Frequently Asked Questions
The CHI Navigator was created to support hospitals, health systems, public health, and other community organizations and stakeholders that are interested in improving the health of their communities. Motivated largely by the Internal Revenue Service requirement for tax-exempt hospitals to conduct triennial Community Health Needs Assessments (CHNAs) and develop implementation strategies, the CHI Navigator is intended to provide a unifying framework and supportive tools to enable collaborative CHI work. The case examples, infographic , and tools provide support for action via examples from other partnerships, a storyline for improving health, and select resources that support the CHI process. By providing examples of proven interventions, the Find Interventions that Work can help move partnerships from planning to implementation and action, and in the end, to improved community health and well-being.
These terms have distinct but related meanings. In the context of the CHI Navigator, community health is “a multi-sector and multi-disciplinary collaborative enterprise that uses public health science, evidence-based strategies, and other approaches to engage and work with communities, in a culturally appropriate manner, to optimize the health and quality of life of all persons who live, work, or are otherwise active in a defined community or communities” (source: Goodman RA, Bunnell R, Posner SF ).
Population health is often defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (sources: Kindig D, Stoddart, G and Kindig, DA ). This definition explicitly emphasizes health outcomes. The reference to the distribution of outcomes within a group implies the need to consider why differences exist, including those in patient populations or in communities, but does not specify how to achieve population health.
For the purposes of the CHI Navigator, community health includes approaches that lead to optimal health outcomes for the whole community with a particular emphasis on reaching vulnerable/underserved populations that experience the highest burden of disease. This definition includes addressing who should be involved, and how to achieve health and quality of life in communities (see definition above).
As noted above, organizations and individuals interested in improving the health of their communities, and specific populations within those communities, will find the CHI Navigator contains a wealth of resources to support their collaborative efforts. Following are descriptions of Navigator components and who might find them useful:
- Infographic : Stakeholders or partners engaged in CHI can use this storyline as an educational tool or roadmap to ensure a common starting point.
- Making the Case for Collaborative CHI : These examples, of health systems successfully collaborating with community partners to improve the community’s health, can be used to educate decision makers within the health system, and others, of the multiple benefits of collaborative vs. independent approaches.
- Find Interventions that Work and Tools for Successful CHI Efforts : Staff of organizations who are on the frontlines working to improve community health can use these resources to strengthen their efforts and improve their chances of success.
Improving the health of a community takes the support and participation of multiple organizations and stakeholders from across the community. Hospitals are not expected to do this work alone or to serve as the sole funder. However, one of the key goals of the Navigator is to support hospitals in addressing the social determinants of health, those factors that impact patients with complex disease burdens and cost hospitals the most. CHI efforts offer a tremendous opportunity for hospitals to position themselves within a health system that is based on value and outcomes more than on the volume of services provided. By collaborating with other organizations that support or conduct community health assessments, hospitals can maximize their resources and efforts for greater impact on health and well-being. This brief from the New York Academy of Medicine provides examples of the complementary roles of various sectors, including health care, public health, and community partners.
Regarding a backbone organization, ideally hospitals, working with community stakeholders and other organizations, can determine a structure that benefits all who are working to improve community health.
CDC offers and supports a variety of web-based tools supportive of collaborative community health improvement. These tools have some commonalities, as well as unique and complementary strengths. Some contain content more specific to a particular target audience, such as health departments, hospitals, community members, or community developers. The tools also vary in purpose, design, and intended use.
Unique features of the CHI Navigator include the infographic, hospital/health system examples of collaboration with external stakeholders, key concepts to guide efforts and a targeted selection of tools for getting started on each, quotes from the Internal Revenue Service Final Rule on Community Health Needs Assessments for Charitable Hospitals, and a Find Interventions that Work that Work.
Other complementary tools for CHI are also available from CDC on www.cdc.gov . Tools that CDC programs have supported on other sites, such as communitycommons.org, are also available. Many of these tools are referenced at specified steps in the CHI Navigator.
We suggest first reviewing the infographic , an educational tool about the storyline and roadmap for improving health.
Next, review the framework shown on Tools for Successful CHI Efforts , and apply it to your initial CHI planning efforts. Keep in mind that the tenets “Work Together, Engage the Community, Communicate, and Sustain Improvement Results” should be addressed before embarking on the five-step CHI process, and should be maintained throughout the CHI effort.
The Tools for Successful CHI Efforts section is not intended to serve as an all-inclusive reference or as a comprehensive beginner’s resource. Many such resources—created by experts in health care, public health, and community development—already exist. See Additional Tools and Resources for some of the more commonly used guide resources.
The CHI Navigator is not currently available as a mobile app; however, portions of the CDC web site—including the CHI Navigator—are mobile friendly.
The graphic provides a visual storyline for improving health and is intended as an educational tool to provide a common starting point for partners and spur dialogue among partner organizations.
The proportions come from the County Health Rankings and Roadmaps What Works for Health model of what influences the health of a community. The model depicts their estimates of the relative influences of modifiable factors on health outcomes. Genetics are not included because they are not modifiable. More information on methodology.
Populations of greatest need—individuals with complex health issues who account for a large share of health care spending—frequently cluster together in certain geographic areas. These areas often have higher levels of poverty and other determinants of health. Thus, addressing root causes of health problems in such areas can lead to a tremendous impact on health outcomes and a significant reduction of health expenditures (source: Robertson TM, Lofgren RP ).
In the CHI Navigator, interventions are grouped according to their influence on the modifiable factors that impact health (similar to the County Health Rankings & Roadmaps model). Research suggests that efforts addressing socioeconomic factors—such as housing, education, income, or social support—increase health equity and have the greatest positive impact on the overall health of the population. Hence, socioeconomic factors are listed first.
Tools for Successful CHI Efforts
The Tools for Successful CHI Efforts section provides key concepts to consider in each part of the CHI process and highlights select tools to help you effectively carry out your approach. This section is intended to serve as your starting point, helping you determine what actions to take and how to carry out the work, by:
- Providing user-friendly tools that offer guidance that incorporates key concepts.
- Including tools with action-oriented, operational, and practical guidance for each tenet or step of the CHI process.
- Pointing users directly to relevant sections or templates, to facilitate efficient identification of appropriate guidance.
- Identifying a select group of unique tools relevant to the key concepts, tenets, and CHI process steps.
Review the framework shown on Tools for Successful CHI Efforts. Then, select a tenet or step from the menu below and review the key concepts (i.e., actions to take) and tools to help address the key concepts. The key concepts can serve as a readiness check to increase your chances for success, and help in identifying tools for use in your CHI efforts.
For best results, we suggest starting at “Work Together.” Review the key concepts for the four cross-cutting tenets and the key concepts for the five-step CHI process. If your CHI efforts are in progress, you can jump directly to the relevant tenet or step most closely aligned with your current activities and refer to other tenets and steps as needed as you carry out your CHI process.
Ideally, the tenets of “Work Together, Engage the Community, Communicate, and Sustain Improvement Results” should all be addressed before embarking on the five-step CHI process, and maintained throughout the CHI effort. If your CHI efforts are already underway, reflect on how you are addressing the four tenets and consider adjusting your plans to incorporate the related key concepts throughout the rest of your CHI process.
The CHI Navigator builds on the well-known Action Cycle by incorporating a set of cross-cutting tenets and adding key concepts throughout the organizing framework. For each tenet and step, the CHI Navigator includes a focused, targeted, short list of tools aligned with the key concepts. Select excerpts from the Internal Revenue Service’s Final Rule on Community Health Needs Assessments (CHNA) for Charitable Hospitals are also included for reference.
The key concepts stem from collaborative CHI guiding principles and were drawn from careful review and analysis of the following sources:
- County Health Rankings and Roadmaps
- Georgia Health Policy Center Sustainability Framework
- Improving Community Health through Hospital–Public Health Collaboration: Insights and Lessons Learned from Successful Partnerships (University of Kentucky 2014)
- Primary Care and Public Health: Exploring Integration to Improve Population Health (Institute of Medicine 2012)
- Principles to Consider for the Implementation of a Community Health Needs Assessment Process (Rosenbaum 2013)
- Robert Wood Johnson Foundation Culture of Health Prize Criteria
Some key concepts can indeed be applied in more than one part of the CHI framework. For the sake of brevity and simplicity, each key concept is described in only one tenet or step. We suggest that you review the key concepts in all four tenets and five steps as you work on your CHI efforts.
Tools for Successful CHI Efforts is intended to be unique, not all-inclusive. The intent is to connect you to targeted tools with guidance, templates, or examples to help you incorporate the key concepts that will lead to success. Use this section as a quick start to inspire action, rather than a comprehensive step-by-step guide. See Additional Tools and Resources for some of the more commonly used comprehensive CHI tools lists.
Tools related to the key concepts were selected from specified sources using a systematic approach and specific inclusion criteria. As noted elsewhere, the CHI Navigator does not contain an exhaustive list of CHI tools. Instead, the CHI Navigator tools have been carefully chosen to provide you with a starting point in line with the key concepts and tenets.
If you find a useful tool that that was not included here and meets the CHI Navigator’s inclusion criteria, please contact us.
Since every collaborative and community has different needs, CDC encourages you to explore tools that are suitable to your specific CHI efforts. Visit Additional Tools and Resources for resources beyond those highlighted in Tools for Successful CHI Efforts , which are specifically targeted and relevant to the key concepts, tenets, and CHI process steps that we have outlined and are not all inclusive nor the only tools to consider for your CHI efforts.
Tools for Successful CHI Efforts contains tools to support needs assessment efforts. Visit Assess Needs and Resources for suggested key concepts and select tools. Additional Tools and Resources also contains a list of useful data sources and other tools and resources for this purpose, including several comprehensive resources for conducting CHNAs.
Select excerpts from the IRS Final Rule on Community Health Needs Assessments (CHNA) for Charitable Hospitals related to the CHI key concepts are included in the Tools for Successful CHI Efforts section. See the Federal Register posting and full final rule for additional information. Other organizations have also developed summaries of the final rule.
Quality improvement frameworks and tools, such as PDSA, can be valuable in supporting and strengthening CHI efforts. There are multiple ways this can occur.
The PDSA cycle – which stands for Plan-Do-Study-Act – is the foundational framework for continuous quality improvement (one aspect of the Evaluate Actions key concepts). When used in rapid cycle improvement, it can help organizations improve many aspects of a project, such as engaging the community, data collection activities related to evaluating actions and assessing needs and resources, or implementation (i.e., acting on what’s important). See an example of how Comanche County, OK used PDSA and several quality improvement tools to improve their community engagement.
Find Interventions that Work
The purpose of the Find Interventions that Work resource is to make it easy for users to identify evidence-based interventions from multiple sources. This information supports community partners in choosing the option(s) that best leverage their collective assets and address their prioritized health needs.
The CHI Navigator intervention resource is intended for staffers in organizations (e.g., hospitals and health systems; public health agencies; community health centers; community action agencies such as United Ways and Accountable Care Organizations) responsible for the frontline work of improving the health of communities. Possible uses of the intervention resource include:
- Finding best practices and evidence-based interventions and approaches
- Generating ideas for proven interventions aligned with the results from needs assessments (e.g., CHNAs, health needs assessment, community health assessment, etc.), community assets, and the desired health outcomes
- Identifying evidence-based approaches to use in assessing current approaches or strategies
- Discovering interventions to consider as part of an implementation strategy, a population health plan, a state health improvement plan, or a community health improvement plan
- Identifying options for potential inclusion in a population management plan that includes innovative approaches to care of populations
This resource has identified and incorporated proven, evidence-based interventions from multiple sources to provide you with approaches that have demonstrated effectiveness. It is not intended to discourage innovative approaches. The evaluation of new, innovative efforts is critical to build the evidence base for reducing health disparities in communities.
Risk Factors and Outcomes Included in the CHI Navigator Find Interventions that Work Resource
The current version focuses on the underlying risk factors for the leading causes of morbidity and mortality in the United States. Those factors include tobacco use and exposure, physical inactivity, unhealthy diet, high cholesterol, high blood pressure, diabetes, and obesity. Other priority risk factors, such as mental health and substance abuse, will be considered for future releases.
Modifiable factors that impact health include socioeconomic factors, the physical environment, health behaviors, and clinical care. Housing, education, and transportation can all have an impact on health and fall into the action areas of socioeconomic factors and physical environment.
The literature indicates that education is a strong positive predictor of several health behaviors and outcomes, including tobacco use, physical activity, weight, diabetes, heart disease and hypertension.1-5As well, studies have noted an association between provision of housing and accessible transportation options and outcomes such as physical activity, healthy diet, diabetes and obesity.6-7 Therefore, while certain reviews and studies included might not have explicitly targeted or documented such outcomes, this resource still generally categorizes education, housing, and transportation interventions as targeting many of these risk factors, so that users could consider these kinds of interventions with longer term impact.