5 Steps to “Turn the Curve” on Community Health
An effective Community Health Improvement strategy is one that:
- Reflects qualitative and quantitative community health data
- Focuses resources on creating improvements with high leverage
- Involves participation of diverse partners and industries
- Focuses on creating equitable outcomes
Once you’ve decided how you’re going to measure progress on your Community Health Improvement Plan, you can use what we call the “Turn the Curve process” to measure, monitor, and improve your health Indicators. Turning the Curve is a simple 5-step process to improving community health conditions that anyone can understand. Partner organizations can also use the same process to monitor and improve their Performance Measures.
Step 1: What’s the Current State of the Data?
Baselines allow us to visualize our progress over time. Turning the Curve is literally turning the data baseline in the right direction. Graph a baseline for your measure. A baseline includes three parts: historical data, current data, and a forecast. A forecast is a line depicting where the data is headed if you do nothing differently. It is not where you want the data to go. Click here to learn more about creating a baseline.
Step 2: What’s the Story Behind the Data?
Identify the root factors that are influencing the direction of the baseline and forecast. There are two types of factors that you will want to consider: contributing and limiting factors. Contributing factors are factors that are causing your data to go in the direction it’s headed. Limiting factors are what’s preventing your data from going in the right direction.
You will also want to consider demographic factors and cyclical factors. Can you identify any predictable patterns in your data over time? Are things usually worse at a certain time of year? This is a cyclical factor. Understanding these cycles will help prevent you from misinterpreting the data. For example, hospitalizations resulting from the flu may be more frequent during certain months. So, we can compare seasonal spikes to previous years to see if it’s getting better or worse. If it’s better than last year’s spike, this should be considered a success. The spike may be worse than previous months in the same year, but since we know that it’s a cyclical factor, we can better understand how we are progressing over time.
Achieving health equity should be a core focus during strategizing. PolicyLink defines equity as “the just and fair inclusion into a society in which all can participate, prosper, and reach their full potential.” Health conditions may be worse for certain groups (racial/socioeconomic/gender/etc.). We need to understand these inequities so that we can move the needle for the most impacted populations. Not only is this the right thing to do, but it will help accelerate the improvement of our measures. If you can, disaggregate your Indicator data based on race, class, gender, or any other relevant category. For example, are mortality rates from cancer higher in certain racial groups? Are obesity rates higher among certain age groups? This information will help you figure out where you should spend your time and resources to create effective strategies with the most leverage.
Step 3: Who are Partners with a Role to Play?
Improving community health is an inherently collaborative process. No one person, agency, or organization should be held responsible for improving every factor influencing a person’s health throughout their lifetime. For example, it wouldn’t be fair to hold the local health department solely responsible for reducing sugar consumption in the community. Schools serve meals, businesses sell food products, and public organizations engage in health communications. These are partners that should also be held responsible.
At this point, you should have engaged community partners through the development of the Story Behind the Curve. This is a continuation of that process. Continue to identify key partners that will have a role to play in improving that specific measure. Some partners may have a role to play in all of the Indicators. Some may be only part of one or two. Try and think outside the box and consider partners who may not have ever been considered. Don’t forget to make community members themselves a key part of the process. An asset mapping toolkit can help you identify partners and resources.
Step 4: What Works to Turn the Curve?
Determine what works to Turn the Curve in the right direction. Based on the Story Behind the Curve, what are the strategies that have a reasoned chance of improving the situation? Try and list ideas for each of the following types of strategies:
- Look at the research. The science part is about the research that has been done over the last 20 plus years on programs that actually make a difference in health and wellbeing. For example, we know that quality child care, regular health care, family support, and parent education all play a key role in the healthy development of children.
- Don’t be limited by research. The common sense part is that not all things that work have been proven by the research community. What works ideas should build on your experience and what you and your partners know about the community in which you live. What do you think would work here? Be disciplined about this part of the work. Not all ideas are good ideas. Test each idea against the question: Would this make a difference in health? Would it help turn the curves we are trying to turn?
- Consider what has worked outside the county. There is a growing body of experience from other counties, states and countries about what works to improve well-being. These are sometimes referred to as best or promising practices. And a number of books, journals, and websites provide access to this experience. Localities with successful efforts are usually willing to host visitors, and this can be a powerful way to get beneath the surface of advertised claims to what really worked or didn’t work. It goes without saying that what works in one community may not work in another. So, look for experience in counties and communities with economic and demographic characteristics similar to your own.
- Consider no-cost and low-cost ideas. No-cost and low-cost ideas can be among the most powerful parts of your plan. We have a tendency to think about everything as a money problem. And while money is certainly important, it is not the only way to turn a curve. There are many ways for partners to make contributions to this work (e.g. use of volunteers, advertising by the media, family-friendly policies by the business community, support groups by the faith community, streamlined policy or procedure by public agencies, etc.) that make a crucial contribution at low cost and without using public funding sources. When groups are given the challenge to turn a curve (say for immunization rates) and are asked to include at least one no-cost or low-cost idea, it often happens that half to two-thirds of the good ideas are no-cost or low-cost. The simple act of asking for no-cost and low-cost ideas has the effect of changing people’s mindsets.
- Use pointers to action. There are two pointers to what works in the preceding steps of the process. Each element of the story behind the curve is a pointer to action. And each partner or potential partner is a pointer to action. The group should seek advice from a wide range of partners on what it would take to get people healthy. Then, ask each partner the following questions:
- What is your best assessment of whether people are now healthy and why?
- What could work in this county to improve this situation (including no-cost and low-cost ideas)?
- What can you contribute (time, money, and expertise)?
- How do we create a strategy to turn a curve or set of curves (i.e. actually measurably improve the well-being of children, adults, families or the community as a whole)?
The kind of process described above usually ends up with a long laundry list of everything anybody ever thought was a good idea, completely undisciplined, and completely unaffordable. The trick in this work is not to create such a laundry list, but a coherent strategy, that we can actually afford to implement that will actually produce the results we want.
Step 5: What do We Propose to Do?
Determine an action plan. Develop a list of specific actions based on your ideas about what works. Be sure to assign actions to specific organizations (at the population level) or people (at the performance level), establish due-dates, and create a timeline.
How do we choose actions? There are four criteria to help you translate your list of what works ideas into a viable action plan. These are:
Leverage – How strongly will the proposed strategy impact progress as measured by the baselines? Given that resources are finite, resource allocation should be based on the expected impact of those resources on progress.
Feasibility – Is the proposed strategy feasible? Can it be done? Once ways to improve feasibility have been adequately explored, leverage and feasibility must be weighed and balanced in choosing the strategy.
Values – Is the strategy consistent with the values of the community and/or agency? Sometimes strategies have high leverage and feasibility, but they do not align with our community values.
Specificity – Is the strategy specific enough to be implemented? Is there a timeline with deliverables that answers the questions: Who? What? When? Where? How?
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