THE RESOURCE LIBRARY provides tools and resources to help essential hospitals and their partners implement community-integrated health care.

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Transportation

Transportation and Health Tool

APHA/ USDOT/ CDC

The Transportation and Health Tool (THT) provides access to data and strategies that examine the health impacts of transportation systems.

THT was created in conjunction with the U.S. Department of Transportation (USDOT), the Centers for Disease Control (CDC), and the American Public Health Association (APHA) to look at specific indicators from each U.S. state addressing how transportation can affect air quality, safety, active transportation, and connectivity to destinations. THT provides information to assist in understanding the relationship between transportation and health as well as addressing tactics to improve public health through transportation planning and policy. Essential hospitals can use the tool to examine transportation-related health indicators by state, metropolitan and urban areas, and to identify transportation strategies to help address those health concerns.

Check out how five unique organizations and hospitals used the Transportation and Health Tool to improve community health on APHA’s website.

Health Behaviors

Hospital Readiness/Community Assessment

CityHealth

de Beaumont Foundation

CityHealth provides an interactive way to view and compare population health related policies in different cities across the United States.

The website can be sorted by city or by policy, with 40 major US cities to choose from. Users can view policies that are in place for topics such as healthy food procurement, tobacco regulation, and zoning for affordable housing. Bronze, silver, and gold medals are assigned to each city, and specific details about each healthy policy are provided. Essential hospitals can utilize this tool to view how their city ranks for a variety of population health related policies, and view recommendations for improving these policy areas.

Health Literacy

Quick Guide to Health Literacy

US Department of Health and Human Services

This guide provides the information necessary for health care providers to better understand health literacy and become clear communicators with patients.

The Quick Guide to Health Literacy outlines a streamlined approach to making health information appropriate for the user and easy to use. It also provides tips for ensuring that health providers are communicating clearly and effectively. Essential hospitals can utilize the examples of easy-to-read flyers, the checklist for improving the usability of health information, and the list of additional resources provided.

Family & Social Support

Hospital Readiness/Community Assessment

The Circle of Support Approach Organizational Self- Assessment

Substance Abuse and Mental Health Services Adminstration

This self-assessment from SAMHSA allows hospitals to evaluate the current policies, practices, and systems at their organization that encourage patients to build and maintain their social network.

Essential hospitals can use this self-assessment to evaluate how well their organization addresses patients’ social network needs. The assessment includes questions about policies, workforce development, procedures and practices, resources and services, and documentation. By ranking their organization on a scale of 0 to 4 for each question, hospitals can evaluate how they are currently encouraging family and social supports, and what additional improvements can be made. Improving patient’s social support systems and resources can lead to better personal health management.

Employment & Income

Strategic Planning

The Future of Health is Local: A Field Guide for Health Sector Leadership

Business Alliance for Local Living Economies (BALLE)

This strategic guide from BALLE is designed to help health care institutions to align the non-clinical assets of their organization and improve local economy.

Essential hospitals can use this guide for ideas and practical strategies for creating local partnerships, particularly with local businesses and entrepreneurs. Throughout the guide, “localism strategies” are linked with six social determinants of health, with specific examples of how to coordinate external partnerships and maximize community benefit. Additionally, several case studies included in the guide provide tactical examples of how hospitals and health systems are employing their non-clinical assets to advance the health of their community.

Sustainable Funding

Financing Regional Health Transformation: A Primer for Changemakers

ReThink Health

ReThink Health’s Financing Primer takes a broader look at health care financing, including the challenges and opportunities in today’s payment environment for population health.

Essential hospitals can walk through the six steps of the Primer to hear commentary from health care thought leaders, watch informational videos, and access resources for sustainable financing mechanisms. The online tool also encourages collaboration in this area and provides examples of community-wide financing arrangements.

Food Insecurity

Food Insecurity, Health Equity, and Essential Hospitals

America's Essential Hospitals

Food insecurity is a serious health problem for people and communities nationwide, with profound clinical consequences and a deep connection to sociodemographic factors that affect health.

This brief summarizes the challenges that food-insecure patients face and measures hospitals can take at the patient, system, and community levels to help create food security.

KEY FINDINGS

  • Food insecurity is significantly associated with a number of physical and behavioral health outcomes.
  • Poor health and food insecurity often exacerbate each other, perpetuating a cycle of chronic illness that contributes to high health care costs and utilization.
  • Food insecurity disproportionately affects vulnerable populations and is driven by social, economic, and environmental factors.
  • Essential hospitals have a unique opportunity and responsibility to address food insecurity to improve  patient and population health.
  • Hospitals can address food insecurity through screening, on-campus resources, community partnerships and engagement, and referral to nutrition assistance programs.

Transportation

The Intersection of Health and Transportation

America's Essential Hospitals

To what extent are transportation services related to the health and wellness of individuals? What role do essential hospitals play in transportation?

This webinar offered a discussion on how transportation services and health and wellness may be related and provides a glimpse into how two essential hospitals are addressing community transportation needs.

Education

Hospital Readiness/Community Assessment

The Children’s Health and Education Mapping Tool

School-Based Health Alliance

This tool allows users to visualize child and adolescent health at the community level, as well as explore characteristics of school-based health centers and public schools, for data-driven decision making.

Essential hospitals can use this resource to create maps which highlight areas of need related to education and health. In addition, features in the tool allow users to map health care access points, public schools, and school-based health centers to identify potential partners. The mapping tool is a free resource offered by the School-Based Health Alliance, which also hosts several other resources for health and education on their website.

Workforce Capacity

Best Practice Guidelines for Implementing and Evaluating Community Health Worker Programs in Health Care Settings

Sinai Urban Health Institute

Community health workers (CHW) can play a vital role in patient and community engagement, and are increasingly being integrated into hospitals and health systems as part of population health improvement.

This report from Sinai Urban Health Institute – an affiliate of America’s Essential Hospitals’ member, Sinai Health System – aims to provide a comprehensive look at the CHW model and how to successfully incorporate CHW into the hospital and health system workforce. The evidence-based guidelines are presented through five sections, from hiring to evaluation, which cover all aspects of CHW integration. Essential hospitals can use these guidelines as they consider adopting the CHW model or revising current programs.

Multisector Partnerships

A Playbook for Fostering Hospital-Community Partnerships to Build a Culture of Health

Health Research & Educational Trust

This playbook provides a step-by-step guide for engaging partners, collaboratively implementing population health strategies, and sustaining successful partnerships.

Essential hospitals can use this playbook to learn more about a “culture of health” and the value of partnerships, and as a workbook for population health collaboration. The document offers graphics, worksheets, templates, and more to walk users through every step of building and fostering partnerships.

Community Infrastructure

Program Implementation

Building Healthy Places Toolkit

Urban Land Institute

This toolkit offers strategies for enhancing health through changes to the built environment, specifically related to physical activity, food and water, and the environment.

Although originally intended for community development audiences, essential hospitals can use this toolkit to develop population health initiatives with urban planning partners. The toolkit provides 21 evidence-based recommendations for community health improvements through an interactive website and formal report. In addition, several case studies are featured on the site for examples of the recommendations in action.

Hospital Readiness/Community Assessment

Community Health Assessment Toolkit

Association for Community Health Improvement

This toolkit provides a step-by-step guide across nine elements of community health assessment.

Essential hospitals can use this toolkit to better engage their communities and assess community needs. As a generic guide, it provides a foundation for IRS regulated community health needs assessments (CHNA), but can be used by all hospitals and their partners. Each step is a quick and easy read which covers key components and strategies. Additionally, case examples are provided for some steps, as well as compendium of resources for the overall process.

Hospital Readiness/Community Assessment

Vital Signs: Core Metrics for Health and Health Care Progress

National Academy of Medicine

Vital Signs comprises a standardized set of 15 core measures aimed at yielding the clearest understanding of the health and well-being of Americans.

The measures are broken down into four categories – healthy people, high-quality care, affordable care, and engaged people – and can be applied at the national, state, local, and institutional level. Essential hospitals can use these measures to better understand the needs of their community and progress in population health improvement. The National Academy of Medicine (formerly the Institute of Medicine) offers several resources for using Vital Signs, including reports, infographics, videos, and webinars.

Hospital Readiness/Community Assessment

Community Commons

Institute for People, Place and Possibility/ Center for Applied Research and Environmental Systems/ Community Initiatives

Community Commons is an online resource center for analyzing and visualizing community data.

Essential hospitals can access the free tools on the site to develop maps and reports for their communities using social, economic, education, health, and environmental data. Such data visualization can provide context to community needs in a way that is easy to understand. What’s more, Community Commons encourages collaborative community initiatives and serves as a space to learn from and connect with potential partners.

Community Infrastructure

Program Implementation

Improving Community Infrastructure: Lessons from Detroit

America's Essential Hospitals

In this webinar, Henry Ford Health System shared how it's working to improve Detroit’s infrastructure through community revitalization programs.

Tom Habitz, an Urban Planning Specialist with Henry Ford Health System, discussed the diverse community development projects underway, how the health system engages its local community, and lessons learned from collaborating with local partners. In addition, Mr. Habitz provided an overview of Henry Ford Health System’s other initiatives to address the social determinants of health.

Health Behaviors

Program Implementation

Park Rx

National Recreation and Park Association/ Institute at the Golden Gate/ National Park Service

Park Prescriptions (Rx) are programs designed in collaboration among public land agencies, health care providers, and community partners to encourage people to utilize parks, trails, and open space.

The ParkRx website hosts a number of resources for developing park prescription programs. Specifically, essential hospitals can use the program toolkit for clinical providers which includes worksheets, videos, and other resources. Additional toolkits are offered for program partners such as public health, community organizations, and park departments. Essential hospitals can also access communication materials, educational webinars and reports, and numerous success stories.

Food Insecurity

Program Implementation

Addressing Food Insecurity: A Toolkit for Pediatricians

FRAC/AAP

This toolkit from the Food Research & Action Center (FRAC) and American Academy of Pediatrics (AAP) aims to help providers screen for food insecurity and connect families to food and nutrition resources.

Essential hospitals can use the toolkit as a step-by-step guide for incorporating food insecurity screening and intervention strategies into institutional workflow. Specifically, the toolkit provides helpful steps for educating staff, screening using The Hunger Vital Sign™ (a validated, AAP-recommended screening tool), and responding to patients’ needs.

Interpersonal Violence

Program Implementation

Interpersonal Violence and Hospital-Based Intervention

America’s Essential Hospitals

This webinar highlighted the hospital role in community violence prevention and intervention, the value of hospital-based violence intervention programs, and resources for implementing such initiatives.

Founding members of the National Network of Hospital-Based Violence Intervention Programs (NNHVIP) – Youth ALIVE! and Boston Medical Center – discussed the core components of hospital-based violence intervention programs and provided examples from their own communities.

Access additional resources for hospital-based violence intervention programs at nnhvip.org.

Social Needs Screening

Hospital Readiness/Community Assessment

SIREN Evidence Library

UCSF

The Social Intervention Research & Evaluation Network’s (SIREN) Evidence Library provides research articles, issues briefs, reports, and commentaries about addressing social needs in the clinical care setting.

Essential hospitals can use this research library to explore the evidence behind population health interventions, which can support community assessment, program design, and communicating return on investment. SIREN also provides resources for other population health strategies, such as screening for social determinants, metrics and evaluation, and grant writing.

Multisector Partnerships

Practical Playbook

Practical Playbook

The Practical Playbook is a printed resource with an associated website aimed at helping public health and primary care collaborate around population health.

The paperback playbook hosts several expert strategies around public health-health care collaboration that may be beneficial to essential hospitals seeking to form community partnerships. In addition, the Practical Playbook website offers further resources and tools for successful partnerships, data utilization, sustainable funding, and other population health topics.

Hospital Readiness/Community Assessment

AGLH Hospital/Health System Self-Assessment Tool

Governance Institute

From Alignment of Governance & Leadership in Healthcare (AGLH), this self-assessment tool can help hospitals/health systems prepare for population health.

The tool includes a seven-part, straightforward assessment in the areas of: board engagement, data systems and management, financing/payment models, delivery system re-design, community benefit/community health, intersectoral collaboration, and policy development. Essential hospitals may benefit from completing this self-assessment as a first step to implementing a population health approach.

Hospital Readiness/Community Assessment

County Health Rankings

University of Wisconsin Population Health Institute/RWJF

County Health Rankings is an online resource center focused on providing reliable data and resources about health and social determinants to inform communities.

The site provides the Health Rankings database for local-level data, as well as numerous resources for implementing population health policies or programs such as the Roadmaps to Health Action Center and What Works for Health compendium. The data provided by County Health Rankings can serve as a valuable benchmark for essential hospitals as they assess community needs.

Multisector Partnerships

Mobilizing for Action through Planning and Partnerships (MAPP)

NACCHO

MAPP is a community-driven strategic planning tool which can help communities identify and address social determinants of health.

This online resource hosts six modules around key public health infrastructure phases, each with several phase-specific tools. In addition, users can access the MAPP Network to connect with local public health departments and other community partners. While designed primarily for public health professionals, MAPP is not an agency-specific tool and can benefit essential hospitals as they work with local organizations around community health assessment and improvement.

Hospital Readiness/Community Assessment

Population Health 101

America's Essential Hospitals

In this educational webinar, Essential Hospitals Institute staff provided an overview of population health and shared how essential hospitals are working to improve the health of their communities.

Attendees learned how social forces affect health and how essential hospitals can partner with local organizations to positively influence these forces. Institute staff shared how America’s Essential Hospitals’ resources and programs can support members in developing, implementing, and growing population health initiatives.

Strategic Planning

Hospitals Aligned for Healthy Communities

Democracy Collaborative

The Hospitals Aligned for Healthy Communities toolkit series, developed by the Democracy Collaborative, offers numerous resources for leveraging the anchor mission for population health.

As essential hospitals often assume the role of anchor institution in their communities, this is a valuable resource for strategic planning. The site features three toolkits specific to workforce, purchasing, and investment. Each toolkit offers case studies, videos, graphics, and step-by-step guides for key strategies.

Learn more in America’s Essential Hospitals’ webinar – Hospitals as Anchor Institutions for Population Health.

Utility Needs

Program Implementation

Green & Healthy Homes Initiative

GHHI

The Green & Healthy Homes Initiative is a national organization dedicated to promoting safe and healthy housing.

Their site offers a number of tools that can benefit essential hospitals working in this area. These include: eight standards for healthy homes, home health risk assessment quiz, information and strategies around common household health risks, and educational and technical assistance resources.

HIT Systems & Analysis

PRAPARE

National Association of Community Health Centers

The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is a tool for health care providers to collect patient data related to social determinants of health.

Essential hospitals can access the PRAPARE assessment tool, as well as the PRAPARE Implementation and Action Toolkit. PRAPARE also includes electronic health record templates for data integration and guides for ICD-10 codes related to social determinants. While PRAPARE was originally developed for community health centers, it has successfully been implemented by hospitals and larger health systems.

Learn more in America’s Essential Hospitals’ webinar – PRAPARE: Using Health IT for Population Health.

Community Infrastructure

Multisector Partnerships

Build Healthy Places Network

Build Healthy Places Network

The Build Healthy Places Network supports collaboration between health care and community development sectors to promote wellness in low-income communities.

Essential hospitals can access the BHPN website for a number of resources for population health, including: a Jargon Buster for “learning the language” of each sector, MeasureUp for program evaluation, the Partner Finder directory, live online discussion events, and multiple case studies of successful collaboration in communities across the country. In addition, Build Health Places Network produces a newsletter (The Pulse) and e-magazine (Crosswalk) to share stories and updates from the field.

Program Implementation

Health Impact in 5 Years (Hi-5)

CDC

Health Impact in 5 Years, developed by the CDC, offers resources for 14 community-based interventions to improve health.

These interventions are categorized by “Changing the Context,” as to make healthy options easy or the default choice, and “Addressing Social Determinants.” Essential hospitals and their community partners can reference these interventions when developing population health initiatives. Each of the 14 interventions is evidence-based and has a proven track record to impact health.