The impact of social factors such as food insecurity, poverty, and transportation on health status is undeniable. Extensive research estimates that up to 20 percent of health outcomes are a result of social and environmental risk factors. To address patients’ unmet social needs before an acute care episode, population health managers increasingly extend care model interventions into the community.

For community-based interventions to be sustainable and effective, they must be as purpose-driven as clinical interventions, well-supported by data and continuously assessed for efficacy. Community engagement starts with leveraging data to identify how to best allocate limited resources. From there, providers can prioritize activities that align to the greatest community needs, community groups, and core population health goals.

This toolkit outlines four steps for focusing on the highest return community health needs: Define core measures, prioritize key activities, create formal partnership compacts, and evaluate performance of community-based interventions. Each step is supported by sample resources including surveys, prioritization tools, and metric pick lists.

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Step 1: Define core measures

When choosing community-based interventions, it is essential to focus on activities that will be most important for improving community health. To accomplish this, the first step is to define a set of measures that capture an organization’s targeted health priorities to track. Read more on p. 8.

This section includes case studies and resources to help providers set core measures for monitoring community health, including:

• Tool 1: A checklist for gathering comprehensive qualitative input (page 12)
• Tool 2: Sample scripting for survey outreach (page 13)
• Tool 3: Qualitative provider and community member stakeholder surveys (page 15)

Step 2: Prioritize by improvement opportunity, resource demand

Tracking core measures will likely highlight several community health challenges. Providers typically end up with a list of 10 to 12 priorities—still too many to address at the same time. Population health managers need to further prioritize the list of challenges by comparing size of the improvement opportunity with availability of resources to address those needs. Read more on p. 20.

This section includes the following resources to help providers prioritize improvement opportunities and interventions:

• Tool 4: Quick reference to determine value-based impact of inflecting non-clinical needs (page 21)
• Tool 5: Initiative scoring template (page 22)
• Tool 6: Initiative decision guide (page 23)

Step 3: Create partnership compacts

Once your organization has decided on which need(s) to intervene on, you can begin to reach out to partners within the community who can strengthen your ability to deliver value to patients. To ensure community initiatives engage high-value partners, providers need to select partners that offer the best culture and strategic fit, and formalize expectations across each partners’ roles. Read more on p. 26.

This section includes the following resources to help providers create partnership compacts with external stakeholders:

• Tool 7: Community partner brainstorming guide (page 27)
• Tool 8: Sample memorandum of understanding (page 29)

Step 4: Evaluate short- and long-term performance

Providers should evaluate community health interventions over time to ensure optimal deployment of resources. Providers can track two types of metrics—process and outcomes—to measure value of community-based interventions. Read more on p. 32.

This section includes the following resources to help providers evaluate the short- and long-term performance of community-based initiatives:

• Tool 9: Metric evaluation guide (page 33)
• Tool 10: Metric picklist for assessing community-based interventions (page 34)