryan White/Part A HIV funding, and refugee health screening, the HCPHES jurisdiction encompasses the entirety of the county including the city of Houston, thus providing services to over 4 million people. Harris County is one of the fastest growing and diverse areas facing a multitude of upstream challenges. We have 19% poverty, 78% HS graduation, and 11 zip codes on a pollution watch list. All are correlated with poor health (Kinder Institute, 2014); some are avoidable, unnecessary, and reversible (health inequities). HCPHES prioritized the elimination of health inequities in its 2013 Strategic Plan. This required moving from an “improvisational” health equity approach to one that’s coordinated, systemic, and institutionalized (NACCHO, 2009). In the two years since, HCPHES has adopted an official approach to improving health inequity (the 4 Es: Economics, Education, Environment, and Engagement), established a senior-level health equity position, and assessed staff and programs for health equity. We are now launching high-impact health equity community initiatives that operationalize improvements in the 4 Es. These efforts were the result of a comprehensive evidence-based health equity strategy (our proposed practice) replicable to other health departments for use in their institutional journeys to health equity. Our goal is to transform local public health practice with the use of a comprehensive health equity strategy. Objectives: Build an evidence-informed foundation for the coordinated migration from a focus on health disparities to health equity; Transform organizational and workforce capacity for providing essential public health services through a health equity lens; Launch a multi-level approach to new place-based and cross-systems initiatives that address priority public health issues through the improvement of social determinants; and Monitor a health equity footprint internally and in the jurisdiction. A portfolio of efforts was assembled to advance the goals and objectives of our practice examples of which are listed below for each of the practice’s four objectives: Under Objective 1, key activities include: Creation of a virtual library of health equity documents Development of an inventory of model health equity initiatives from other jurisdictions Adoption of an HCPHES health equity theory of change Under Objective 2, key activities include: Engagement of a cross-section of staff in health equity planning using Project Management theory Adoption of an HCPHES Health Equity Policy Implementation of a competency-based all-staff health equity training plan Under Objective 3, key activities include: Adoption of program-level work plans for internal activities retrofitted to health equity lens Launch of new community based projects focused on priority public health issues through improvement of social determinants Under Objective 4, key activities include: Adoption of internal Performance and Quality Improvement (PQI) measures Application of a health equity lens to assessment, surveillance, and performance management data A pilot Harris County Health Equity Index A mixed-method evaluation has been conducted on the practice since our practice began.  Examples of key process and proximal results include: 35 staff developed as champions for health equity in their respective divisions, offices, and programs; Adoption of a department-wide Health Equity Policy outlining expectations for integrating health equity goals into all essential public health services; and Receipt of a national BUILD Health Challenge implementation award (one of only 7 nationally) to reverse inequitable determinants of health in the vulnerable community of north Pasadena, Texas. These will lead to the following: 100% of HCPHES staff receiving “Health Equity 101” training; 100% of HCPHES divisions and offices with micro-level work plans for retrofitting current activities with a health equity lens; and 100% conformity with Public Health Accreditation Board (PHAB) measure 11.1.4. Our practice can be replicated by other health departments seeking to embrace health equity goals. We have already presented the practice as a replicable model to other public health professionals at local, state, and national conferences, including the Texas Office of Minority Health, American Public Health Association, and the University of Texas, Medical Branch (UTMB). HCPHES Website: www.hcphes.org      
Public Health Issue Social and economic opportunities and the physical conditions of communities (i.e., the social determinants of health) account for half of all health outcomes (UWPHI, 2015). Moreover, many of the ongoing disproportionate poor health outcomes occurring among specific populations relates back to the inequitable distribution of these social and environmental resources (Stillman, L. et al., 2015). Harris County individuals with lower education levels, lower household income, or are of minority race/ethnicity have a statistically lower chance of being in good health (Klineberg, S. et al., 2014). The same is true for people who live near environmental exposures or are less engaged in their communities (Klineberg, S. et al., 2014)).   The improvement of long-term health outcomes, particularly for populations experiencing the greatest inequities in health over time, requires a shift in focus to the upstream factors that are the underlying causes of ill health.  Such health inequities include disparate rates of disease, disability, and premature death.  A shift to upstream factors provides all individuals, regardless of socioeconomic or environmental conditions, the opportunity to attain their full health potential.  This shift in public health thinking has been occurring at a national level. In 2009, NACCHO released guidelines to assist local health departments in moving from an “improvisational” approach to addressing upstream factors to one that is systemic and institutionalized by infusing a health equity lens throughout the department.  The Public Health Accreditation Board (PHAB) included a health equity standard in Version 1.5 of the Standards & Measures for local health department accreditation. The standard notes that excellence in local public health practice includes health equity incorporated in policies, processes, and programs. Other national benchmarking, assessment, and health improvement systems also include a social determinants and health equity focus (e.g., Healthy People 2020, MAPP, Health in All Policies).  Harris County is one of the fastest growing and diverse areas facing a multitude of upstream challenges. We have 19% poverty, 78% HS graduation, and 11 zip codes on a pollution watch list. All cause poor health (Kinder Institute, 2014); some are avoidable, unnecessary, and reversible (health inequities). Harris County Public Health and Environmental Services (HCPHES) prioritized elimination of health inequities in its Strategic Plan. This requires moving from “improvisational” health equity approaches to one that’s coordinated, systemic, and institutionalized (NACCHO, 2009). Our goal is to systematize health equity via collaborative learning, staff engagement, and policy. To advance the public health mission of “fulfilling society’s interest in assuring conditions in which people can be healthy,” HCPHES must ensure that departmental efforts align with prevailing current and anticipated health needs of Harris County residents. Consistent with population health trends in the U.S., leading causes of preventable death have shifted away from communicable diseases to more chronic diseases at the local level. There is also growing recognition that while individual behavior plays a key role, opportunities to make healthy choices are shaped by the choices one has available. Social and economic conditions created by societal norms and policies in both health and non-health sectors determine these opportunities; such opportunities are not always distributed equitably across population groups. Even further, Harris County’s rapidly changing population with respect to both growth and demographics, as well as its unique climate and physical conditions all have local implications for how HCPHES will carry out its public health mission. Taken together, HCPHES must engage in ongoing situational awareness to anticipate and respond to current and emerging public health issues effectively, and at the same time integrate principles of health equity so that reasonable and fair opportunities for good health are achievable for all Harris County residents. These activities will also position HCPHES for meeting new requirements issued by the Public Health Accreditation Board (PHAB) for becoming an accredited local health department. Harris County Public Health & Environmental Services (HCPHES) prioritized the transition from the concept of health disparities, a focus in the 2005-2010 Strategic Plan, to one of health equity in its 2013-2018 Strategic Plan. We use a four-part evidence-informed model for organizational transformation that includes culture change, policy and workforce development, collaboration, and data as health equity tools. Target Population The primary target of the four-part evidence-informed model (practice) for organizational transformation that includes culture change, policy and workforce development, collaboration, and data as health equity tools is HCPHES Executive Leadership and the employees.  The following describes the current demographics of HCPHES employees: 600 employees, including contractors; 75% females; Race/Ethnicity reflect 25% Black/African American; 45% Hispanic/Latino; 20% White/Caucasian and .07% Asian; average age is 41 years old; average tenure of employees is 7.56 years.  HCPHES organizational structure includes 5 Divisions: Mosquito Control, Environmental Public Health, Disease Control and Clinical Prevention, Nutrition and Chronic Disease Prevention and Veterinary Public Health.  In addition, there are 3 Offices: Policy and Planning; Communication, Education and Engagement; and Public Health Preparedness and Response.  Previous/Current Practice Like many local health departments, HCPHES had prioritized the concept of health disparities beginning as far back as our 2005-2010 Strategic Plan. However, in response to the evidence and modelling on the true drivers of health in Harris County and nationwide, we shifted this focus to one of health equity, as codified in our most recent Strategic Plan (2013-2018). This new focus requires HCPHES to move from an “improvisational” approach to addressing social determinants and health inequities to an approach that is systematic, institutionalized, and comprehensively infused by a health equity lens throughout public health practice (NACCHO, Guidelines for Achieving Health Equity in Public Health Practice, 2009). We used a four-part evidence-informed model for organizational transformation that includes culture change, policy and workforce development, collaboration, and data as health equity tools. This current practice provides HCPHES an agency-wide coordinated effort, resources and vision to transform our practice with the use of a comprehensive health equity strategy. This framework can be replicated by other health departments seeking to embrace health equity goals. Evidence-based/Innovation Multiple sources were used to ensure our practice was rooted in evidence of success. During the design phase, we archived and reviewed documents from the CDC, NACCHO, National Partnership for Action, PHAB, WHO, and others to identify potential evidence-based components of the practice. Our key references include: APHA Health in all Policies: A Guide for State and Local Governments (2013) BARHII Local Health Department Organizational Self-Assessment for Addressing Health Inequities CDC Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health (2008); and Practitioner's Guide for Advancing Health Equity (2010) NACCHO Guidelines for Achieving Health Equity in Public Health Practice (2009); and Policy Statement on Health Equity and Social Justice (2015) The National Prevention Strategy for Elimination of Health Disparities (2014) The National Stakeholder Strategy for Achieving Health Equity; and WHO’s Governance for Health Equity (2014); and Closing the Gap (2008) What we learned through this scan is that no step-by-step process model exists for the application of health equity principles specifically in a local health department setting and at an agency-wide scale. Therefore, we synthesized the best and most relevant aspects of all of these tools to design our own four-part model of practice. In this way, our practice is also an innovative use of multiple existing tools and practices. Lastly, our practice does not address a specific Winnable Battle, but does impact all Winnable Battles in Harris County by improving root causes of HIV, nutrition/physical activity, teen pregnancy, etc.        
Our goal is to transform local public health practice with the use of a comprehensive health equity strategy. Objectives: Build an evidence-informed foundation for the coordinated migration from a focus on health disparities to health equity; Transform organizational and workforce capacity for providing essential public health services through a health equity lens; Launch a multi-level approach to new place-based and cross-systems initiatives that address priority public health issues through the improvement of social determinants; and Monitor a health equity footprint internally and in the jurisdiction. To achieve continual organizational transformation, HCPHES approach involves: Guidance from HCPHES 2013-2018 Strategic Plan HCPHES Employee Assessment Creation of Health Equity Coordinator position Development of a Health Equity Portfolio   Implementation of Health Equity Portfolio Strategic Plan The HCPHES 2013 – 2018 Strategic Plan set forth a path for pursuing health equity as a department-wide goal.  The plan’s Guiding Principles codified an acknowledgment of the role of social determinants in health outcomes and a commitment to health equity.   The plan also included a specific Action Strategies on health equity, which prioritized it for implementation.  Action Strategy 1C states Work towards the goal of eliminating health inequities by assessing the extent to which inequities exist among Harris County populations and preventing additional inequities that could occur as an unintended consequence of work by HCPHES or community partners.  Taken together with Action Strategy 1B Emphasize population-based approaches with “upstream solutions” that shape policy, educate, and build capacity among targeted groups and various sectors to bring about system-wide improvements in health strengthens HCPHES commitment to transform our practice with the use of a comprehensive health equity strategy. Assessment To address the organizational goals in the Strategic Directive 1C (Health Equity) with Strategic Directive 1B (Upstream Solutions) as an integral component, HCPHES Leadership determined the need to understand the readiness and attitudes of employees for change into a new Upstream thinking environment.  The aim of this approach was to address the following questions: How ready is staff to address upstream solutions? How ready is staff to change how they “do things” at work? Does staff feel they are currently part of the HCPHES change process? What is staff’s perception of leadership, mentoring and learning capacity? In the fall of 2013, the HCPHES Team researched, identified and adapted the Bay Area Regional Health Inequities Initiative (BARHII) Organizational Self-Assessment for Addressing Health Inequities Toolkit (http://barhii.org/) to address the aims of HCPHES. The BARHII Staff Survey and Staff Focus Groups were adapted to assess areas within the BARHII Domains and Matrixes of most importance to the HCPHES Team and reframed terminology to be more reflective of HCPHES Strategic Planning document. All full-time HCPHES (n=440) staff were eligible to participate in the survey to assist in assessing our overall capacity for Strategic Planning and using Upstream Solutions to address the conditions that impact health where people live, work, play, learn and worship.  Over 80% of employees (362) responded to the survey.  Key findings included: Majority of staff felt HCPHES strategic plan addresses upstream solutions Staff perceives that HCPHES demonstrates commitment and practices addressing upstream solutions Respondents had a positive perception that HCPHES encourages members to be creative in addressing new challenges An overwhelming majority of respondents had a positive rating of the need to be aware on their own beliefs and values to understand others’ perspectives. Overwhelming majority had a good understanding of the conditions that impact where people live, work, play, learn and worship. Strong majority believe achieving health equity for Harris County community is a goal HCPHES should pursue as part of its mission. To delve deeper into the results of the HCPHES Staff Survey, Staff Focus Groups were planned comprising of approximately 30 self-selected and invited staff assigned to one of the six (6) 90 minute sessions. Purpose of the Focus Groups was to help better understand the culture of HCPHES related to Upstream Solutions and Health Equity particularly: How to apply upstream solutions and health equity principles into practice Its openness for change Its encouragement of innovation and associated learning Key finding of focus group included: When presented with the two key terms, “Upstream Solutions" and “Health Equity” participants only had a partial understanding of the terms. Employees expressed high interest in creatively addressing upstream solutions, health equity, and general organizational challenges. Employee perception of their ability to do so, however, is broadly considered limited Focus group participants see a number of barriers and challenges facing HCPHES as it attempts to move towards health equity and upstream solutions Focus group participants were asked to rate HCPHES and themselves individually on their readiness to change using the stages of change continuum. In regards to moving towards upstream solutions and health equity, focus group participants believe that HCPHES is in the “contemplation stage” (thinking about making changes) while the majority of employees listed themselves in the “preparation stage” (getting ready to change). This is a helpful realization as employees are potentially ahead of HCPHES in their readiness to adopt upstream solutions and health equity. Health Equity Coordinator In 2014, HCPHES created a Health Equity (HE) Coordinator position that would apply principles of health equity to perform a variety of public health planning, assessment, and capacity-building activities for Harris County Public Health and Environmental Services (HCPHES). In this capacity, the HE Coordinator would work collaboratively with staff across the HCPHES organization, residents and stakeholders of Harris County communities and agencies at local, state and federal levels.  This position was located in the Office of Policy and Planning. Health Equity Portfolio A portfolio of efforts to help all people in Harris County attain their full health potential – one that also helps create a Harris County where no person is disadvantaged from this potential due to economics, education, environment, or disengagement – begins with our goal and four objectives that lays the groundwork in HCPHES, help change organizational culture, engage allies and communities, and use data to set objectives and monitor impact. Each objective has 4-5 planned strategies that are outlined below. 1. Build an evidence-informed foundation for the coordinated migration from a focus on health disparities to health equity. Health equity is a well-codified HCPHES priority, most recently in the 2013-2018 Strategic Plan. The next level will coordinate health equity efforts under a senior staff lead and then build-out a structured health equity program. To maximize the success, we will line-up our efforts with what works, by identifying models and experts and by creating our own frameworks and communications tools. We will: Build a virtual library of health equity plans, profiles, trainings, and other principal guidance materials. Review examples of health equity offices, programs, and initiatives at other local government agencies. Interview and have on-deck a core panel of national, state, and local health equity experts. Develop an HCPHES Health Equity Framework. Develop slide decks and infographics on health equity concepts, key health disparities, and examples of the 4 Es in Harris County. 2. Transform organizational and workforce capacity for providing essential public health services through a health equity lens. Though health equity has been a high HCPHES priority, there are gaps in HCPHES’s internal health equity infrastructure including policies and procedures for staff and programs. These gaps need filling in order to fully articulate HCPHES’s vision for health equity, to build HCPHES’s workforce capacity, and to create an agency culture of health equity. They also need filling in order to meet national accreditation standards. We will: Engage staff in HCPHES’s health equity programming by forming a Strategic Plan Health Equity Project Team (Strategy 1C) and Learning Collaborative. Develop and adopt an HCPHES Health Equity Policy that outlines the vision, values, internal/external guidance, indicators, and tools for health equity.  Design a workforce development and training plan, including cultural and linguistic competence. Meet Public Health Accreditation Board health equity and cultural competence standards. 3.  Launch a multi-level approach to new place-based and cross-systems initiatives that address priority public health issues through the improvement of social determinants. For HCPHES’s health equity mission to translate into health impact, it must manifest throughout our work.  Within our walls, we will identify public health practice re-designs in the direction of Upstream Solutions; in the community, we will develop cross-sector projects focused on improving health inequities through policy, systems, and environmental (PSE) change. We will: Develop Division and Office-specific workplans that apply a social determinants lens to practice. Identify new cross-Divisional/Office and cross-sector community-based projects that expand PSE change aligned with best practice and national guidance. Reach across County departments that focus on root causes to identify joint systems-focused projects. Become the go-to source on health equity through a robust public presence and key collaborations. 4.  Monitor a health equity footprint internally and in the jurisdiction. Data on health disparities and root causes provide insight on both the current state and desired future. They reveal needs by population, place, priority health issue, and program. They can also plan and predict health impact. As a local health department, HCPHES is uniquely positioned to use data as a descriptive, monitoring, and predictive health equity data tool. We will: Adopt health equity data indicators for: (1) HCPHES performance and quality improvement; and (2) health outcomes, issues, and determinants in Harris County. Apply a methodology to current data collection to identify health disparities early and often. Generate profiles of high-impact disparities in health outcomes, key health issues, and root causes. Pilot a Health Equity Predictability Index for specific priority public health issues, populations, and places. Implementation The portfolio provided the groundwork for transforming HCPHES public health practice toward a comprehensive health equity system.  Activities for implementation can be categorized into 3 components: 1) Strategic Plan Chartered Team, 2) HCPHES organizational structure/resources and 3) Community-based activities. 1.  Strategic Plan Chartered Team To address the Action Strategies in the HCPHES Strategic Plan, HCPHES engage employees to produce meaningful work through chartered Project Team or department wide committees to solve and/or address a particular issues.  For each there is direct involvement/participation of Executive Leadership.  Each team is comprised of approximately 6 employees representing the Divisions/Offices and levels within HCPHES.  Each team is facilitated by a project manager, led by a Project Champion and a member from Executive leadership is the Team sponsor. A Health Equity Team was chartered to address Action Strategy 1C: Work towards the goal of eliminating health inequities by assessing the extent to which inequities exist among Harris County populations and preventing additional inequities that could occur as an unintended consequence of work by HCPHES or community partners. The HCPHES Health Equity Coordinator was the Team Lead.  The vision of this Team was to create and operationalize the HCPHES Health Equity Policy, with detailed guidelines in adherence with the PHAB measures.  This Team has produce and contributed to several of the areas within the portfolio to include: Health Equity Policy. An essential part of HCPHES’s health equity goal is to prevent additional inequities from occurring as the unintended consequences of our work or the work of our partners. To ensure such unintended consequences do not occur, policies and procedures must be in place to design, assess, and monitor HCPHES’s programs, services, and materials for their impact on health disparities and root causes. HCPHES Health Equity Framework. Frameworks (or logic models) that describe complex systems like health equity are useful tools across the planning continuum, from communicating with staff and partners, to identifying and evaluating solutions. An HCPHES Framework on Health Equity can be used for all of these purposes and will begin by serving as the foundation for internal policies and other pivotal guidance going forward. The framework is tailored to meet HCPHES and local needs. Workforce Development Plan. To achieve a more health equitable Harris County, HCPHES’s greatest asset is the knowledge, skills, and abilities (KSAs) of our nearly 500 staff, contractors, interns, and volunteers. Activities to develop health equity KSAs will apply health equity principles themselves; they will be assets-based, tailored to staff needs and roles, and inspire new perspectives and dialogue. Based on national Core Competencies per staff tier: Frontline/Field, Management/ Supervisor, and Executive/Leadership; Include multi-modal learning options (e.g., reading-&-reflections, webinars, field exercises) to be completed in-place for a “Learn-by-Do” methodology. Utilize Peer Trainers within Divisions/Offices developed through the Learning Collaborative. As of October 2015 there have been 16 Strategic Planning Teams chartered which are at various stages of completion. Strategic Planning Teams have contributed to the groundwork of the portfolio such as the Employee Development Team.  This team covered the end to end processes, methods, and resources to train, mentor, and develop employees throughout the organization. This would involve all aspects of employee training, competency development, leveraging of skills across employees, divisions and offices, and ensuring that employees develop and exhibit the HCPHES core values of Excellence, Compassion, Flexibility, Integrity, Accountability, Professionalism and Equity. 2.  HCPHES organizational structures/resources The 2014 HCPHES Upstream Staff Survey showed strong commitment to the principles of health equity. Creating a culture of health equity in HCPHES means involving staff in decisions about how these principles will translate into practice. Staff engagement in health equity programming also provides the opportunity to identify and develop new champions, diffuse messaging, and build support for future cross-Divisional/Office efforts to push the equity needle. Activities have included a facilitated Health Equity Learning Collaborative webinar-based staff discussion groups that also serve as a “Train-the-Trainer” program and HCPHES Strategic Plan Health Equity Project Team (Strategy 1C) chartered to assist with the ongoing implementation of this Agency Capacity Plan.  Both of these activities have been referenced in this application.  In 2015, HCPHES initiated PHES Talk, an adaptive and innovative approach (Ted Talks) for all HCPHES employees to be challenged to think creatively.  HCPHES Health Equity Coordinator presented health equity as a “story” that provided a simple, personal and relevant description of the term in “How I explained Health Equity to my Mom” (www.youtube.com/watch?v=PKZhhinomd4)  .  During the second half of PHES Talk, a panel was facilitated with representatives from HCPHES Built Environment and Health Impact Assessment Unit, Mosquito Control and WIC Program to discuss and share current efforts to address health equity issues. HCPHES’s new Built Environment and Health Impact Assessment Unit located within the Environmental Public Health Division will engage municipal planning processes across Harris County to ensure that health is a consideration in all planning decisions. The Unit will also conduct Health Impact Assessments and other methods for gauging the impact of policy on vulnerable communities. HCPHES has developed and accessed resources that will support the transformation process: The HCPHES virtual library is the go-to location for essential reading, training, tools, and templates on health equity. It can be used for staff and stakeholder orientation and as references during the development of HCPHES’s own health equity products.  Content includes: Readings on healthy equity concepts, National plans, guidance, and policy statements, Local data profiles and reports, Links to online health equity trainings and Tools, such as assessments and checklists In addition to a framework that articulates HCPHES’s model of health equity, we have also articulate, in a series of slide decks and infographics, why health equity matters in Harris County, including presentations of the highest-impact place-based health disparities and examples of their underlying causes, the 4 Es: economics, education, environment, and engagement. A series of in-person interviews supplemented the model programs inventory by hearing first-hand from subject matter experts about ideal health equity portfolio design. From these conversations, an on-deck panel of health equity advisors has been established. HCPHES is using the Council of State and Territorial Epidemiologists (CSTE)’s Health Disparities Monitoring Methodology to identify local trends in infectious and chronic diseases associated with poverty.  The methodology links geocoded public health data to Census-derived area-level poverty measures. 3.  Community-based   The portfolio provided a framework to enhance existing and newly formed HCPHES community-based initiatives using a health equity “lens”.  Examples of these initiatives that contribute to the transformation of HCPHES public health practice toward a comprehensive health equity approach are: HCPHES is the backbone organization for Healthy Living Matters (HLM) Collaborative formed in 2011 to change policy, systems, and environments in Harris County neighborhoods with disparate rates of childhood obesity. HLM is engaging community and groups to eliminate food deserts, create Complete Streets, launch Safe Routes to Schools, and build social capital. An initiative of HCPHES, the Houston Food Bank, and the University of Texas MD Anderson Cancer Center to launch a new healthy, accessible, and community-supported local food system in north Pasadena. It emerged from the partners’ work on Healthy Living Matters (HLM). The initiative is one of seven projects awarded $250,000 by the BUILD Health Challenge in recognition of its efforts to improve community health. The BUILD Health Challenge is a national awards program supporting “bold, upstream, integrated, local, and data-driven” (BUILD) community health interventions in low-income, urban neighborhoods founded by the Advisory Board Company, the de Beaumont Foundation, the Colorado Health Foundation, the Kresge Foundation, and the Robert Wood Johnson Foundation. Additional members of the Partnership include: CHI St. Luke's Health, Memorial Hermann Health System, Brighter Bites, CAN DO Houston, city of Pasadena, Neighborhood Centers Inc., Pasadena Health Center, and the U.T. School of Public Health. The HCPHES Built Environment and Health Impact Assessment (BEHIA) Unit was created in the fall of 2014 to improve health and health equity of Harris County residents, through the development of healthy, safe and active environments where individuals live, learn, work, worship and play. This includes community engagement and urban planning design, use of rigorous epidemiologic methods and applying GIS special analysis of health problems. The BEHIA is currently working with 2 local communities: East Aldine District to address connectivity plans for a new 51-acre community development project and city of Pasadena to address connectivity for a city-wide comprehensive plan.  Both have potential impacts on injury, obesity, CVD and other health problems. Selection Criteria There is no applicable criteria as to who was selected for practice. Timeframe The timeframe below represents current efforts to develop and implement HCPHES comprehensive health equity strategy.  The strategy provides the framework to continually transform HCPHES health equity public health practice. 2013 - Health equity integrated into Strategic Plan Spring 2014 - BARHII-based staff assessment conducted November 2014 - Health Equity (HE) Coordinator position filled; HE Strategy for Organizational Transformation developed January 2015 - First HE Project Team chartered; HE Learning Collaborative 1.0 launched Spring 2015 - HE glossary developed; Internal HE inventory conducted; HE Framework designed; HE all-staff training plan developed         June 2015 - First major HE community initiative awarded and launched (BUILD) July 2015 - HE Policy Adopted by executive leadership September 2015 - Second HE Project Team chartered; Cultural and Linguistic Competence Policy Assessment conducted; HE procedures enter drafting phase November 2015 - HE measures included in the HCPHES Performance Quality Indicator dashboard Stakeholders The HCPHES Health Equity practice transformation required the inclusion of stakeholders in the planning and implementation of the practice.  HCPHES Executive Leadership (9) and HCPHES employees (700), representing each of the 8 HCPHES Divisions/Offices and level within, were the primary stakeholders for the planning and implementation of the practice. The planning phase included the active participation in the development of the HCPHES 2013-2015 Strategic Plan and the HCPHES Upstream Employee Assessment Survey.  Executive Leadership provided input and approved the HCPHES Health Equity Portfolio and demonstrated their commitment to the creation of comprehensive health equity strategies to transform HCPHES public health practice.  The Office of Policy and Planning (OPP) Health Equity Coordinator and staff provided planning oversight, researched best practices, coordinated the facilitation and development of strategies and fostered collaboration among stakeholders. The HCPHES practice required the above stakeholders to be actively engaged in implementation aspects as members, Champions and/or Sponsors of the Strategic Plan Chartered Teams, contributors to the development of HCPHES organizational structure/resources and as coordinators, manager and supporters of community-based activities.  HCPHES provides ongoing partner engagement, communications, and coordination activities to the BUILD Partnership and continues as backbone support for Healthy Living Matters (HLM) and the HLM-Pasadena Community Task Force (CFT). HCPHES also coordinates the Community Trustees, the Resource Panel, and those components of the Partnership’s food system model originally developed by HLM as they expand into north Pasadena (Healthy Corner Stores and Healthy Dining Matters). HCPHES staff are also Co-Leads in specific operational units of the Partnership governance structure as indicated.  To this end, HCPHES fosters collaboration with existing and new community stakeholders to launch a multi-level approach to new place-based and cross-systems initiatives that address priority public health issues through the improvement of social determinants (Objective 3). Community stakeholders include:  NONPROFIT ORGANIZATIONS: The Houston Food Bank (HFB) is the fiscal agent for the BUILD Partnership and manages the grant award and sub-awards. HFB is also responsible for the payment and reporting schedule to the National BUILD Team. In addition, HFB sources the healthy food to the Partnership’s food system distribution and consumption components and coordinates its food insecurity-related interventions (Food Scholarship Program and Food FARMacies). HFB staff are Co-Leads in specific operational units of the Partnership governance structure as indicated, and Project Staff to the Partnership is an HFB employee. HOSPITAL/HEALTHCARE SYSTEMS: The University of Texas MD Anderson Cancer Center (MD Anderson) coordinates the Partnership’s hospital/healthcare system partners. MD Anderson is also providing the process and outcome evaluation of the Partnership’s food system model and Collective Impact approach in collaboration with the University of Texas, School of Public Health (UTSPH). MD Anderson staff are also Co-Leads in specific operational units of the Partnership governance structure as indicated. OTHERS: The University of Texas School of Public Health will collaborate with MD Anderson to evaluate the BUILD project; and the HLM-Pasadena Community Task Force will continue serving as an avenue for community input, including engaging BUILD Community Trustees. The city of Pasadena is facilitating construction of the Community-Supported Agriculture (CSA) campus via a commercial partner committed to $4.75M. The city is providing land, facility, multi-year low-cost leases, and property tax abatement Costs/Funding The start-up cost for the practice is staff time beginning with a portion of executive leadership (during strategic planning) followed by staff participation in the assessment survey (minimal; less than one hour per staff), the Project Teams (about 20 hours per cohort over three months), and Learning Collaborative (about 24 hours per cohort over three months). All of these staff were redirected to these activities as part of “other duties as assigned;” and it was short-term. The sole direct cost of the practice is a portion of a senior-level staff position specifically established and hired to plan, coordinate, and facilitate the practice; however, replication of this practice does not require a dedicated paid staff. It can be replicated by assigning duties to a current staff. There are no direct costs in terms of supplies, materials, curricula, etc.          
The goal of the HCPHES practice is to transform local public health practice with the use of a comprehensive health equity strategy. Objectives (% complete as of the writing of this application): Build an evidence-informed foundation for the coordinated migration from a focus on health disparities to health equity (80% complete); Transform organizational and workforce capacity for providing essential public health services through a health equity lens (67% complete); Launch a multi-level approach to new place-based and cross-systems initiatives that address priority public health issues through the improvement of social determinants (50% complete); and Monitor a health equity footprint internally and in the jurisdiction (50% complete). The completion and launch of the HCPHES Health Equity Strategy itself is a key outcome of our organizational transformation process, and this occurred in November 2014. Since that time, additional tangible milestones in staff capability, departmental policy, and community health improvement have occurred as a result of the strategy’s implementation. Key process and outcome results include: One assessment (n=362) of staff knowledge, skills, and abilities related to health equity and cultural competence using the Local Health Department Organizational Self-Assessment for Addressing Health Inequities (BARHII); Two Health Equity Project Teams convened per Project Management theory and chartered to design institutional health equity guidance (teams total 24 staff engaged in organizational health equity policy change); 35 staff representing a cross-section of the agency (in both of hierarchy and discipline) matriculated through the Inaugural HCPHES Health Equity Learning Collaborative and, thereby, developed as champions for health equity in their respective divisions, offices, and programs; Adoption of a department-wide Health Equity Policy outlining expectations for integrating health equity goals into all essential public health services (the policy also includes a Health Equity Framework unique to HCPHES’s theory-of-change); Adoption of a competency-based (using BARHII) tiered all-staff training plan on health equity and cultural competency and a pilot “Health Equity 101” self-study (slated for launch in 2016); One assessment of the cultural and linguistic competence of HCPHES programs, policies, services, interventions, and communications using the Cultural and Linguistic Competence Policy Assessment (CLCPA) (Georgetown University); and Receipt of a national BUILD Health Challenge implementation award (one of only 7 awarded nationally) to help reverse inequitable determinants of health in the vulnerable community of north Pasadena, Texas. These deliverables will ultimately lead to the following distal outcomes for our organization: 100% of HCPHES staff, contractors, and interns/volunteers receiving “101” training in health equity and cultural competence; 100% of HCPHES divisions and offices with micro-level work plans for retrofitting current activities with a health equity lens using the HCPHES Health Equity Policy and procedural guidance; and 100% conformity with Public Health Accreditation Board (PHAB) Standards and Measures (v. 1.5) related to health equity (11.1.4). A mixed-method approach has been used to evaluate our heath equity practice, including secondary data collection and review (document archiving), primary data collection and review (pre/post-tests, focus groups), and performance management. Methods per objective are described below: (Obj. 1) Build an evidence-informed foundation for the coordinated migration from a focus on health disparities to health equity. To evaluate this objective, we conducted an online assessment of health equity initiatives at other city and county health departments as a comparison cohort for our practice. The inventory included a review and archiving of each health department’s health equity goals and objectives, program plans, data measures and benchmarks, formal documentation of processes, and staffing structures, including the presence of internal or external advisory boards.  A list of key informants and a key informant interview survey and script were also developed from this research for use in a later stage of the evaluation. (Obj. 2) Transform organizational and workforce capacity for providing essential public health services through a health equity lens. Primary data were collected to evaluate the collaborative learning components of this objective. The purpose of this evaluation was to ensure the training’s effectiveness in increasing knowledge, application, and self-efficacy of staff to apply a health equity lens to current practice and to serve as health equity champions for future work. A pre/post-test survey was administered to participants of the HCPHES Health Equity Learning Collaborative (based on NACCHO’s Roots of Healthy Inequity web-based platform) using a series of agreement-disagreement statements on a Likert scale. Results showed a nearly 1.7 point improvement at post-test in self-assessed understanding of, capability to teach others about, and aptitude for applying health equity concepts; and this positive change was seen regardless of the number of Learning Collaborative sessions completed (as few as 1-2 sessions completed to 100% of sessions completed).  The process evaluation of the Learning Collaborative also showed positive results: 85% of graduates would recommend the Learning Collaborative to others, and 44% would facilitate a future Learning Collaborative. Qualitative results from the evaluation, including a post-graduation focus group, were also folded into the design of the all-staff “Health Equity 101” self-study training curriculum component of this objective and will inform Learning Collaborative 2.0, scheduled for 2016. (Obj. 3) Launch a multi-level approach to new place-based and cross-systems initiatives that address priority public health issues through the improvement of social determinants. Efficacy of this objective is being measured by the number of new health equity-explicit initiatives launched by HPCPHES both internally and externally following the practice’s official implementation. For example, the awarding of the national BUILD Health Challenge to Harris County, which is an explicitly health equity-focused initiative addressing the HCPHES 4 Es (economics, education, environment, and engagement), is one example of how this objective has been confirmed. We also use a tracking form to monitor the extent to which we are becoming a “go-to” source on health equity. This form tracks the number of presentations on health equity provided locally, statewide, and nationally. To date, we have presented on our practice at the 2015 APHA Annual Meeting, the 2015 Texas Office of Minority Health (OMH) annual conference, and the University of Texas Medical Branch 2015 Health Equity Leadership Academy. We are already slated to present on the practice at the 2016 Texas Public Health Association annual conference. (Obj. 4) Monitor a health equity footprint internally and in the jurisdiction. Several methods were used to monitor completion of this objective. First, we conducted a second inventory; this time, of health equity reports, indices, and tools specific to social determinants and other health equity data points from national organizations, academic researchers, and local health departments. NACCHO’s Resources for Social Determinants of Health Indicators served as the selection criteria for the review; reviewed sources included: the Connecticut Health Equity Index, THRIVE, MAPP for Health Equity, the Rockefeller Intercity Hardship Index, the Annie E. Casey’s Child Opportunity Index, and Seattle King County’s Preliminary Measures of Equity. The pilot HCPHES Health Equity Index was then compared against these models. We have also designed a Performance and Quality Improvement (PQI) dashboard for HCPHES (based on the Turning Point model) that includes performance standards and measures for monitoring community-level and internal health equity improvements. Domains include both efficiency and effectiveness. Some example health equity standards in the dashboard are: improve physical determinants of health; aim for staff and leadership to reflect the people we serve; and increase collection of and stratification by REALIE (Race, Ethnicity, primary Language, Income, and Education) data.  Documentation of this process includes a standards selection matrix, a metrics worksheet, and a reporting schedule as outlined in the HCPHES PQI policy.  Inclusion of health equity as a PQI standard was a requirement of the HCPHES Health Equity Policy developed per Obj. 2 above.    
HCPHES has developed and is implementing an evidence-informed model for health equity agency transformation that is producing tangible results in staff capability, departmental policy, and community health improvement. We believe the model is applicable to other sectors and that its replication will help move the needle on the culture change necessary to solve health problems upstream. In fact, we have already presented the practice as a replicable model to other public health professionals at local, state, and national conferences, including the Texas Office of Minority Health, American Public Health Association, and the University of Texas, Medical Branch (UTMB). We did not conduct a cost/benefit analysis; however, we did closely analyze the evidence on health factors to reach the conclusion to focus public health practice on the improvement of social determinants as this focus would yield greater return on investment vs. a continued focus on individual/clinical outcomes (see for e.g., University of Wisconsin, Galea et al., Klineburg, S etc.). The inclusion of health equity as a Strategic Directive in our Agency Strategic Plan has been the institutional linchpin for sustaining the practice (despite availability of resources) since implementation of the practice is how we will attain our strategic priorities. The adoption of an agency-wide Health Equity Policy further institutionalizes the practice, particularly those components that require ongoing commitments of staff and/or time (e.g., workforce development, community-based projects, divisional work plans, performance monitoring, etc.). Evaluation results of staff and their feelings of ownership of the practice (conveyed anecdotally) are also indications of sufficient stakeholder commitment to continue the practice long-term. To further ensure the sustainability of our practice, we have purposely instituted certain principles in the implementation of the practice, which constitutes a sustainability plan: All institutional-level expectations for health equity transformation (e.g., policies, procedures, monitoring) have been designed from the “bottom up” of the organization, with non-executive level staff comprising the Project Teams tasked with developing such guidance. This approach builds depth and breadth of staff commitment to the practice. Health equity work is being integrated into current public health practice across all divisions and offices. This ensures true organizational adoption of equity principles vs. implementation as a separate and isolated effort that could be halted or curtailed if resources or priorities are shifted. Community-based health equity efforts will be designed and implemented using Collective Impact and shared leadership principles including with members of the community who are experiencing health inequities (affected stakeholders). This sustains external stakeholder engagement in the practice and assures that the needs of people with lived experience are being met.  Where possible, health equity objectives utilize other evidence-informed practices and data for decision-making, which ensure a greater likelihood of success.  
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