Community-Centered Health Homes Background Document for National CCHH Meeting February 13, 2017

Community-Centered Health Homes Background Document for National CCHH Meeting February 13, 2017 Introduction As the nation transitions into the next era of healthcare reform with uncertainty and anticipation, there is a critical opportunity to embrace the great strides and successes over the last decade towards a more equitable, affordable, and high quality health system that promotes health and wellbeing. This transition provides an opportunity to capitalize on the tremendous advances in public health and prevention of the last generation, and marshal them in partnership with the innovations of healthcare to improve health across the population. It has been six years since Prevention Institute first introduced the model and vision for Community Centered Health Homes (CCHH). Commissioned by the Community Clinics Initiative 1, the resulting report Community-Centered Health Homes: Bridging the gap between health services and community prevention offered a concrete framework for how healthcare organizations can systematically address the community conditions impacting the health of their patients. At its core, the Community Centered Health Homes model combines the significant capacity and influence of healthcare with the experiential practice of how to advance quality community-based prevention. It offers the opportunity to improve ties between healthcare, public health, community and other sectors to mutually advance population health. The CCHH model is grounded in the actions and experiences of the many community health centers and healthcare organizations actively engaged in advancing health equity through community-based strategies and public policies to shift the social, physical, and economic environments of communities. From improving substandard housing and preventing violence to impacting food deserts and traffic safety, innovators within the health system have long recognized that these types of community environmental change efforts are necessary complements to clinical care activities. The defining attribute of a CCHH is therefore active involvement in community advocacy and systems change: a CCHH not only acknowledges that factors outside the healthcare system affect patient health outcomes, it also actively participates in improving them. Though the work and mission of community health centers deeply informed the initial development of the CCHH model, it has elicited growing interest across healthcare systems as a broader way of thinking about the role of healthcare in community prevention. The model itself emerged both in response to a growing understanding that: 1) the greatest proportion of factors influencing health occur outside the clinical walls; and 2) the challenges faced by the healthcare system are too significant to ignore. These healthcare challenges from the mounting costs of healthcare without comparable improvements in overall health outcomes to the pressures and frustrations of clinicians who are trying to treat patients suffering from complex but preventable conditions are still present six years later. The CCHH model offers hope of enhancing healthcare to better respond to this dilemma. It can translate its treatment experience into information about the prevalence and location of specific medical conditions. And it can identify 1 Now the Center for Care Innovations Draft - Not Intended For Broad Dissemination www.preventioninstitute.org 1

and engage in specific actions with others to improve the underlying community conditions, thus ultimately reducing the likelihood, frequency, and intensity of those conditions. Dissemination and Uptake of CCHH Shortly after publication of the paper, the Kresge Foundation supported dissemination efforts and seed work across the country. David Fukuzawa proposed broadening the vision to Community-Centered Health Systems. We have seen increasing uptake for advancing the vision of a community-centered health system nationally, and for testing the CCHH model. Blue Shield of California Foundation commissioned profiles of CCHH-type efforts among community health centers in California. The Blue Cross and Blue Shield of North Carolina (BCBSNC) Foundation sponsored a landscape analysis of readiness for CCHH, and developed a strategic priority to increase the capacity of safety net healthcare organizations and communities in the state to implement practices associated with the CCHH model. The initiative uses the CCHH model as a conceptual framework for bringing together healthcare providers and community-based organizations. BCBSNCF is currently supporting three grantees for planning/capacity-building grants (up to $125,000 for an 18-month grant period) and an additional nine communities are participating in select technical assistance opportunities with direct funding. Communities that demonstrate readiness to implement their plan after 14 months will be invited to apply for a minimum of two years of implementation funding. In the Gulf States region, PI partnered with the Louisiana Public Health Institute (LPHI) to launch the first CCHH demonstration in the nation. The initiative officially launched in March 2015, with the selection and announcement of five sites (two in Louisiana, and one each in Florida, Mississippi, and Alabama) for grants in the amount of $250,000 over two years, in conjunction with supportive technical assistance. Because it is a two-year demonstration project, the focus is on developing strategies for how clinics can begin to change their organizational culture, structure, and procedures to support community change and the CCHH model, rather than focusing on health outcomes. This includes developing the right staffing roles, cultivating leadership, managing the flow of information and data (both internally among clinic staff and externally with community partners), making the case for adoption of this model, and building authentic community partnerships. In Texas, PI has been engaged by Episcopal Health Foundation (EHF) as a strategic partner in helping the foundation design and launch the Texas CCHH Initiative. This is a signature initiative for EHF, which serves 57 counties in East and South Texas, that is aligned with their vision for transformation to healthy communities for all. To date, this four-year, $10-million-dollar investment will be the largest CCHH demonstration in terms of the number of sites that will receive funding, financial resources, and involvement by PI in working with clinics on the ground. The foundation is currently funding 16 health centers as part of an Action Planning phase, which includes intensive one-on-one coaching, technical assistance on the CCHH model and community change strategies, and an award of $25,000 to fill funding gaps for community and other activities. This phase has two objectives: 1) for the health center to take actions to 2

practice implementing the CCHH model and learn more about implementation needs; and 2) for the health center to plan and develop a grant application to support the award of an 18-month Capacity Building Grant or a three-year Implementation Grant for continuing and accelerating the CCHH work. Both the Capacity Building Grant and the Implementation Grant will be awarded in the latter half of 2017. Several other sites have are initiating or exploring CCHH approaches including the NYC Department of Health and the St. Joseph s health system operating in California and Texas. The Community-Centered Health Home Model CCHH is an evolving model, an expanded mindset, and a metaphor for healthcare engagement in changing community conditions that shape health. CCHH expands the orientation of patientcenteredness to include community-centeredness as a core function and attribute to guide the engagement of healthcare organizations as both a provider of clinical care and a partner in community prevention. As healthcare providers and partners, CCHHs prioritize delivery of high quality care to ensure physically and emotionally healthy patients while also collaborating with community partners to meet complementary population health goals of creating healthy, safe, and equitable communities for residents. The skills needed to engage in community change efforts are closely aligned with the problem solving skills providers currently employ to address individual health needs; it is a matter of applying these skills to communities. Specifically, with patients, practitioners follow a three-part process: collecting data (symptoms, vital signs, tests, etc.), diagnosing the problem, and undertaking a treatment plan. The CCHH functions in a parallel manner by developing capacity and expertise to systematize a three-part process for addressing the health of the community, classified as inquiry, analysis, and action (see diagram below). 3

The elements of inquiry, analysis, and action were developed by analyzing the work of healthcare organizations actively involved in community environmental change efforts. For example, a clinic in South Los Angeles, St. John s Well Child and Family Center, was successful in identifying and addressing underlying environmental issues impacting their patients health. Clinicians were noticing extremely high prevalence of skin conditions, insect bites and infestations, and other allergen issues. They surmised these conditions might be related to substandard housing conditions, so they incorporated questions about housing into their patient intake form. The data collection confirmed that many patients presenting with lead poisoning, insect bites, and other health issues lived in the same housing complexes, which were not up to code. St. John s then partnered with a local housing agency, human rights organizing agency, and a tenant rights organization to determine how to best take collaborative action to improve community conditions. This process of engaging key partners to identify priority community-level health issues and developing comprehensive strategies is consistent with the element of analysis. St. John s was able to pool its resources with the work of the housing collaborative to take action by developing reports that brought public attention to housing conditions in the area. They also established a community health worker s program to conduct home health inspections for referred patients and support them in accessing needed improvements, through legal aid if necessary. Additionally, the collaborative was able to pass local administrative policies and secure agreements from high level leadership at different government agencies, including the City Attorney s Office and the LA Department of Public Health, which led to improved landlord compliance with standard housing requirements. Action focused on broader community-wide change that benefitted and improved health outcomes for both patients and community residents. See Appendix A for an additional CCHH case study. The Importance of Community Conditions Over the last five years, there has been an exponential increase in awareness among healthcare professionals on the role of social determinants of health on health outcomes. Frameworks such as County Health Roadmaps and Rankings Population Health model underscore that clinical care contributes 20%, while environments, social and economic factors and behaviors constitute 80% of the determining factors of health. 2 There is growing interest among healthcare providers in complementing medical treatment with action to address these factors in order to improve treatment outcomes as well as prevent illness and injury. Notably, the largest driver of demand for healthcare treatment is chronic conditions, which in many cases are preventable. Similarly, the medically complex patients that are high utilizers of medical care suffer from multiple chronic physical and mental health conditions that can also be partially traced to community conditions such as lack of affordable housing, exposure to environmental toxins, limited access to healthy food, street violence, structural bias and discrimination. These community conditions are shaped by policies, practices, and procedures by government and other institutions that have led to low-income and communities of color in 2 County Health Ranking and Roadmaps. University of Wisconsin Population Health Institute. Robert Wood Johnson Foundation. http://www.countyhealthrankings.org 4

the US shouldering a burden of unfairness and diminished opportunities for health and wellbeing. Quality Prevention Today, more healthcare institutions, including community health centers and other health systems, are actively addressing the social and community conditions faced by their patients as an extension of providing quality care. They refer patients to support services, such as public health insurance options, legal services, and SNAP benefits. These outer-facing strategies are critically important and necessary for moving closer to a healthcare system that promotes health and well-being. At the same time, in order to achieve lasting change and more far reaching improvement in health equity and population health, it is important to build upon these one-person-at-a-time efforts by identifying ways to improve the related community environment (e.g., expanding from supporting a patient in reducing asthma triggers in their home environment to taking action to improve the quality of all units in the same building or in the community). As Dr. George Albee put it, No epidemic has ever been resolved solely by attention to the affected individual. A generation ago, many people relegated prevention to messages promoted in health brochures and health fairs. However, over the last generation in particular, community prevention strategy has come of age, and effective prevention practice has achieved much greater success, particularly those strategies focused on changes in policy, systems, and the environment. Comprehensive prevention successes including in HIV, tobacco prevention, car seats, healthy housing and more -have established a solid foundation of quality prevention practice. Leveraging the knowledge, assets, intuition, and skills of community members through authentic, ongoing community prevention is imperative to support and sustain community prevention. CCHH offers a framework to involve healthcare in incorporating community prevention practices and strategies, driven by community engagement, to achieve lasting and positive change in policies, systems, and the environment. Quality prevention employs a distinct set of practices: 5

Individually-oriented services and community-oriented prevention are complementary, and are core components of a comprehensive approach for improving and sustaining population-wide health. Screenings and referrals to social services are critical for addressing patients immediate social needs, and can serve as a bridge to deepen partnerships for community prevention. However, many healthcare organizations remain at the one-patient-at-a-time paradigm. This may be due to limited resources, or to unfamiliarity about how to bridge the clinical and community contexts that shape health outcomes. Healthcare institutions can take action to improve community conditions depending on existing community relationships, capabilities and strengths across local organizations and groups, and community health efforts in place or underway. CCHH action builds upon strengths and assets in the clinic and community to engage in targeted advocacy efforts to influence local policy (e.g., smoking bans), invest in or contribute to community development/revitalization efforts (e.g., healthy corner stores), or implement model organizational practices to create a healthpromoting environment for providers, staff, and patients (e.g., food procurement). Healthcare Organizations Role in Advancing Community Health Healthcare organizations play a unique role advancing community-wide health as institutions with a mission to promote the health of the patients they serve. They bring numerous assets to the table, including their tremendous knowledge about medical treatment and the capacity to identify patterns of illness and injury among patients, as well as their intuitive understanding of the community conditions that shape these patterns. Health centers and health providers have tremendous credibility when it comes to health, and can serve as valuable partners in community efforts, and champions for improvements and policies. Many health systems also have influence as anchor institutions, bringing their ability to purchase, hire and employ, influence neighborhood real estate patterns, as well as their relationships with other major institutions in a community or city. Community health centers, in particular, have traditionally played a role in improving communities and have historically implemented programs and strategies that address cultural, social and economic environments. Through CCHH, healthcare organizations can use clinical efforts as a building block to incorporate community prevention as reflected by the figure below. 6

CCHH Practice Standards: Working Draft The following chart presents seven core domains of CCHH practice that serve as a framework for healthcare organizations to assess current actions and capacities. These standards express principles that can help guide a quality improvement approach to becoming a CCHH. They are being tested with clinics via the Texas CCHH Initiative, as well as reviewed with healthcare champions who are engaged in practices aligned with the model. The standards will continue to be refined and informed by these processes, and other learnings as appropriate. See Appendix B for more detailed description of the practice standards and elements. 7

Community Centered Health Home Practice Standards (working draft) Foundational CCHH Capacities Practice Domain 1: Adaptive and engaged leadership (LEAD the change) The Health Center integrates CCHH principles and practices into the fabric of their organization. Board, executive leadership, and senior team prioritize community prevention as part of the Health Center s vision, mission, and goals, and sets strategic direction for building their CCHH. Structures, systems, and process are built to support the team with CCHH implementation. Organizational leaders are effective in stewarding strategic change within the Health Center, as well as engaging community leaders and stakeholders around common aims. Practice Domain 2: Designated staffing to lead and implement CCHH (BUILD the team) Health Center leadership identifies internal assets and staff capacities for implementing the CCHH. Leaders, staff, and clinicians across departments and disciplines understand how community conditions outside the clinical setting shape health, and apply that knowledge to their role in the Health Center. Dedicated (FTE) CCHH staff who are proficient in community prevention and engagement coordinate and implement CCHH initiatives, and serve as a bridge between the Health Center and community partners. Practice Domain 3: Knowledge and skills to advance community prevention (EQUIP the team) The designated CCHH Team is proficient in the models, tools, and competencies needed to advance community prevention. Health Center care teams receive continuing education, tools, and support to identify and address the community context of their patients, and to support the CCHH team by lending their knowledge and credibility to CCHH initiatives. Practice Domain 4: Authentic community partnerships (ENGAGE with partners) The Health Center is a credible and trusted partner in the community and lends its strengths to advancing community prevention. The Health Center effectively collaborates with multi-sector stakeholders to leverage collective strengths and enable community-level action to improve community conditions impacting health and health equity. The Health Center invites and enables patients, community members, and community-based organizations to participate in inquiry, discovery, invention, design, and decision-making around community prevention strategies. Functional CCHH Capacities Practice Domain 5: : Assessment and Identification of Community Determinants of Health (INQUIRY) The Health Center supports the CCHH team to identify, compile, and share internal knowledge and data useful for understanding community health conditions and determinants. The CCHH team is supported in gathering and utilizing internal and external knowledge and data sources that are indicative of the community health context. Staff and clinicians have opportunities and venues to contribute their insights into community-level issues, factors, and causation that may be underlying the prevalence of injuries and illnesses in both the clinical and community settings. Patients, community members, and partners participate in the production of knowledge and data regarding community conditions. Practice Domain 6: Collaborative Planning and Priority Setting (ANALYSIS) The Health Center shares knowledge and data with relevant community partners to support the identification and prioritization of issues, and to develop comprehensive intervention strategies. The CCHH Team is proficient in presenting and communicating data trends and implications, designing and facilitating collaborative planning processes, and in developing action plans, in concert with community members and community-based partners. Practice Domain 7: Contribute to Improvements in Community Conditions (ACTION) The Health Center participates with partners to improve the community conditions that shape health outcomes and health equity. Health Centers and their partners aim for changes in organizational and governmental policies, in systems, and in practices that impact the social-cultural environment, the physical-built environment, and economic-educational environment that shapes health. Health Centers embrace, and lead with, model organizational practices that contribute to community-level prevention. 8

Observations and Lessons Learned Clinics that develop and sustain a CCHH approach exhibit certain characteristics and foundational organizational capacities. These foundational capacities are related to how the health center functions internally and externally when undertaking community-centered work. They include adaptive and engaged leadership, designated staffing, community prevention knowledge and skills, and authentic community partnerships. Engaged and adaptive leadership provides an essential catalyst for prioritizing CCHH principles and practices as part of an organization s mission, vision, and operations. Designated staff are needed to support integration of CCHH principals and activities into organizational practices. Building the community prevention knowledge and skills of these key staff help to effectively bridge clinical care and community-based prevention. Lastly, being community-centered means engaging in authentic community partnerships with local organizations from multiple sectors, such as community-based organizations, businesses, local government, schools, and community residents; working in collaboration presents opportunities for leveraging assets and resources for advancing a shared community health goal. These core capacities are outlined further in the practice standards and elements shared below (Page 11 and Appendix B). While CCHH methodology provides a structured framework for operationalizing CCHH, the model is flexible and is not designed for the rigidity of a certification process. At the heart of successful adoption of CCHH is a cultural change in the organization that motivates staff to recognize and take action to improve community conditions that are impacting health. Adopting CCHH as an overly formal model all at once can seem overwhelming for a healthcare organization. Organizations can develop comfort and familiarity with CCHH principles by embarking on initial conversations and exploration related to one or two key medical concerns and their associated community determinants. Potential starting points have emerged for institutions committed to the CCHH approach. Some may start by re-examining their patient intake form when faced with a prevalent health condition; others may provide comments at a city council hearing when approached by a local coalition. The common end goal is to institutionalizing community prevention practices to change community conditions impacting health. Model organizational practices are an opportunity to simultaneously improve community conditions and to help staff better understand and engage in CCHH. Healthcare institutions walk the talk by reflecting healthy environments, and in turn help influence broader community norms. For example, healthcare facilities were some of the first to become smoke-free. Engaging in actions like improving food availability for patients, staff, and visitors or encouraging wellness benefits for staff can catalyze greater understanding and enthusiasm for CCHH. 9

The CCHH approach encompasses adoption of new paradigms. CCHH reflects an expansion of paradigms: from treatment to prevention, from medical care to community determinants of health, and from one-person-at-a-time to population wide impact. Making this explicit can help with exploration and incorporation of the model, as well as in identifying staff with existing capacities to support implementation. The healthcare training and paradigm initially makes advocacy on healthcare-related issues seem inappropriate to many practitioners. While the primary function of healthcare organizations is healthcare delivery, there are important examples of healthcare advocates and organizations speaking up in transformational ways. Numerous examples of clinicians serving as important champions of prevention-oriented policy efforts include Bob Saunders and car seats, Deborah Prothrow-Stith and violence prevention, and Milt Silverman and HIV. Reminding healthcare staff of the impact of these champions can support them in being more comfortable engaging in this work. Intensive coaching is critical to help healthcare staff understand and implement the model. Even for organizations deeply interested in implementing CCHH, several interactions and touchpoints through training, coaching, and technical assistance may be necessary to understand exactly what a CCHH is and how to put it into practice. Healthcare organizations need tailored support to fully engage in the core practices and clarify their role. Healthcare payment models are key for scaling CCHH, but not required for making progress on adopting CCHH practices. Many providers and healthcare organizations cite the lack of reimbursement for CCHH-type activities as a barrier to adopting them. Yet many healthcare leaders have engaged staff in community health, often because their organizational principles are grounded in community change, and are able to creatively leverage and align this work with existing activities. Currently, these institutions rely on sources such as grant funding, community benefit dollars, philanthropic support or fundraisers to support their efforts. Thus far, momentum toward pay-for-value continues, as well as an emphasis on accountability of healthcare for population health outcomes, which is opening the door to more flexible financing, and provides an opportunity to promote healthcare engagement in community efforts. Acknowledgments This brief was produced by the Prevention Institute Community-Centered Health Home Team with primary support from The Kresge Foundation. We also want to acknowledge the deep contribution of our partners Juliana Anastasoff, MS, at the University of New Mexico-Health Sciences Center, Eric T Baumgartner, MD, MPH, and Louisiana Public Health Institute. Progress on CCHH has been supported by The California Endowment, The Kresge Foundation, Blue Shield of California Foundation, Blue Cross Blue Shield of North Carolina Foundation, and Episcopal Health Foundation. 10

APPENDIX A CCHH Case Study: Asian Health Services: California Healthy Nail Salon Collaborative Ingredients used in popular nail products have been tied to conditions such as cancer, lung diseases, miscarriage, and other illnesses. Clinicians at Asian Health Services, a Federally Qualified Health Center in Oakland, CA, found troubling symptoms amongst the mostly Vietnamese manicurists. Inquiry: Following this disturbing discovery, Asian Health Services began working with the Cancer Prevention Institute of California to conduct a health survey of nail salon workers in Alameda County, where Oakland is situated. Other studies followed, collecting both quantitative and qualitative data on the health and experiences of the area s manicurists. Background research found that dibutyl phthalate, toluene, and formaldehyde are the three chemicals found in nail products that are most closely associated with serious health concerns. These chemicals have been dubbed the toxic trio by advocates. Analysis: The data collected by Asian Health Services and the Cancer Prevention Institute of California found that nail salon workers were at increased risk for developing gestational diabetes and delivering underweight infants. Interviews with manicurists revealed epidemic levels of sickness. Qualitative data collected from individual salon workers included stories of thyroid conditions, breast cancer, asthma, and many other preventable illnesses. Action: Asian Health Services initiated the formation of the California Healthy Nail Salon Collaborative, a coalition of over forty organizations, including members from environmental and reproductive justice groups, the salon workforce, non-profit organizations, researchers, government agencies, and other key stakeholders. Since its inception, the California Healthy Nail Salon Collaborative has worked to change policies to protect nail salon workers. It successfully passed legislation in Alameda and other California counties and cities that charges local governments to implement Healthy Nail Salon Recognition Programs, conferring Healthy Nail Salon status on businesses that meet certain criteria that protect the health of their employees and customers. To be recognized as a Healthy Nail Salon, business must adopt safer products and practices, including: All products must be free of the toxic trio of chemicals, including products that customers bring to the salon Staff must wear masks, goggles, and nitrile gloves during certain procedures Spaces must be well ventilated, with special areas served by a mechanical air-filtration system A free health and safety training must be provided for all staff In addition, Asian Health Services co-sponsored the California Healthy Nail Salon Bill (AB2125), successfully passed in 2016, which calls for a consumer education program focused on the benefits of patronizing a Healthy Nail Salon, and an awareness campaign for local governments on the benefits of implementing local Healthy Nail Salon Recognition Programs. i 11

APPENDIX B CCHH Practices Standards & Elements Practice Domain 1: Adaptive and Engaged Leadership Standard: The Health Center integrates CCHH principles and practices into the fabric of their organization. Board, executive leadership, and senior team prioritize community prevention as part of the Health Center s vision, mission, and goals, and sets strategic direction for building their CCHH. Structures, systems, and process are built to support the team with CCHH implementation. Organizational leaders are effective in stewarding strategic change within the Health Center, as well as engaging community leaders and stakeholders around common aims. 1.1 Establish shared organizational vision and commitment to becoming a CCHH 1.2 Understand & communicate the CCHH model, key concepts, grounding frameworks (community prevention, health equity) and implications for organization s mission & objectives 1.3 Establish an infrastructure for supporting and sustaining CCHH aims, initiatives, and evaluation 1.4 Cultivate an organizational culture that values and promotes community prevention and health equity 1.5 Utilize adaptive leadership skills in managing change within the organization and with external partners to support CCHH design and implementation 1.6 Identify & leverage opportunities to integrate community prevention aims & related CCHH practices into Health Center programming, operations, and quality improvement initiatives 1.7 Incorporate CCHH aims and practices into the organization s strategic plan Practice Domain 2: Designated Staffing to Lead and Implement CCHH Standard: Health Center leadership identifies internal assets and staff capacities for implementing the CCHH. Leaders, staff, and clinicians across departments and disciplines understand how community conditions outside the clinical setting shape health, and apply that knowledge to their role in the Health Center. Dedicated (FTE) CCHH staff who are proficient in community prevention and engagement coordinate and implement CCHH initiatives, and serve as a bridge between the Health Center and community partners. 2.1 Develop and designate CCHH team roles, responsibilities, and functions across the organization, from leadership to the frontline 2.2 Assess human resources, staff capacity, competencies, and inclinations toward roles and relationships to advance CCHH 2.3 Establish the internal team convening structures and communications practices to assure a continuously aligned, competent, and learning CCHH team 2.4 Query all Health Center employees, board members, advisory committee members, patients to learn who is involved in activities to improve community conditions 12

Practice Domain 3: Knowledge and Skills for Advancing Community Prevention (EQUIP the Team) Standard: The designated CCHH Team is proficient in the models, tools, and competencies needed to advance community prevention. Health Center care teams receive continuing education, tools, and support to identify and address the community context of their patients, and to support the CCHH team by lending their knowledge and credibility to CCHH initiatives. 3.1 Assess CCHH Team knowledge and experience with the principles, models, and practices of community prevention, and implement comprehensive training and development plans for the team accordingly: how community conditions lead to toxic exposures (infectious agents, toxins, toxic stress), and behaviors that shape health outcomes and produce inequities; the primacy of community participation and empowerment; establishing trust and collaboration with identified community partners; engaging in multi-sector partnerships and comprehensive strategies to improve community conditions and advance equity; skills and tools for policy advocacy and organizational practice change 3.2 Provide the CCHH team with the leadership and support needed to be authentic and effective partners in community prevention 3.3 Develop communication pathways and tools for care teams and clinicians to be informed of and contribute their perspectives and energies to the CCHH team and related initiatives Practice Domain 4: Authentic Community Partnerships (ENGAGE with Partners) Standard: The Health Center is a credible and trusted partner in the community and lends its strengths to advancing community prevention. The Health Center effectively collaborates with multi-sector stakeholders to leverage collective strengths and enable community-level action to improve community conditions impacting health and health equity. The Health Center invites and enables patients, community members, and community-based organizations to participate in inquiry, discovery, invention, design, and decision-making around community prevention strategies. 4.1 Identify and establish community engagement principles and practices to inform and guide the Health Center interface and activity in community 4.2 Identify, participate in, or develop opportunities to engage community members in identifying and prioritizing community prevention needs and opportunities 4.3 Identify, participate in, or develop opportunities to engage community partners across sectors that possess experience, strengths & expertise to address community-identified concerns 4.4 Co-develop structures and agreements for collaboration, communication, and accountability 4.5 Cultivate trusting and effective relationships with external partners and community 13

members to meet shared community prevention goals Practice Domain 5: Assessment and Identification of Community Determinants of Health (INQUIRY) Standard: The Health Center supports the CCHH team to identify, compile, and share internal knowledge and data useful for understanding community health conditions and determinants. The CCHH team is supported in gathering and utilizing internal and external knowledge and data sources that are indicative of the community health context. Staff and clinicians have opportunities and venues to contribute their insights into community-level issues, factors, and causation that may be underlying the prevalence of injuries and illnesses in both the clinical and community settings. Patients, community members, and partners participate in the production of knowledge and data regarding community conditions. 5.1 Develop, identify, and analyze internal quantitative and qualitative data sources that reflect community determinants impacting the health & health outcomes of patients 5.2 Identify and utilize community-level data sources to understand and describe the community context, trends, and links to health indicators and outcomes 5.3 Join or convene partners to conduct collaborative health policy scans (HPSs), health impact assessments (HIAs), health equity assessments (HEAs) 5.4 Develop opportunities for patients, staff, care teams, communities, and partners to contribute to the production of knowledge regarding community conditions Practice Domain 6: Collaborative Planning and Priority Setting (ANALYSIS) Standard: The Health Center shares knowledge and data with relevant community partners to support the identification and prioritization of issues, and to develop comprehensive intervention strategies. The CCHH Team is proficient in presenting and communicating data trends and implications, designing and facilitating collaborative planning processes, and in developing action plans, in concert with community members and community-based partners. 6.1 Share and interpret relevant knowledge and data within the Health Center, and with community partners, for feedback and to inform CCHH-related actions 6.2 Engage in collaborative planning and priority setting with external partners and community members 6.3 Participate in (or initiate) collaborative, comprehensive strategy development and multi-sector action planning to address community conditions Practice Domain 7: Contribute to Improvements in Community Conditions (ACTION) Standard: The Health Center participates with partners to improve the community conditions that shape health outcomes and health equity. Health Centers and their partners aim for changes in organizational and governmental policies, in systems, and in practices that impact the social-cultural environment, the physical-built environment, and economic-educational 14

environment that shapes health. Health Centers embrace, and lead with, model organizational practices that contribute to community-level prevention. 7.1 Partner and engage in community-based initiatives to improve community conditions that shape health 7.2 Communicate with and mobilize patients, staff, Health Center peers, community members, and other allies for the purpose of influencing health-impacting policy 7.3 Implement and champion model organizational policies and practices that promote health, well-being, and equity 7.4 Educate and influence peers in the healthcare sector to be advocates and champions of community prevention aims, priorities, planning, and action i Information for the Asian Health Services case study was adapted from: Nir SM. Perfect Nails, Poisoned Workers. New York Times. May 8, 2015. Itchon NP. How safe is your mani-pedi? San Francisco Chronicle. October 22, 2015. California Healthy Nail Salon Collaborative Web site. http://www.cahealthynailsalons.org. 15