CHAPS Phases

Identifying key planning staff 

The CHAPS point of contact and project management team are responsible for planning and management of the entire CHAPS process. The structure and makeup of the team will depend on how you are conducting the CHAPS process: as a single entity, regional LPHA partnership, or partnering with other local organizations.

It is very likely that the planning staff at your agency will need to take on multiple roles to successfully carry out your CHAPS process. You should also involve leadership and program subject matter experts at various points throughout the assessment and planning cycle. Some important roles to consider are: 

• Agency decision-maker(s): responsible for final approval of the assessment and plan. Agency decision-maker(s) should be looped into the process early on. 
  • Note: Your local board of health will also need to approve your final plan per Colorado Revised Statute (CRS 25-1-505)
• Project manager: coordinates and manages the implementation of all CHAPS activities.
• Health planner: gathers, interprets, and communicates data
• Facilitator: plans, facilitates, and records meetings
• Administrative support: coordinates logistics and communicates with stakeholders
• Content/subject matter experts: LPHA staff in various core public health programs throughout the agency 
  • Content experts will be especially important to engage once priority areas have been identified

It is helpful to have staff and partners with a range of skills and expertise supporting the CHAPS process. Some areas of expertise that will be helpful include: 

• CHAPS
• Project management
• Data collection (quantitative and qualitative)
• Public Health Accreditation
• Change management
• Health equity and community engagement
• Social determinants of health
• Strategic planning
• Facilitation

Hiring new planning staff 

If you are hiring someone new to support this work, the following sample job descriptions provide examples of the roles and responsibilities that may be required:

• CHAPS Project Manager Position Description
• Health Planner Position Description
• CHAPS Facilitator Position Description
   

County & regional leadership involvement

Determine which organizational leaders in the community will need to be involved in this process ahead of time so they can support it. Then, determine how you will continually engage them in the process. Those with approving authority, such as agency leadership and your local board of health, will be some of the first levels of leadership you will work with. Your agency’s local board of health will be required to provide final approval of your plan before you submit it to CDPHE. 

Early on in your planning processes, consider additional key supporters that you should communicate with regarding your upcoming assessment and planning cycle. These are stakeholders who may or may not be formally involved in the process but who need to know about it early, so that they can be supportive. This may include:

• County administrator
• County commissioners
• Public health/environmental health agency staff
• Local hospital(s)
• Local non-profit entities, including those outside of public health
• Local school district(s)
• Local service organizations
• Other county governmental agencies, including those outside of public health
   

Colorado planning resources

Familiarize yourself and your partners with the following:

• Formal requirements for assessment and planning
  • State Statute (See Colorado Revised Statutes Section 25-1-505)
  • Public Health Accreditation Board Version 2022 Standards & Measures 
• Phases and steps of the CHAPS process 
• Your agency’s most recent CHA and CHIP
• Partner agency or local hospital CHA/CHNA/CHIP documents 
  • Community Health Needs Assessments (CHNAs) can generally be found on the hospital’s website 
  • All past and current LPHA CHA/CHIPs can be found in OPHP’s Local CHAs and CHIPs Google Folder
• Current State Health Assessment and Improvement Plan (CDPHE) 
• Download the Colorado Assessment and Planning Requirements Checklist   
   

Additional national resources:

• Community Health Assessment and Improvement Planning (NACCHO tools and training)
  • NACCHO’s Mobilizing for Action through Planning and Partnerships (MAPP 2.0) Framework (Multi-step framework and toolkit for local public health agencies to use in assessment and planning)
• Healthy People 2030 (National health objectives and indicators)
• Community Planning for Health Assessment: CHA & CHIP (CDC guidance for assessment and planning)
   

Optional: Conduct a Starting Point Assessment

The Starting Point Assessment is one of the assessments included in the MAPP 2.0 framework (linked above.) It helps people who are facilitating the community health improvement (CHI) process reflect on their past CHI cycle, identify resources for the current cycle, and develop goals to improve their CHI work throughout the cycle. 

Workplan and Timeline 

A common time frame for the full CHAPS process is approximately 18 to 24 months. Use a timeline to outline how long you expect each phase to take. Use a work plan to outline more detailed activities, time frame, and the person or people responsible for each phase.

Download a sample CHAPS Work Plan here. 

Some other helpful project management tools for planning timelines and responsibilities include: 

• GANTT Charts
• Flowcharts
• RACI Charts 

You can find information and examples of these and other tools online! 

Budget 

The resources needed to complete assessment and planning activities will depend on factors such as: 

• Size of the community(ies)
• Amount of in-kind resources (i.e. donated time, money, supplies, space, etc.)
• How extensive the assessment and planning process needs to be, based on what is already available

Some items to consider when budgeting include: 

• Personnel/staff time
• Contractors/consultants 
• Operating expenses:
  • Meeting space
  • Equipment (laptop, projector, conferencing capabilities)
  • Supplies for meetings (flip charts, markers)
  • Travel funding (mileage reimbursement to promote participation)
  • Funding for producing a printable and/or online version of the community health assessment and public health improvement plan
  • Funding for community engagement activities
  • Staff training and capacity building

Download a Sample CHAPS Budget Template to help you get started 

Working with contractors

Some agencies may elect to consult or contract with other organizations that specialize in quantitative and qualitative research and/or assessment and planning for support with one or more of the CHAPS phases. OPHP maintains a list of organizations that local public health agencies have worked with over the years. You can reach out to ophp@state.co.us for questions and considerations related to contracting this type of work and for a list of contractors that other LPHAs have previously worked with. 
 

Identifying additional resources

Determine if there are community partners who might also benefit from a public health improvement process and may be willing to contribute resources, such as:

• Nonprofit hospitals: required to complete a community health assessment every 3 years and may contribute staff time, supplies, equipment, meeting space.
• Community partners: may contribute staff time, supplies, equipment, meeting space.
• Public Health or Nursing Students: may be interested in assessment and planning projects for practicum or capstone credits. Reach out to ophp@state.co.us if you’d like to connect with the Colorado School of Public Health’s experience-based learning program. 
   

Who and Why

Convening an Advisory Group to guide your CHAPS process is a great example of Public Health 3.0 and illustrates the chief health strategist role that public health plays. It is also an opportunity for LPHAs to strategically seek and engage stakeholders and partners beyond public health. It is important to include sectors outside of public health as the Colorado public health system works to address and support priority issues such as climate change and behavioral health in ways that focus on the root causes of the issues and associated inequities. Engaging diverse perspectives in the data collection, prioritization, and decision-making activities will strengthen the validity, transparency, and potential impact of the assessment and planning process in your communities. Use a health equity framework, like the Bay Area Regional Health Inequities Initiative (BARHII) Framework as a guide for which sectors and parts of your community you can engage in this advisory group. See Phase: 2 Engage Stakeholders for further guidance on engaging stakeholders throughout the CHAPS process.

The make-up of this group will be dependent upon your local process. It can be an already formed group of local partners, such as a health care coalition, public health alliance, or LPHA staff representing different counties in a regional partnership. It can also be a newly formed group for the purpose of guiding the CHAPS process. Once you have determined the internal roles of your LPHA staff, create an Advisory Group that also includes key community or regional stakeholders. 

External partners

Partners external to the LPHA may include: 

• Partner organization(s): some agencies choose to develop a regional CHA/CHIP with neighboring LPHAs and/or collaborate with their local hospital partner(s) on a joint CHA/CHNA and Improvement Plan
• Content/subject matter experts: Community partners with knowledge across specific public health topics of interest
• Community representatives: other community members and community-based organizations can provide valuable insight for your agency’s assessment and planning efforts
• Stakeholders from other key sectors: consider including folks with expertise outside of public health, such as those working in education, transportation, business, and more. 

Advisory group purpose 

The advisory group can serve a number of purposes, including:

• Advise the assessment process and support data collection
• Identify opportunities for community engagement 
• Support further connection to community members
• Participate in prioritization of public health and environmental health issues
• Develop goals for the public health improvement plan
• Form work groups to create action plans for addressing priority issues
• Be responsible for or advise implementation
• Contribute to the monitoring and revision of action plans
• Support communications efforts to the community 

Additional notes on Advisory Group processes & engagement 

1. It is recommended that you establish a formal governance structure and/or project charter for the advisory group to guide the groups vision and mission and ensure that responsibilities are clear 
2. The advisory group should meet regularly to advise the assessment process, participate in prioritization, then support development and implementation of the public health improvement plan.
   1. This type of committee usually meets monthly, bimonthly, or quarterly, depending on the planned milestones and timelines.
   2. A trained facilitator is useful to manage advisory group meetings, as this is where key decisions will be made. 
3. The internal project management team should be a part of the advisory group, in addition to external partners.
4. The advisory group may range in size from a few people to 20 or more. If you have too many participants to reasonably manage, consider using topic-specific subcommittees, each with a representative to the larger steering committee.
5. Recruit members who can influence systems, provide a voice to underserved communities and/or champion priorities. 
   1. New members can be added at any time! Membership in the advisory group may fluctuate depending on people’s availability throughout the process and the specific needs of the CHAPS phase that you are currently in. 
       

Working with partners

You may choose to do this work in partnership with another entity. Partnering with neighboring local public health agencies, community organizations within your jurisdiction, other government agencies, or hospitals can increase the efficiency and effectiveness of your CHAPS process. Colorado local public health partnerships have sprung up around conducting assessments on shared populations and implementing shared, county-wide and region-wide public health improvement plans. As LPHAs develop strategic partnerships to address pressing priority and emerging issues, variations of partnership models are needed to tackle issues that public health cannot tackle by itself.

If this is the route you take, consider developing a legal agreement such as a memorandum of understanding (MOU) to formally delineate roles, expectations, leadership, and funding. 

Examples: CHIPs developed in partnerships

• West Central Public Health Partnership Regional 2024-2029 CHIP (Regional LPHA partnership)
• Baca, Bent, Crowley and Otero Health Departments Regional 2025-2029 CHIP (Regional LPHA partnership)
• Pueblo County 2024 Joint Community Health Assessment (LPHA/Hospital partnership)
   

Purpose of engagmenet & equity

By engaging a variety of stakeholders throughout the CHAPS process in an intentional and thoughtful way, you can ensure that your assessment and plan reflects your community's voice and priorities. You and your partners are strongly encouraged to incorporate community member input to help your agency better understand the reasons for and the solutions to equity-based health issues. Without community involvement, you may miss aspects of their lived experience that shed light on root causes and potential local interventions that may not otherwise appear in your data collection processes or in the literature.

“By fostering trust and mutual respect, exposing unforeseen or unintended barriers to health, and improving program efficacy by accounting for the experiences of the people impacted by programs and policies, community engagement can promote equity.” (Transformational Community Engagement to Advance Health Equity, Robert Wood Johnson Foundation)

External resources 

The 2022 PHAB requirements also include Community Engagement. PHAB states defines community engagement as “an ongoing process of dialogue and discussion, collective decisions, and shared ownership. Public health improvement requires social change; social change takes place when the population affected by the problem is involved in the solution. Community engagement also has benefits of strengthening social engagement, building social capital, establishing trust, ensuring accountability, and building community resilience.

In 2021, The Urban Institute and Robert Wood Johnson Foundation developed a research report, Leveraging Community Expertise to Advance Health Equity. This brief draws on interviews with representatives from national organizations, health equity experts, state agencies, community-based organizations, consumer advocacy groups, and foundations. Through these interviews, they investigate ways that community engagement is being used to advance health equity and factors that promote or hinder community engagement.

The CDC Practitioner's Guide to Advancing Health Equity is another helpful resource that provides guidance on how to go about meaningful community engagement. As described in the Guide, it is important to understand the history of engagement in the communities you seek to support and work with. What has worked well or not in the past is important for your relationship building going into an engagement. The Guide focuses on policies and strategies for chronic disease prevention, but the principles outlined can be applied to other aspects of public health work as well. 

There are many resources on methods for engaging stakeholders, conducting community engagement, and how to thoughtfully use the results of your engagement efforts to improve health equity. Here are a few recommendations:

Link with other community initiatives

There are likely many other health initiatives occurring within your community and it can be helpful to align with local organizations and their ongoing efforts. The public health agency's role as leader and convener of this stakeholder process can help promote local alignment of priorities, strategies, and resources to improve community-driven focus areas.

An initial meeting with potential partner organizations in your community can determine whether they are collecting data that can help inform your assessments and whether the issues and work that they are championing can be supported through the public health improvement process. For example, the local hospital may be mandated to conduct a community health assessment under the Affordable Care Act. There may also be community coalitions that are organized around a particular health issue, determinant of health(e.g., housing, transportation), or population (e.g., seniors/adolescents) that can contribute to or join your process.

Community engagement spectrum 

Use a community engagement spectrum or continuum to understand what types of engagement you are employing or would like to employ, why, and how. One frequently used resource is the public participation spectrum developed by the International Association for Public Participation (IAP2.) Find ways to move along the community engagement spectrum towards collaboration and empowerment. Additional resources on the spectrum of community engagement include: 

• CHAPS Community Engagement Spectrum 
  • During a CHAPS peer-networking event in 2017, a CHAPS-specific version of the public participation spectrum was created. It includes recommendations on specific actions that can be taken at each level of engagement throughout your CHAPS process.
• Colorado Health Foundation’s Community Engagement Spectrum 
• Evolving the competitive edge: Rural Community Engagement

Accessibility in community engagement 

Consider the accessibility of your community engagement opportunities. Some important considerations include:

Explore options for monetary compensation, including stipends, travel reimbursement, etc. for those who volunteer their time to support your assessment and planning efforts. Compensation recognizes the value of lived experiences as expertise and acknowledges and respects the limited time and resources of many of the individuals who live in communities left out by the usual processes and policies of society.

You can also explore options for non-monetary compensation if your budget or specific funding source does not allow for monetary compensation. For example: 

• Power-sharing and power-building during the engagement experience
• Professional and/or leadership development obtained through the engagement experience, such as building advocacy and civic engagement skills
• Writing or being a recommendation for a career opportunity
• Co-planning meetings and content
• Sharing decision making power
• Team building
• Providing capacity building training(s) for participants
• Networking opportunities

Explore options for providing language services for community members who do not speak English as their primary language. This can include providing written materials, including promotional materials or surveys, in other languages as well as interpretation services during meetings or interviews. Consider your community needs regarding:

• Spanish language interpretation/translation
• American Sign Language (ASL)
• Other language services 

Consider the accessibility of meeting rooms (availability of ramps, elevators, etc.), including virtual meeting room accessibility (translation services, closed captioning, etc.)

Give adequate notice for public participation opportunities so that people who wish to participate can plan ahead.

Provide options for people to engage after regular work hours, like evenings and weekends. 

Consider power dynamics

Consider any differences in power or communication skills among your stakeholders and explore ways to ensure that each participant has an equal voice in any given process. 

Optional: The MAPP 2.0 Power Primer is a useful resource that explains why and how to address power dynamics within assessment and planning work, acknowledge societal power imbalances as a root cause of health inequities, and support building community power

Review community engagement resources that center health equity 

Health in Partnership (formerly the Human Impact Project) developed the Health Equity Guide for government entities with a specific focus on "Share[ing] power with communities" as a way to use community engagement effectively. Best practices to keep in mind include:

• Remaining open to learning about community priorities
• Allowing time and space to get to know one another
• Identifying strategic opportunities for communities to contribute their expertise and knowledge
• Sharing resources to develop skills and capacity to partner with the health department

Another great resource is NACCHO’s CHIP Strategy Bank, which is a repository of evidence-based, model, or otherwise vetted strategies submitted by communities participating in the Mobilizing for Action through Planning and Partnerships (MAPP) framework. The CHIP Strategy Bank is searchable by topic area for inclusion in a CHIP. Strategies are presented alongside the MAPP Health Equity Action Spectrum, below:

It can be helpful to use an objective tool that facilitates the process of understanding what you and your partners know, what you need to learn, and where you can learn it from.

Assessment tools that can help you get started:

• MAPP 2.0 Community Partner Assessment tool developed by NACCHO allows community partners to look critically at their individual systems, processes, and capacities as well as their collective capacity as a network of community partners to address health inequities. 
• Community Engagement Assessment tool developed by the Nexus Community Partners organization is a self-assessment to ask why, how, and when you will engage. 
• Racial Equity Toolkit developed by the Government Alliance on Race and Equity (GARE) also includes a 6-step toolkit with questions to ask yourself specific to promoting racial equity in your work. 
• Meaningful Community Engagement for Health and Equity, a mini-version of the CDC Guide referenced in Step 1 of this CHAPS phase includes a brief “Questions for Reflection” section on the last page, which can help you understand where your organization is now, what barriers exist to community engagement and what approaches you should consider, and determine what your next steps are. 

Questions to consider:

In place of a formal capacity assessment, some key questions can be asked to help you prepare for equity and engagement work: 

1. What training do staff need to meaningfully engage stakeholders? 
2. What resources do we have internally to engage stakeholders through community engagement activities and events? 
3. What resources do we have in the community that can help us manage and execute engagement efforts? (e.g., existing coalitions, other efforts engaging the community for different purposes, grants available, CSPH community health assessment class.) 

Determining engagement activities - as well as who you will engage with - will depend on the level and type of expertise that you need to incorporate into your process. With your advisory group, identify the points at which it would be most helpful to engage stakeholders and consider your capacity for managing engagement efforts in addition to your community’s capacity for participation.

Community engagement can be built into many of the phases of CHAPS. Some examples include: having community members and partner organizations participate on planning or advisory committees, including them in your data collection, using their input to inform prioritization process, and including collaborative work with partners in your CHIP strategies. 

Timelines 

Local customization of community engagement techniques is the key to making them work. While some of your stakeholders, such as advisory group members, will play a consistent role throughout your process, others may engage only at specific times. It is also very important that all stakeholders have a role that's purposeful, specific, and defined, and that their time and contributions are recognized and celebrated.When to involve stakeholders depends on the role they will play. The scheduling of stakeholder activities will be driven by the timeline of your overall project and the related outputs and milestones. Below are some recommendations for when in the CHAPS process to involve certain stakeholder types. 

Key leaders & decision makers 

Stakeholders whose support, approval, and/or funding that you need to make sure the process is successful from the start and able to move forward should be engaged first. In CHAPS, these are called "key supporters" and include the local board of health, LPHA staff, county commissioners, county administrator, and other community leaders. Before selection, you may want to take an initial look at community health data to aid in identifying steering committee members based on known health issues.

• The Local Board of Health will ultimately need to approve your final CHA/CHIP. This is an important stakeholder to meet with early in your planning process. 

You should also engage stakeholders who will be involved in an ongoing advisory capacity, such as a steering committee, early on in your process.

• You may already have a community group working broadly on health issues that can fulfill the role of the steering committee.

Coalitions or other organizations

Coalitions or other organizations working on a singular health issue should also be engaged as soon as the topic becomes relevant to the process. This may be during Phase 3: Develop a Community Health Assessment, as you’re gathering data, or during Phase 6: Develop a Plan, once you’ve determined priority areas. 

• You may want to invite a designated representative to the larger steering committee to ensure alignment. 

Subject matter experts & community members 

During Phase 3: Develop a Community Health Assessment and Phase 5: Prioritize Issues, you may want to conduct interviews, focus groups, or surveys of community members and subject matter experts. Engaging community members through these mechanisms can:

• Elicit community perceptions of health issues
• Determine why certain health indicators look the way they do, including likely root causes
• Suggest strategies to address health issues, including programs or initiatives already planned or in progress
• Identify community entities in the best position to take the lead on an issue

Subject matter experts on each of your selected priority areas should also be engaged during Phase 6: Develop a Plan

You likely already have ideas of who you need to involve in this process. However, as public health works to address ever more complex health issues and the social determinants of health, consider this recommended list of potential stakeholders.

Deciding who to invite to participate 

Ask yourself the following questions and consider some of the examples below. This is not an exhaustive list, but may provide a helpful starting point: 

1. Whose support is needed to assure the process is successful?
   1. Public health agency director
   2. County administrator or local board of health
   3. Elected officials
2. Who can represent populations that should be assured a voice in the process?
   1. Community-based organizations
   2. Business community
   3. Faith-based organizations
   4. Civic groups such as Rotary Club or Lions Club
   5. Local hospital and other medical providers
3. Who can provide lived experience with the issue we are working to address?
   1. Community members, especially those who will be impacted by the plan, such as youth, parents, seniors, LGBTQ, refugees and immigrants, and/or people with disabilities, etc.
4. Who can impact the leading causes of disease, injury, disability, and death and/or the greatest health risk to our community?
   1. Community-based organizations
   2. Other non-health local governmental departments or agencies
   3. Local hospital and other medical providers
5. What other entities are also providing foundational public health services or addressing a pressing health issue?
   1. Neighboring local public health agencies
   2. Other non-health governmental departments or agencies
   3. Community-based organizations
   4. Local hospital and other medical providers
6. Who is in a leadership position to change or influence policy, impact large systems, provide a new service or contribute resources?
   1. Elected officials or local board(s) of health
   2. Directors of community-based organizations & community coalitions
   3. Public health director from a neighboring county
   4. Other non-health local governmental departments or agencies 
   5. Area Health Education Centers (AHECs)
   6. Local hospital and other medical providers
7. What subject matter experts are needed to inform the process?
   1. Community members and trusted leaders in the community
   2. Representatives and members of disparately affected populations
   3. Community advocates/organizers that may provide a voice for hard-to-reach populations
   4. Issue-specific experts at local, state and/or national level

Tips for communicating with partners outside of public health

Potential stakeholders will need to understand the "why" behind your work in order to find shared beliefs and values that would motivate engagement. Learn more about messaging and communication, especially around complex issues such as housing and mental health at the FrameWorks Institute. The County Health Rankings and Roadmaps Action Center also provides concrete tools and resources to develop sound communication plans.

Tips for maintaining engagement

Stakeholders will be engaged throughout the process, so while they all do not need to be contacted immediately, it will be useful to have a plan for who gets contacted when, in what manner, and by whom. Here are general recommendations:

• Be clear about your ask & responsibilities/time commitment from the beginning 
  • When engaging stakeholders for the first time, it will be particularly important to define expectations such as their role, time commitment, level of decision-making authority, how communication will occur, and intended outcome
  • Are you asking stakeholders to participate for the entirety of the CHAPS process or just for a small portion or single activity? What will they be responsible for by committing to supporting your CHAPS process? 
• Be considerate of and strategic about time commitments     
  • Some stakeholders may "wear many hats" within the community and be involved in many volunteer and community efforts. Be mindful of this when considering how often they are engaged, in what methods or mode, and why. 
  • If an organization's leader cannot commit to regular meetings, ask her or him to delegate a representative and see if she or he would agree to serve as a subject matter expert. This will keep her or him engaged, even if she or he cannot participate in an ongoing manner.
• Ensure that all meetings have a clear purpose and goal 
  • Hone your facilitation skills to be the most efficient with your stakeholders’ time
  • Consider a variety of methods of engagement so that stakeholders have multiple ways and opportunities to participate 

Engage new stakeholders as the process evolves

Determine if additional stakeholders would benefit the process. This may occur through mechanisms such as:

• Asking the steering committee who's missing
• Asking subject matter experts to recommend additional experts
• The emergence of new environmental and public health issues during the assessment or prioritization phases
• Realization of the need for further community input for prioritization and planning

New stakeholders may be added at any time. If new members are added to the advisory group, consider providing them with an orientation before their first meeting. Likewise, individuals in certain positions may change over the course of the CHAPS process (e.g. county commissioners and other leadership positions.) Do your due diligence to get them up to speed so that you can maintain institutional knowledge in the process and incorporate the expertise and insights that a new individual will bring to the process.
 

The CHAPS process is a great opportunity to build relationships and seek new partnerships. Some ways to maintain strong relationships and acknowledge the contributions of your partners include: 

• Thanking people for their time, both face-to-face and by including partners in the Acknowledgments section of your completed CHA & CHIP 
• Compensating partners and community members as it is possible to do so
• Sharing final products with partners and sharing results of surveys, etc. with those who participated
• Maintaining ongoing communications to keep stakeholders informed and engaged at the appropriate level for their role and level of interest
• Celebrating milestones as a group!
   

The first step in a Community Health Assessment (CHA) is to select a model or framework to use during data gathering and analysis. The model is used to help think through the data, providing a defined approach to what data to gather and the storyline for describing the community’s health. Additional benefits of using a model include providing a structure of categories and naming conventions for organizing all the data, and to help identify topics where data aren’t available. It’s important to note that you do not need to use the same model for all activities like the presentation of the CHA results or in every phase of the Colorado Health Assessment and Planning System (CHAPS). 

Why use a model for Community Health Assessment?

• Provides a defined approach to what data to gather and the storyline for describing the community’s health. 
• Provides a structure of categorizing and naming conventions for organizing all the data.
• Identifies topics where data might not be available.
• Promotes health equity throughout the CHAPS process.
• You do not need to use the same model for all CHA activities like the presentation of results or even in other phases of CHAPS.

What are the considerations for selecting a model for Community Health Assessments?

• The public health law describes a comprehensive review of the data at the local level as a main activity of the assessment and plan. 
• Ideally the model should emphasize a comprehensive equity perspective, looking at all aspects that influence the health of a community, and not only specific aspects like racial  and other demographic diversity. 
  • The Public Health Accreditation Board (PHAB) requirements have heavy emphasis on the incorporation of health equity during the community health assessment process. Even if your agency is not currently seeking accreditation, following PHAB requirements is a good way to ensure that you are following national best practices. 
• It’s beneficial to use a model that encompasses all of the Core Public Health Services so your CHA can clearly show how these services are available in your community as required by public health law.

Do we have to use a specific model for the assessment?

• The CHAPS process does not prescribe a specific model that should be used.
• Selecting a model for the CHA that incorporates health equity is one of the most direct ways to ensure health equity is integral to the CHAPS process.

Is there a model that is most commonly used in Phase 3?

• The Bay Area Regional Health Inequities Initiative Framework (BARHII) is a model that is commonly used for community health assessments. The BARHII model does a great job of incorporating equity, including many social determinants of health, which helps to guide the collection of data resulting in a comprehensive review across a community. Additionally, the BARHII model includes all of the Core Public Health Services in the framework design.
  • Colorado Health Indicators dashboard used the BARHII to help guide which indicators to include as a primary CHA tool supporting CHAPS work. The dashboard also organizes and visualizes the large set of metrics using the BARHII model.
  • See below for examples of how local public health agencies have used the BARHII model to guide their assessment: 
    • Mesa County Public Health Department modified the BARHII model to meet their local assessment needs. See page 5 of the linked 2018-2020 Community Health Needs Assessment. 
    • Pitkin County Public Health used the BARHII model to guide data collection for their Community Health Assessment. They outlined their CHA findings according to each BARHII topic area. See the 2022 Community Health Assessment. 
    • Chaffee County Public Health used the BARHII model to guide data collection for their Community Health Assessment. While they reference the model throughout their assessment and plan, you can see the main areas of alignment at a glance in the “Key Findings” section starting on page 34 of the linked 2021 Community Health Assessment.
• See below for examples of other models used by local public health agencies for their assessment work:
  • Pueblo County’s 2021 CHA process utilized the Healthy People 2030 Social Determinants of Health (SDOH) model. View Pueblo County’s 2021 Community Health Assessment.
• The MAPP 2.0 framework's Community Status Assessment, can help guide decision making related to data collection and analysis. It is a quantitative assessment for public health improvement planning and helps communities move upstream and identify inequities beyond health behaviors and outcomes, including their association with social determinants of health and systems of power, privilege, and oppression.

NOTE: Don't forget to include environmental health!
The Colorado Public Health Act includes the field of environmental health under the broad definition of public health; therefore, environmental health service capacity and environmental and health outcomes should be documented during local assessment processes.

Much of the time and energy during this CHAPS phase is spent gathering and reviewing data for inclusion in the community health assessment. This section answers questions about where to find data and how to interpret it.

Access

Where should I start my search for data?

• The Colorado Health Indicators was created and designed specifically for CHAPS to assist with the community health assessment. Dashboard Instructional Video
  • It is a comprehensive set of metrics that describe community health at the county, regional and state levels. The data are already pulled from over 30 different sources and it organizes the data so you can start reviewing right away.
  • You are not required to use each data indicator from the CO Health Indicators. It’s mostly just a great place to start comprehensively looking at the data so you can better decide what next steps you need to take for this CHAPS phase.
  • Using the Health Indicators also creates some alignment across counties and with the state by tracking some of the same measures
• The Colorado Health Information Dataset (CoHID) website provides access to state and local-level data and resources compiled by the Colorado Department of Public Health and Environment.
  • CoHID Instructional Video
  • Most of the dashboards available from CoHID have data available at the county level and here are a list of a few particularly helpful for CHA work:
    • Chronic Disease
    • Colorado Health Indicators
    • Environmental Public Health Tracking
    • EnviroScreen
  • If you are unable to find the data you were looking for on CoHID or you’d like to see the data a different way (from how it’s been provided), you can submit a request using the Data Request System (DRS).
• There are other sources of data, besides those from CDPHE, that can be helpful in looking at data for the CHA. Below are a few particularly helpful places to look for data:
  • Public Health Digital Library
  • CDC PLACES
  • US Census Bureau American Community Survey (ACS)
  • County Health Rankings
  • Kaiser Family Foundation
  • United Health Foundation America’s Health Rankings

What should I do when there are small numbers in the data? What if my estimates are suppressed (not shown)?

• Sometimes estimates are suppressed due to small numbers geographically and/or demographically. When this happens, there are two suggested strategies for getting useful estimates:
  • It’s perfectly acceptable to use aggregated years of data to get an estimate. Sometimes aggregated estimates are already available online and can also be requested from the data source. By combining multiple years of data, there is usually enough sample size to calculate a stable estimate at the county level. It is typical to combine 3 years of data for most sources. Due to the 5 year cycle of assessment and planning, it is not recommended to use more than 5 years combined for an estimate that will be used in a CHA.
  • Often when the data are not available to the county level, they are available for the CO Health Statistics Region. While a regional estimate is not as specific as a county estimate, it still may be useful. If the regional estimate aligns with what is known to be true (from other data sources, anecdotal evidence, etc) in the community, then the regional estimate is still useful in telling the data story.

What is the best way to cite data sources in a CHA?

• The single most important thing is to cite the data accurately and specifically! Since the CHA informs several later phases in the CHAPS process and is repeated every 5 years, it is especially important to have proper information about the data used in the CHA. This will ensure that you can easily find the original data source again later if you need to reference it again. It will also provide greater transparency for others who want to utilize the data from your CHA to inform their own work. 
• There is no prescribed format for CHA citation but make sure the following components are included in the chosen format: 
  • Primary data source (including the name of the dataset and the program/agencies who provide it); 
  • Data year(s);
  • And website where the data were found (could be a primary or secondary source’s website).
    • A primary data source is the name of the data collection system and the original program/agency who collected the data. A secondary data source may visualize and distribute that data, but are not the collectors nor original ‘authors’ of the data.
  • Example using an indicator from the CO Health Indicators dashboard:

2021 Colorado Behavioral Risk Factor Surveillance System. Center for Health and Environmental Data Division, Colorado Department of Public Health & Environment. Accessed from: https://cohealthviz.dphe.state.co.us/t/HSEBPublic/views/CHITemplate-Redesign1_0-latest3-11m_16527278788750/CHI?%3Aembed=y&%3Aiid=2&%3AisGuestRedirectFromVizportal=y

• CoHID is a secondary data source, providing access to several data dashboards with data from numerous primary data sources. Make sure not to cite the name of the secondary source’s website where you found the estimate, but provide both the primary data source who created the data and also include the secondary source’s website address where you found the data.

What are the types of data used for CHAs?

• In the data world, there are two main types of data; quantitative and qualitative. Quantitative data are often more objective, counted or measured, and usually represented by numerical values (Height, age, distance, etc). Qualitative data are often more subjective, are descriptive and observational, and usually expressed using language (emotions, stories, quotes, etc). One type is not more valuable than the other; rather the two forms of data capture different dimensions of experience and complement one another. Check out this blog for more information about these two types of data.

What are the best ways to handle situations where there aren’t data to describe certain topic areas (aka ‘data gaps’)?

• Before deciding there is a data gap, it’s helpful to do a quick check of the approach while searching for that topic area. It’s easiest to keep an open mind about what data exist. It’s much harder to search for very specific information rather than to search by topic area. 
  • A useful mindset while searching for data sounds like “What data are available for tobacco use?” versus a less productive mindset of “Where can I find the exact number of people who smoked a pack of cigarettes per day in February 2022?”. 
  • Although the specific data that originally came to mind might not exist, there still may be data to describe this topic area for the community using what data are available.
• Utilize the partners and stakeholders in your network to identify data for the topics you are missing. Ask colleagues, community organizations, other local public health agencies, state health department staff, etc what data they use to describe the missing topic(s).
• Search for qualitative data that describes the missing data topic(s). [Read the Qualitative Data section for more information.]
• Data are not perfect so don’t expect the data story to be perfect. In other words, there won’t (and doesn’t need to) be an existing data measure for every detail of the data story. Use as much of the data and information that already exists to tell the story of the health of the community.

Should I collect my own data for the CHA?

• You are not required to collect your own data. In most cases, collecting new data from the community is not a necessary part of a CHA.
• Utilize as much of the quantitative and qualitative data that’s already been collected. It is not recommended to collect quantitative data because most has already been collected through traditional surveillance systems. If data needs to be collected for assessment and planning, it’s usually qualitative data around prioritization of community needs and interests. [Read the Qualitative Data section for more information.] 
• Collecting new data is resource intensive, requiring lots of time, support, and money. And often the end result will not yield results that can be used for describing large populations in the community. 
• Engage in conversations with the CHA project team, other health planners, and the OPHP staff to decide whether this is the only option for collecting certain data of interest. The OPHP staff have access to data people who specialize in designing data collection tools and can also make connections to academic partners who can assist with this activity. 

Analysis

When is it best to use rates, proportions and frequencies?

• Rates are really helpful for comparing over time and comparing with other geographies (county, region, state, etc) because the rate has accounted for changes and differences in population sizes. Typically infectious diseases, mortality data, and injuries are described using rates. Age-adjusted rates are useful because these calculations have accounted for the differences in populations by age in a community as well as the differences in diseases by age.
  • Ex: The suicide death rate for County A is 16.3 deaths per 10,000 people.
• Proportions, often reported as percentages, are helpful for describing the magnitude of the burden. Typically morbidity data including chronic conditions and diseases are expressed as proportions.
  • Ex: 6.5% of Colorado adults have diabetes.
• Frequencies, also known as counts or numbers, should be used as little as possible in CHAs. The biggest concern around using frequencies has to do with confidentiality and privacy of individuals in the community. Additionally, analyzing frequencies over time is tricky because changes to populations or circumstances make it harder to understand any observed differences. The best time to use a frequency is to quantify things or places but not people. 
  • Ex: There are 5 community clinics in County A that currently accept Medicaid. 

What is a confidence interval and how does it determine statistical significance?

• Simply explained, a confidence interval is a way to describe the certainty of an estimate. For a 95% confidence interval, if we measured a sample 100 times, 95 of those results would fall within the specified range of the confidence interval. In other words, 95% of the time the “true value” is between the lower and upper limits of the confidence interval range.
• Watch this video for a helpful explanation of error and confidence intervals.
• One of the simplest and fastest ways to determine statistical significance between two estimates is to compare the confidence intervals. See illustrations below:

• The ‘true estimate’ can be anywhere within the range of the interval. So when confidence intervals overlap, that means there is a chance that those estimates could be the same value. And that means the estimates are not statistically significantly different. For example, there is no statistically significant difference between Groups 1 and 2. 
• When the confidence intervals do not overlap, this means there isn’t a chance that the estimates are the same. Therefore the estimates are statistically significantly different. For example, the difference between Group 2 and Group 3 is statistically significant.
• The wider the range of the confidence interval, the less certain we are of the estimate. In other words, there are more possible values that the ‘true estimate’ might be.
• The more narrow the range of the interval, the more certain we are of the estimate. In other words, there are fewer possible values that the ‘true estimate’ might be.

Why is statistical significance important in CHA work?

• The large volume of data included in a CHA makes it complicated to understand where the greatest areas of strength and need are without a tool to help narrow it down. Using confidence intervals to help understand where the community is statistically significantly different is a useful tool for narrowing down to the most important themes from the data.

One of the best practices in community health assessment is to narrate the story of health across the community. In other words, use quantitative and qualitative data to tell the story of what's happening in the community.

Why is data storytelling useful in community health assessments?

• Extremely large amounts of data are gathered during the community health assessment process and can easily lead to an overwhelming amount of information that will need to be communicated to multiple audiences with varying levels of data knowledge.
• Data Storytelling makes data and statistics more approachable for yourself and your audiences. 

How do I tell a data story?

• Social Math is one approach to simplifying complex statistics by reframing them in a more familiar context. Here is a LINK to an article describing what and how to use Social Math.

What’s the difference between data analysis/interpretation and data storytelling?

• Data analysis and interpretation happens during the data gathering process where you understand what each indicator means and is saying about the community.
• Data storytelling is a strategy to communicate the findings or results of all the data that were analyzed for the community health assessment.

Does data storytelling work for all audiences?

• In general, data storytelling will effectively communicate the important messages to most audiences. Sometimes it will make sense to provide different levels of statistical information about the data to different audiences. 
  • For example, it might be appropriate to share the statistically significant differences with the Executive Director of your LPHA so they can see how data decisions were determined. Whereas it would not be beneficial to share the statistical significance of data to community members.

What are some examples of data storytelling?

• The 2018 CO Statewide Health Assessment
• Healthy Communities NC 

Data visualization is a huge piece of the CHA phase because it is one of the primary ways of communicating the story of health for the community. This section provides information on what is needed for CHA submission and tips for current best practices in data visualization. Resources to explore more on data visualization practices are listed at the end of this section.

Is there a required format for the CHA?

• There is no required format for the final product of the CHA data and information. 

What is required for the CHA submission?

• The CHA must be approved by your local board of health and then it may be sent to OPHP. LPHAs must also submit proof of board approval, such as a copy of an email exchange with the board of health or a copy of meeting minutes.
• LPHAs may submit their CHA on its own, upon completion OR agencies may wait and submit their CHA & PHIP together.
• Both CHAs & PHIPs should be turned in via a Google form upload. The form can be accessed here: https://forms.gle/VtiHD3fRrjK3xvuw9. If there are any questions about this form, please reach out to ophp@state.co.us

What are some of the ways to visualize the CHA data and information?

• Many assume that they need to provide their CHA in a traditional report format, but that is often not the most useful way to share the information. Other format options include a slide set, data dashboard, series of one-pagers covering each section/topic area, 
  • The previous statewide health assessment provides examples of both one-pagers and a data dashboard.

Is there a best way to visualize the CHA data and information?

• The best way to visualize the CHA results is to do it in the most useful way possible. Design the product(s) to be meaningful for the audiences you will be sharing the information with and in a format that you can easily use.
• A traditional report is not a format that is easily presented to audiences, so slides may work better and can be easily modified for a variety of presentations and audiences.
• A data dashboard might easily display the data, but can be resource intensive and require a lot of maintenance over time. How many people will use it, how often, and if the data are already visualized on other data dashboards are all important considerations for whether a data dashboard will be meaningful and useful for your CHA data and information.
• Discuss with your colleagues, partners, OPHP staff, and other LPHA health planners to hear how they are packaging their CHAs and why they used those formats. 

How can I use the CHA products for other work?

• If you intentionally design your CHA information in a useful way, it will help be relevant for several other future activities:
  • The CHA data will be used for later CHAPS phases for the Capacity Assessment and Improvement Plan. The CHA data can be informative for demonstrating strengths or advocating needs related to the Core Public Health Services.
  • The stronger the CHA product, the smoother the CHA process will go in future CHAPS cycles. 
  • The data and information created from the CHA can be used where other data are needed in your public health work like grant writing and program evaluation.

What are some tips for incorporating health equity into the visualizations of the CHA data?

• Remember that population based data are data about people. So treat the data as people and not simply as points of information. 
  • Some data can be used to simply describe. Not all data are suitable for comparisons. Consider the appropriateness of comparing groups of people. 
  • An easy practice to use when handling data about people is to avoid making comparisons across groups of people; rather make comparisons within groups of people.
  • Example of the less ideal comparison across groups of people:
    • Example interpretive statement for Figure 1.1: Hispanic adults are more obese (31.7%) compared to White (22.2%), Black (27.5%), and Other (14.0%) adults.
      • This is an inappropriate comparison because it creates the standard that the racial/ethnic populations should have the rates of other groups of racial/ethnic populations; when the standard should be to decrease the proportion of obese adults and/or increase the proportion of adults with ‘normal’ weight. 

• Example of more ideal comparison within groups of people:
  • Example interpretive Statement for Figure 2.3: Asian adults have the highest proportions of people with normal weight (54.5%) compared to Asian adults who are overweight (29.4%) or obese (6.9%).
    • This is an appropriate way of describing the population and doesn’t compare them or set a precedent of what the proportions should be based on race/ethnicity. 

• Consider using different types of figures to help engage the audience and avoid unintentional comparisons. 
  • In the example below, several different data points are displayed on the same screen. If traditional bars were used to display them, it would unintentionally lead audiences to compare them like they were part of a stacked bar graph displaying data for a comparison. So in this example from the CO Health Indicators dashboard, ‘lollipop’ graphs were used to distinguish the data points and to be interpreted individually.

• The next example, also from the CO Health Indicators dashboard, provides examples of visual options for displaying demographic characteristics. It’s not useful to compare the percent of people by demographics within a community because there are no defined demographic percentages that a community should have (i.e. We don’t, nor should, have definitions like ‘communities should have at least 25% Hispanic population’ or ‘30% of a community should be less than 18 years of age’). The ‘tree map’ and ‘butterfly’ graph do a better job describing and visualizing what the demographics are for the community than a traditional table or bar graph.

• Often quantitative data are presented alone as tables and figures and aren’t the full story of what is happening in the community. Provide context alongside the quantitative data to explain the whole ‘story’. This can be done in a number of ways that are described in the Data Storytelling and Qualitative Data sections of this chapter.
  • The example below comes from the VISION dashboard and provides an example of what it looks like to include context alongside the quantitative data.

• Focus on the protective factors versus the risk factors wherever possible. 
  • For example, instead of only including in the CHA the measure for obesity in the community, include the measure for the percent of the population that has a normal weight. 
  • This doesn’t always make sense, particularly where a community has significant differences for the negative health outcome. Often in this scenario, it makes sense to describe the negative health outcome and then also present a positive health outcome alongside it.
    • Example: If a county has a statistically significantly high percent of people who are obese, include both the estimates for obesity and normal weight along with a narrative about increasing the population of people with normal weights.
• Data equity and visualization resources:
  • We All Count: Project for Equity in Data Science
  • Evergreen Data Visualization
  • Depict Data Studio’s Top 22 Resources of 2022

Click here to download a fillable PDF version of CHA Checklist (with space for taking notes):  

The checklist for completing your Community Health Assessment includes the following components: 

• Select model for data organization
• Using the selected model as an outline, review and pull data from CO Health Indicators for my county
• Review and pull data from other dashboards on CoHID
• Explore other sources of quantitative data
• Explore and include potential sources of qualitative data
• If need is determined, collect local data
• Analyze and interpret the gathered data to decide which data to include in assessment
• Design data product(s) to visualize selected data
• Incorporate a narrative voice to tell the data story of health in the community
• Incorporate best visualization practices to clearly and equitably tell the data story

Begin this phase by determining the area(s) of agency and/or community capacity that you want to assess. Think about what information will best support the overall assessment and planning process. This will look different for each agency and depend on various factors, including:

• Top health and environmental issues as identified in the community health assessment 
• Current delivery of foundational public and environmental health services and capabilities within the jurisdiction
• Whether incorporating quality improvement methods and/or sustainability planning into the process is an identified agency goal
• Whether the agency is preparing to seek national public health accreditation and/or is interested in measuring performance against state and nationally recognized public health performance standards

Understanding the capacity of your agency and your community can influence the priorities, goals, and strategies of the public health improvement plan. It can also help to ensure successful implementation of your plan. Capacity assessments are especially helpful as agencies move towards highlighting and addressing root causes of health inequities in their communities.

Below are three examples of capacity areas to consider. The first example is most important for gathering enough information to prioritize issue areas coming out of your CHA. However, you can choose to assess additional areas to better understand both internal and external capacity to deliver foundational public health services to serve your communities.

1. Capacity to address leading public health issues: 
   1. This type of assessment examines the ability of your agency and partner(s) to address public health issues in your community(ies), county, or region.
   2. Important for gathering enough information to prioritize issues identified in your CHA
   3. Meets 1 requirement of the Public Health Act:
      1. “Identify financial resources available to meet identified public health needs and to meet requirements for the provision of core public health services.”
2. Capacity to fulfill the Core Public Health Services (CPHS): 
   1. Identifies resources available for implementing core public health services and explores the scope of core service implementation and may help identify additional areas that should be prioritized in your plan.
   2. Meets 2 requirements of the Public Health Act:
      1. “Assess the capacity and performance of the county or district public health system”
      2. “Identify financial resources available to meet identified public health needs and to meet requirements for the provision of core public health services.”
3. Agency or system performance: 
   1. You may also elect to assess agency performance. PHAB standards require agencies to address quality improvement and performance management (Domain 9.)
   2. Meets 1 requirement of the Public Health Act:
      1. “Assess the capacity and performance of the county or district public health system”

Internal resources that your agency may have available 

Based on the scope of assessing capacity, here are some recommended resources to review for your process:

• Previous agency capacity assessments. Some local public health agencies have a history of assessing the public and environmental health needs in their community in relation to existing services and required resources.
• OPHP Annual Survey of Local Public Health Agencies 
  • Each LPHA submits an annual survey to the Office of Public Health Practice, Planning, and Local Partnerships (OPHP) which covers topis such as funding, workforce, and core public health service capacity. For information on your agency's responses and for support in interpreting the data, contact OPHP@state.co.us.
  • OPHP Annual Survey dashboards report aggregate, statewide data from the Annual Survey. This is available via our Public Health Systems webpage. 
• Data on staffing, resources, activities, and other capacity-related topics may already be collected by your agency through: 
  • Annual reports
  • Grant activities/deliverables, and applications prepared by your agency or partners
• The de Beaumont Public Health Workforce Interests and Needs Survey (PH WINS) and NACCHO’s National Profile of Local Health DepartmentsNational Profile of Local Health Departments (Profile Study) are two national resources that provide insights into governmental public health capacity. This information may be beneficial to compare to your local context. 
• Capacity assessments conducted by other organizations providing public health or environmental health services for your jurisdiction may also be helpful if available. Discuss with partners to learn more and to gain additional local perspectives.

Examples of LPHA capacity assessments

Reviewing other LPHA capacity assessments can help generate ideas for the approach and scope of your own assessment. See some examples from Colorado:

• West Central Public Health Partnership (Assessed regional CPHS capacity) 
• Larimer County Department of Health and Environment (Assessed partner capacity to address public health issues; Survey tool available in Appendix C) 
• Pitkin County Public Health (Assessed agency & partner capacity to address public health issues) 
• Boulder County Public Health (Assessed agency capacity to address public health issues)  
• El Paso County Public Health (Assessed the Healthy Community Collaborative’s capacity to address public health issues; Survey tool available in Appendix B)  

Additional external resources

Health Equity Consideration: The purpose of this Baseline Organizational Assessment for Equity Infrastructure from the California Department of Public Health is to provide a streamlined tool for LPHAs to collect baseline data on their current equity infrastructure and use it to inform their future planning for equity. Many of the domains included in this tool align with Colorado’s Core Public Health Services, such as Domain 2: Collaborative Partnerships and Domain 3: Equity in Organizational Policies and Practices.

You and your partners may need to collect additional data. Aim to gain a wide variety of perspectives of the agency/system's ability to address priority issues and/or provide core public health services. Reference Phase 2 when considering the best way to engage stakeholders in collecting data.

Data collection techniques to consider

• Facilitated input discussions with stakeholders
• Key informant interviews
  • Conducting Interviews, KU Community Toolbox 
  • Conducting Focus Groups, KU Community Toolbox 
• Online partner surveys
• Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis 
  • SWOT Analysis Template
• Core services baseline review analysis or core service cost assessment result analysis 
  • Sample CPHS Capacity Assessment Matrix
• Community asset inventory 
  • Mapping Community Assets, KU Community ToolBox
• MAPP 2.0 Community Context Assessment 

Example questions to ask in your assessment:

• What type of support can your agency/various partner organizations provide?
• What are your agency’s/your partners’ interest levels in addressing different priority issues?
• What expertise does the workforce have in order to address priority issues?
• Likert-scale questions regarding alignment with work supporting various core public health services and capabilities 
• Are there equity-specific questions that should be asked regarding populations served and impacted by your agency/partner organizations?
• What strengths and resources does the community have that support health and well-being? 
• Anything else that will help guide the selection of CHIP priority areas, goals, and strategies! 

Using your capacity assessment results 

After data collection is complete, analyze and interpret the story it tells. Highlight areas of strength and strategic opportunities for moving toward increased capacity in whichever capacity area(s) you have chosen. These strategic capacity-building opportunities and assets may ultimately become key goals or strategies in your public health improvement plan over the next five years or the agency's next strategic plan.

Once you have analyzed capacity data, it is time to summarize and share the information based on how the results will be used. Here are a few examples of how the results can be used, based on the type of assessment you chose to conduct. Please note that these lists are not exhaustive and there are many other ways that you can meaningfully utilize your capacity assessment:

Capacity to address leading public health issues

• Phase 5 - Prioritize issues: Results can help make decisions about the potential priority areas identified in the CHA.
  • As you are narrowing down the list of public health issues for your prioritization in your CHIP, consider your agency/partner’s capacity to address each issue 
• Phase 6 - Develop the Plan: Results can inform action steps to address important capacity shortfalls.
  • If you select a priority that was flagged as “low” capacity, you can include strategies focused on capacity building 
• Phase 7 - Implement, Promote and Monitor: Including the implementation of capacity-building and performance-improvement activities and ongoing evaluation of capacity-building progress over time.
• Collective impact: Results can provide opportunity(ies) to identify system partners that can help take the lead on individual components of the CHIP.

Capacity to fulfill the Core Public Health Services (CPHS)

• Phase 5 - Prioritization process: Results can help make decisions about the potential priority areas identified in the CHA to drive the public health improvement plan.
  • If you have areas of lower capacity that need to be addressed before committing to other public health issues, you could consider incorporating a general “Capacity Building” priority area into your CHIP 
    • Northeast Colorado Health Department included a Goal of “Expanding Organizational Capacity” in the NCHD 2024-2028 CHIP
    • The West Central Public Health Partnership included a Priority of “Capacity Building for WCPHP” in the WCPHP 2024-2029 CHIP
• Determine your agency's capacity to meet the requirements of the Colorado Public Health Act and align with Core Public Health Services and Capabilities.
• Use the information gathered to support your agency’s annual report, strategic plan, performance management plan and/or quality improvement plans.
• Determine health equity/social determinants of health capacity gaps and strengths.
• Communicate and advocate for public health and environmental health services to a variety of different audiences (e.g. county commissioners, funders, local partners).

Agency or system performance

Use the information gathered to support your agency’s annual report, strategic plan, performance management plan and/or quality improvement plans.
Use this information to support the PHAB accreditation process (Domain 9.)

Use your assessment findings to identify top issues for consideration 

Review the results of the community health assessment create a list of the main topic areas to consider for prioritization that were included in the assessment. This may include issues where health outcomes are trending in an undesired direction, issues that are improving but need continued momentum, issues that were raised by community members through community engagement efforts, and more. You should also review the results of any capacity assessments completed in Phase 4 for additional topic areas to consider for prioritization. 

Aim to identify 5-10 potential priority areas to consider. You will use the steps in this phase to narrow down your list from there. Focus areas may include: public health issues, environmental health issues, capacity/infrastructure needs, or issues that address the social determinants of health or health equity. 

Selecting focus areas for public health improvement helps ensure that limited public health resources can be targeted and important issues can be spotlighted. Focus areas are high-priority, high-visibility issues that organizations serving the community will come together to champion. Efforts to support the focus areas will occur alongside the maintenance of regular public health activities.

Determine who to involve

Leadership: 

At this point, it is helpful to loop in your Executive Director and/or Local Board of Health again, especially if they have not been active members of the advisory committee. Learn if there are any parameters and/or expectations that you should keep in mind during your prioritization process. 

Staff and external partners: 

The prioritization process is an important way to gain buy-in from those in the best position to influence outcomes of the CHIP and ensure that under-represented communities and participants have a voice. 

Be sure to clearly communicate the participants' roles and level of decision-making authority to the group ahead of time. Determine and be transparent about the level of control that participants will have in the prioritization meeting(s). Is it the role of the participants in the meeting to make the final decision on priorities or to make recommendations to the Board of Health or another entity? 

Examples of partners you may want to invite to participate in prioritization: 

• Advisory group
• LPHA staff who may be responsible for implementation and who are experts in any of the top identified health and environmental issues
• Community organizations or neighboring local public health agencies (LPHAs) that may offer to enhance or provide a new program
• Community advocates that can give voice to the underserved
• Potential champions who can generate support, advocate and fundraise
• Decision-makers who can impact policy adoption, implementation, or enforcement
• Potential funders that may contribute toward addressing an issue (e.g., a municipality or hospital)Other government directors who would naturally take the lead on an issue (law enforcement, planning department, transportation, school district, human services, etc.)

Note that the public health agency does not need to be the lead organization on every community health priority. The more engaged stakeholders are in terms of being able to make decisions, the more likely that advocates and lead organizations will step forward.

There are probably many groups already focusing locally on priority health issues. Some may be addressing an issue with great success while others may be struggling because they lack funding, staff, or other resources. A prioritization process can help stakeholders align by focusing energy and resources on the same areas and respective strategies that result from this process.

Explore options and select a prioritization method

It is important to develop a standardized process by which you’ll determine priorities for the CHIP. There are a number of widely used techniques which can help you examine issues in greater detail, clearly rank your options, and identify priorities in as little as one meeting. The one that you choose will depend on your agency’s unique needs. There are benefits to all of the different process options listed below - you may choose from these or design something different. 

When determining a method, ensure that you outline a structured process that you will follow that incorporates guided discussion among all participants.

Common prioritization techniques include: 

1. Multi-Voting 
   1. Multi-voting is typically used when a long list of health problems or issues must be narrowed down to a top few. This process is appealing because it allows a health problem that may not be a top priority of any person, but is favored by all, to rise to the top. In contrast, a straight voting technique would mask the popularity of this type of health problem and make reaching consensus harder.
2. Prioritization Matrix 
   1. A prioritization matrix is a common tool for prioritization and is ideal when health problems are considered against many criteria or when an agency is restricted to focusing on only one priority health issue. Although decision matrices are more complex than alternative methods, they provide a visual method for prioritizing and accounts for criteria with varying degrees of importance.
3. Strategy Grid 
   1. Strategy grids facilitate agencies in refocusing efforts by shifting emphasis toward addressing problems that will produce the greatest results. This tool is particularly useful when agencies are limited in capacity and want to focus on areas that provide the greatest return on effort. This tool may help shift from brainstorming with many options to a focused plan of action.
4. Nominal Group Technique
   1. The nominal group technique is useful in the early phases of prioritization when there is a need to generate many ideas in a short time and when input from multiple people must be considered. This technique can be used to brainstorm ideas and create a broad list of possibilities. A great advantage of this technique is a democratic process allowing for equal say among all participants, regardless of their position in MAPP or the community.
5. Hanlon Method
   1. The Hanlon Method for prioritizing health issues is a well-respected technique that objectively considers explicitly defined criteria and feasibility factors. Though complex, the Hanlon Method is advantageous when the desired outcome is an objective list of health priorities based on baseline data and numerical values.

(Adapted from MAPP 2.0 User Handbook: Phase III, Step 1: Prioritize Issues for the CHIP)

Additional recommended resources:

• CHAPS Prioritization Matrix is a commonly used method in Colorado. It comes with pre-populated prioritization criteria that can be adjusted to meet your agency’s needs and interests 
• Guide to Prioritization from the National Association of County and City Health Officials (NACCHO) provides in depth-guidance on the methods outlined above as well as case examples demonstrating each method in practice

Choose criteria

The following criteria should be used to discuss, evaluate, and score each potential priority area:

1. Significance of the issue to the community's health
2. Availability and sustainability of evidence based practices and resources to implement them 
3. Presence of community support, leadership, and capacity to move the issue forward
4. Impact on health equity

Your team can choose to add to or modify the above list of criteria. 
 

Using your health and capacity assessments 

Utilize your community health assessment, capacity assessment and other resources to create a profile of each potential priority issue for the purpose of decision making. This can be especially helpful if the stakeholders that you are engaging in the prioritization process have not been involved in previous CHAPS phases. It is important for everyone to join the prioritization process with the same baseline understanding of the various health and environmental issues that you are considering for your CHIP.

For each potential priority issue, it is recommended that you provide your stakeholders with information about each of the following areas, at a minimum:

1. Significance of the issue to the community's health & it’s impact on health equity. This can include:
   1. The prevalence of individuals affected or at risk (e.g., mortality, morbidity, and injury rates).
      1. Resources: Community Health Assessment data
   2. The degree of health disparities or impact to subpopulations.
      1. Resources: Community Health Assessment data 
2. Availability and sustainability of evidence based practices and resources to implement them. This can include:
   1. Existence of strategies/best practices likely to have an impact.
      1. Resources: County Health Rankings Roadmap - What Works for Health | CDC Guide to Community Prevention Services
   2. Level of community readiness and support for change (including political will).
      1. Resources: Capacity Assessment 
3. Presence of community support, leadership, and capacity to move the issue forward. This can include:
   1. Local organizations that are prepared to take the lead.
   2. Sufficient resources, including staffing and funding, are available or obtainable.
      1. Resources: Capacity Assessment

Presentation format

Determine the best format(s) to present this information to stakeholders participating in the prioritization process to ensure they have a common understanding of the issues and all of the information needed to select priorities. Methods of delivery include:

• PowerPoint presentation
• One-page issue summary profiles
• Infographics
• Gallery of posters
• Report

Depending on your group, provide information either before the prioritization process or during to ensure everyone has had an adequate amount of time to take in the information and to be prepared to make a decision.

These presentations can also be a good resource for briefing leadership, local boards of health, etc. on the top public and environmental health issues uncovered during your assessment. 

Documentation

Documenting the process, method(s), who is involved, how the prioritization process was created demonstrates the integrity of your process. It is a PHAB requirement as well as a best practice in being transparent about a critical part of the CHAPS process. It will also be helpful in future CHAPS cycles to be able to look back at how and why decisions were made. 

Select a facilitator 

The prioritization process will involve a considerable amount of facilitated discussion. Determine who will facilitate the meeting or meetings. This may be the Public Health Planner, agency Director, an external contractor, or someone else. 

Your facilitator should be able to guide discussions before the issues are scored and ranked. You will also need to guide the process itself and discussions afterward, to  confirm the rankings and talk through any disagreements. Before entering into the prioritization process, take some time to think through the ideal number of final priorities given your agency’s capacity. Note: To meet PHAB accreditation requirements, your agency must select at least 2 priority areas

Recommended meeting agenda 

A thorough prioritization process will probably take three to four hours or longer, depending on the number of stakeholders and the number of issues. It may be structured as one or more meetings or you may give people prep work before the meeting to help facilitate discussions.

Sample agenda: (Could take place over one or multiple meetings)

1. Purpose of the meeting/background
2. Set meeting norms (also known as ground rules)
3. Overview of decision-making roles and process
4. Discuss/determine criteria for scoring/ranking
5. Present issue profiles with facilitated discussion
6. Participate in scoring/ranking of each issue
7. Facilitate discussion on ranking outcomes
8. Select final priorities
9. Identify the next steps in the planning process

Suggested meeting steps, in detail: 

The initial part of the meeting should provide background in terms of purpose, the role of the group, the decision-making process, and method of scoring. Ask the group to brainstorm norms for working together (e.g., confidentiality, respecting one another's opinions, etc.) and record them somewhere that all participants can see during the meeting. Choosing priorities can be challenging, as decisions will be difficult and not everyone's preferred issue will be selected. Meeting norms can help mitigate tension or conflicts. 

The next part of the meeting will be the presentation of the issue. These are the five to ten issues up for consideration to be focus areas for the public health improvement plan. The objective of this activity is to educate the participants about the issues, provide enough background so they can score them, and have a discussion so that participants can exchange thoughts and ask questions. 

Next is the prioritization method that you have selected or designed. See step 2 of this phase for suggested prioritization methods. 

Once issues are ranked, facilitate a discussion around the activity's outcomes. Scoring and ranking are not perfect processes. As such, the group should discuss how the rankings come out. The facilitator can use questions such as the following to prompt discussion:

• Do these issues seem like they are ranked in the correct order?
• Are there any criteria (like a political will or lack of a lead agency) that may make a particular issue difficult to implement regardless of its score?
• Of the highest-ranked issues, are there any that you think are not doable, and if so, why?
• Of the lowest-ranked issues, are there any that you think are doable that should be considered?
• Who is identified as the lead agency for the top issues, and how does this affect the overall number of priorities that can be selected?
• Of the top issues, how many should be public health improvement priorities?

The final part of the meeting is selecting priorities based on the discussion of the rankings. At this point in the process, the group should be close to consensus on all or most of the issues. A voting method such as the “fist-to-five” can indicate consensus or disagreement. 

If there is disagreement among several members, facilitators can help guide discussion to move everyone towards consensus. Some questions to ask include: 

• What concerns do you have about the proposed priority areas? 
• How would you revise our decision to incorporate these concerns? 
• What could we do to make sure your concerns are reflected in the final decision? 

End your meeting by discussing the next steps of the process. The priorities will need to be developed into action plans by workgroups (explained in Phase 6 - Develop the plan). Consider what communication might need to occur with stakeholders who were not able to attend. Help the participants understand and/or determine their potential roles in future steps. Lastly, celebrate the completion of this pivotal milestone in the public health improvement process.
 

Scope

The scope of the plan will depend upon factors such as:

• The end goal(s)/additional uses for the plan 
  • Possible use cases beyond improvement planning: advocate for funding, support grant applications, engage other sectors 
• Which regional public health and community partners are involved
• The level of internal/regional capacity & skills
• Whether or not your agency is using the plan to apply for accreditation or re-accreditation

Discuss and define the "right scope" of the plan with your advisory committee so that it is usable, measurable, meets requirements, and has the potential for impact.

Planning process

A well-thought-out process will ensure that the plan's development and execution is successful. Some steps to consider include: 

1. Identify a timeline for completing the plan
   1. Consider building in extra time for revisions, leadership reviews, etc. 
2. Determine whether you will use an existing framework or develop your own (see Phase 6, Step 3)
3. Determine meeting schedule and logistics, such as location, frequency, length, agendas, communication method, etc. to complete the planning process
   1. Ensure adequate time for communication, discussion, and inclusion of stakeholders to participate 
4. If there has been a lapse between the development of the CHA and the development of the CHIP, reengage your advisory group 
   1. Estimate the amount of time that each advisory group member will need to commit to this next phase and ensure that expectations are clear
5. Review the skills and expertise of your advisory group participants and invite additional participants as needed 
   1. Determining strategies for an action plan or designing an evaluation will require specific skill sets and/or knowledge to accomplish
   2. You will want to include participants whose knowledge base and current work activities are in line with the priority areas selected in Phase 5 
6. Identify communication methods to ensure that advisory participants are kept up-to-date on processes and action items
   1. Consider how you will track progress on action items 
7. Delegate components of the plan/action items to those involved 

Determine needed resources

Just as you determined resources for the assessment, you will now determine the resources needed to develop the community health improvement plan.

Useful questions to consider:

• Are there any deadlines driving our timeline and if so, what can be accomplished in the allotted time frame?
• Is your leadership team prepared to help provide guidance, input, and investment of time and resources?
  • This may include executive leadership, office/program directors, local board of health, etc.
• How will you engage your advisory group? 
  • Consider resources relevant to meeting location, structure, and access 
  • What aspects of plan development/implementation are they committed to supporting?
• What other partners do you need to engage to help fill information gaps or gain additional community perspectives?
  • Will you need to engage subject matter experts to inform strategy development for certain priority areas?
  • Do you have staff or within the advisory committee members with evaluation skills?
    Will a variety of sectors be involved in the creation and implementation of the action plans?
  • Do you or your stakeholders have grant writing experience to apply for grants to implement priority area action plans?
• Will you use a consultant, contractor, or partner with the Colorado School of Public Health?

Ultimately, you need to ensure that you, your advisory group, and other partners have the knowledge, skills, partnerships, and resources on hand to develop and implement a public health assessment to the best of your abilities.

Begin developing the plan by gathering available resources and insights. This work will be done by a core group of stakeholders, including both your advisory committee and agency staff members.
Useful questions to consider:
What are the requirements for a local community health improvement plan (CHIP)? (See table below)
Have you reached out to current and potential partners to learn about their priorities in your county or region?
Are there specific efforts to address health inequities happening in your county or region?
What are other current local and/or regional priorities?
What are the current public health and environmental health priorities at the State level (CDPHE)?
How does this information inform your plan process?
Collect and review requirements and additional relevant materials. The following table includes recommendations to start your process. 
 

While the entire advisory group can collectively work through the plans for each priority area together, it may be a more effective use of peoples’ time, expertise, and resources to create individual work groups for each priority area. Each priority area workgroup should have a designated facilitator who can ensure alignment and continued progress between workgroups. Workgroups should generally follow the same format and process for identifying areas of improvement within each priority so that there is consistency in how goals & strategies are laid out throughout the plan. 

Breaking this process down into workgroups not only makes the work more manageable but also provides an opportunity to bring in additional subject matter experts and individuals with lived experience depending on the priority area. For example, if you have a priority area focused on substance use prevention, you will want to invite people with expertise in substance use prevention programming and/or lived experience to help guide the selection of goals, strategies, and metrics for future evaluation. 

If you invite new participants to support your priority area workgroups, make sure that they are oriented to the work that the group has done leading up to this point. It may be helpful to have an orientation meeting so that new participants are caught up on processes and progress so far.

Who should be involved

Different sectors 

• When discussing the root causes and potential capacity for addressing your priority health issue(s), identify the different stakeholders that are already involved and working in this/these area(s). 
• For example, if an issue includes transportation barriers, engage transportation entities. If an issue includes the built environment, engage those who are responsible for land use and planning. 
• Engage groups who may not be the typical players as early as possible so that you can collaborate to reduce duplicative efforts or fill gaps in services. Having sound subject matter expertise can also provide insight into aiming for policy-level solutions that have a broad base of support.

People with lived experience

• If you have not already, consider involving community advocates or organizers that can give a voice to underrepresented populations or those who can help address relevant health disparities. 
• These types of organizations can help engage communities that otherwise might not participate in public health activities, and may help tailor your strategies to appropriately fit the population.
• By having the "right people at the table" especially in the workgroups, you will all be more prepared to incorporate the strategies that address social, cultural, economic, and educational causes of priority health issues.

Responsibilities of workgroups

1. The priority area workgroup(s) will help ensure that the plan focuses on health inequities by working together to identify the root, systems-level causes contributing to an issue.
2. They will be responsible for collecting any additional data and research necessary to make decisions about goals and strategies. 
3. They will use this information to develop an action plan (Step 5) for meeting priority area goals. 
4. They can also provide local knowledge about how to communicate and promote the action plans. 
5. They may contribute to developing an evaluation plan or support ongoing data collection for evaluation.
6. Finally, they may potentially serve as partners in implementation (Phase 7). 

Use this step to develop goals, strategies, and action plans for each priority area. The main part of the community health improvement plan will be the priority area action plan(s). An action plan is where priority area workgroups document how the agency and partners are going to address the priority issue, including when, how, by how much, and by whom.

Action plans are multi-purpose tools that will be used to guide implementation, support accountability, and enable you and your partners to review and revise the plan. They can also serve as a communication tool and aid in monitoring and evaluation. Throughout this phase, look for ways that you can adapt these recommendations to support your planning process and to develop efficient and effective plans that are feasible to implement.

Tips for identifying goals, strategies, and actions 

The first thing that you should do is identify an overarching goal for the priority area. For example, many agencies have a priority area of substance use. That is a very broad topic. Use your CHA to identify where the specific need is in your community. Should your focus be on preventing or delaying youth substance use? Do you want to focus on one specific substance or all substances? Is the issue actually increasing access to substance use treatment and resources? You can have more than one goal for your priority area. Clear goals will help drive strategy selection.

Next, keeping the overall plan goal, scope, and capacity in mind, take an adequate amount of time to research, identify and discuss strategies. This is a time to think about strategies that you are already implementing within your agency or community and how well they are working. It is also a good time to look for creative, innovative solutions that address the root causes of public health and environmental health issues.

Depending on your process, you can choose a formal strategy identification method (see NACCHO’s Guide to Prioritization Techniques) or decide through group discussion. Here are some criteria to discuss in selecting strategies:

• Likelihood of population impact
• Capacity to implement
• Impact on health disparities and inequities
• Community assets and resources
• Ability to measure change
• Ability to evaluate for process improvement and/or impact
• Political/community support
• Policy level strategies exist

Helpful planning tools and frameworks

There are many tools and frameworks that can be used to help guide you through this process. You can mix and match the following resources, create adapted versions to fit your needs, or come up with your own process, as long as you are leaving with clearly defined goals and strategies for each of your identified priority areas. See below for some recommendations: 

Logic models

A logic model is a helpful tool for big-picture thinking. Creating a logic model for each priority area will allow you to think critically about the interventions (strategies) you’d like to implement, the changes that you hope to see as a result of those strategies, and the resources that will be needed to accomplish the work. 

Logic model templates & guidance: 

• Learn more about logic models from the University of Wisconsin-Madison 
• CHAPS Logic Model template and guidance  

A logic model is also a valuable activity and product to use to communicate progress and evaluate impact (Phase 7).

Results-Based Accountability Framework 

The results-based accountability (RBA) framework is a data-based approach to problem solving and is a good tool for moving group decision making from goals to strategies to evaluation. It can easily be adapted to fit the needs and timeline of the agency. RBA starts with “ends” (your CHIP goals) and works backward, towards “means” (strategies), or how you will reach the goal.

The Civic Canopy in Colorado has created a facilitation guide for those wanting to implement RBA in their agency. It is available in both English and Spanish.

• “Turn the Curve” Facilitation guide for using RBA to move from goals to action

Action Plan Templates 

An action plan is helpful to clearly spell out, step by step, how a group will accomplish its objectives. Action steps should be developed for each strategy or intervention that you’ve identified and should clearly define the timeline and person responsible for each action. A helpful method to use to start filling out an action plan is to develop SMART objectives, or objectives that are Specific, Measurable, Achievable, Relevant, and Time-limited. 

• CHAPS Action Plan Template 1 (Google Document)
• CHAPS Action Plan Template 2 (Google Spreadsheet)

You can use the templates above or create your own. You can also include additional fields as necessary to support the feasibility of the action plan and to clearly communicate how you will address the priority issue. There are many different types of guidance around action planning. This is an important process, so build plans that work well for you and your partners.

Additional Considerations

Health Equity 

This is the time to address upstream, social influencers of health. Invest time and resources into identifying equity-specific strategies for the plan. Refer back to the equity and engagement assessment tools recommended in Phase 2. 

You can also start by asking your advisory committee important questions such as the following set included in the 2019 State Assessment and Planning process from the Office of Health Equity:

• Could the efforts burden traditionally underserved communities?
• How will this proposed strategy benefit traditionally underserved communities?
• Will affected communities have decision-making power in the decision-making process?
• How are affected communities involved in defining success?
• Are there mechanisms in place for affected communities to hold decision-makers accountable?

To further illustrate how chosen strategies are addressing root causes, social determinants, and influences on population health and environmental health, consider using a tool such as the NACCHO Community Health Improvement Matrix. It overlaps a strategy identification process with the socio-ecological model to visualize different levels of strategy intervention. 

Evidence-Based Strategies 

It is important to ensure that the strategies you are implementing throughout the course of the CHIP are evidence-based. The following resources can help you dig into the evidence-base behind certain strategies that you might be interested in implementing: 

• Public Health Digital Library, NIH 
  • All LPHA staff have free access to the PHDL through OPHP! Learn more about how to access the library here.
• The Community Guide, CDC
• What Works for Health, County Health Rankings and Roadmaps 
• Evidence-based Resources, Healthy People 2030

Here are additional topic-specific resources developed by CDPHE programs for evidence-based strategy identification:

• CDPHE Community Organizing for Prevention - View the “Menu of Proven Systems Change Strategies” for information on evidence-based shared risk and protective factor approaches to preventing substance misuse.
• CDPHE Oral Health Resources for CHIPs - This resource was curated for LPHAs interested in incorporating oral health into their CHIP. It is a unique health issue with strategies that can have cross-cutting impacts.

“Effective community health improvement plans should not be stagnant, but dynamic to reflect the evolving needs of the population served. Health departments should continuously work with multi-sector partnerships to evaluate and improve the community health improvement plan.” - Public Health Accreditation Board, Standards & Measures, Version 2022. 

Preparing for Monitoring and evaluation 

Monitoring and evaluation are important components of an assessment and planning cycle. Monitoring and evaluating progress in each of your priority areas provide you with a starting point for understanding which strategies are working and which strategies are not working or need to be adjusted. 

Ultimately, ongoing evaluation should answer the question, "Did we do what we said we were going to do?" Some resources for learning more about evaluation processes and best practices are listed below:

• Evaluate actions, County Health Rankings and Roadmaps Action Center
• Measuring Success: Evaluating Comprehensive Community Initiatives, KU Community Toolbox

During Phase 6, you should be thinking about what aspects of your action plan you’ll want to measure over the course of the cycle. One necessary component of this will be selecting “indicators” for each goal, which are measurable factors and health outcomes that you can track over time. Generally, there are two types of indicators that you can select. Both are helpful in their own ways:

Tips for selecting indicators: 

Ask yourself the following questions when considering potential indicators for use:

1. Who will collect and report the data?
2. How often is data updated and from what sources? 
3. Are there any threats to future availability of the data? (i.e. a question being removed from a survey.)
4. If this data is not already being collected, what resources will you need in order to collect it? (Time, staff, money, etc.)
5. If the exact data you’re wanting does not exist, is there a good proxy measure that you could use? 

Ongoing revision

A CHIP is not useful to your agency if it just “sits on the shelf.” Create a process to keep your action plans accountable, current, and responsive to internal and external factors. Use this process to monitor action plans on an ongoing basis to improve and revise them as progress is made and changes occur.

A process should include guidelines for how changes will be tracked, when and how often, who will be responsible, and when and how revisions will be made. The following are some questions to consider when developing your monitoring and revision process.

• What type of monitoring system will be used to track progress? Some options include a spreadsheet, database, dashboards, or scorecards.
• How often will the monitoring system be updated?
• Are there adequate resources to complete data collection and analysis?
• Will the monitoring plan answer useful evaluation questions that can inform process or strategy improvement?
• How will stakeholders access action plan status?

If revisions need to be made...

• What are the criteria for action plan revision?
  • Will it be based on quantitative or qualitative data sources?
  • Will it be influenced by state or national scale changes (e.g., CDPHE state health improvement plan, Healthy People 2030)
  • What is the time frame?
  • Who will need to approve?
• What will you change?
  • Objectives: Actual aim, or just the number you were trying to reach?
  • Strategies: If what you are doing is not working, how will you change it?
  • Indicators: Will you change the indicator if you realize that it is not measuring your objective or the indicator is not suitable?
     

Format and Components

Most agencies develop their CHIP as a written report. While this is the most common way of reporting the CHIP, it is not required that you do it this way. It is also up to you whether the CHA and CHIP are presented as two separate documents or if you combine the assessment and plan into one report. 

Consider what formats are most likely to be used by the intended audience. For internal stakeholders, this includes what formats can allow you to easily revise and update the action steps in years two to five, as needed. For example, your final plan can be developed as a slideshow, website, or whatever other format works best for your agency and your community. 

Regardless of the format(s) you choose, be consistent and systematic with documenting the processes, methods, and data sources. This will make it easier to monitor, refresh, evaluate, and replicate your assessment and plan.

In any format, there are certain standard components that you will want to consider including in the final CHIP:

• Letter from the Director 
• Introduction and orientation to the purpose and content of your plan
• A description of how stakeholders were involved in plan development
• A description of your jurisdiction: community profile, important demographic or geographic context, community vision, and values
• Results from your capacity assessment (if not already included in the CHA)
• A description of the process used to determine priorities
  • Include how community members and stakeholders influenced priority area selection 
• A summary of your CHIP priority areas, including why these were chosen and how your plan aligns with the state priorities.
• For each individual priority area, include:
  • Data indicators and trends
  • Equity considerations 
  • Goals and objectives
  • Improvement strategies
  • Action steps, including the lead agency/partner
  • Measurable indicators & evaluation plan 
• Financial resources available/needed
• A description of the plan for monitoring and evaluation
• Acknowledgments
• Local board of health approval
• Notes on how/where stakeholders can access information

LPHAs or partnerships that have not developed separate community health assessment reports are encouraged to include health assessment data in the CHIP. At a minimum, assessment data should be included in the summary of priority areas.

Notes on Accessibility

Develop final products that are accessible and trackable by your partners. This will ensure transparency in your process and make it easier for your advisory group and any additional stakeholders to contribute to monitoring and evaluating the plan. 

Since most content is available and posted online, you will also want to ensure that your final product(s) comply with Colorado’s digital accessibility laws. 

The Colorado Public Health Act requires that the local CHIP be submitted to both the local board of health and the state Board of Health. Ideally, you will have engaged your local board of health (LBOH) throughout the CHAPS process, allowing them to provide feedback and direction and to be advocates for potential priority areas that have been identified in your community health improvement plan.

The following Local Board of Health Approval Guide & Fillable Form provides more detail on acceptable methods of documentation for board of health approval. The second page of this form is a fillable template that you may use to provide proof of LBOH approval. Just click the "download" button in the top right for a fillable PDF version of the form. 

If you are submitting a plan as a partnership, the local board of health for each LPHA in the partnership will need to approve the plan individually. 

Upon review and approval from the BOH:

• Post on your agency and/or partnership website
• Submit your completed community health improvement plan and website link to OPHP via the CHIP Submission Google Form
• If you have any questions about submitting your plan online, contact us at ophp@state.co.us

OPHP presents regular updates to the State Board of Health regarding the status and current trends among local CHIPs. The Office also analyzes and summarizes local CHIPs to inform the state health improvement plan (SHIP) and to share with other local public health agencies, CDPHE programs, and other stakeholders.

Submit your CHIP to OPHP here

Who is responsible?

Determine the entity(ies) responsible for ensuring that the CHAPS process stays on track. Most likely, this will be the health department. 

Within the health department, or other lead entity, designate one or two people, such as the Public Health Planner or Executive Director, who will be responsible for the overarching coordination required to ensure that the plan is being implemented. This may or may not be the same person who is doing the implementation.

Responsibilities of this person/people include: implementing the action plan(s) as well as continuing to coordinate the overall process, including monitoring, evaluation, and communication. Other options to accomplish this include re-directing the role and responsibilities of the advisory committee, designating priority area leads, or empower the internal agency staff to lead and coordinate accordingly with partners. Regardless of who is responsible, changes should be made in partnership with stakeholders through an agreed-upon process.

Questions to consider:

• Is there anyone missing from the advisory group with either content area knowledge or expertise in evaluation?
• What are your expectations from the leaders of the committees in terms of commitment and coordination?
• What kind of agreement would be most helpful in solidifying participation or financial commitment from partners? (e.g. MOU, IGA, contract, informal agreement)
• Are agency, community, and partnership members represented equitably?
• What are the expected outputs from implementation, evaluation, and monitoring activities? (e.g., evaluation plan, reports, etc.)
• What measures or processes will you put in place to ensure accountability and monitor the progress of the plan?

Implementation teams

A helpful way to keep plans on track is by developing Implementation Teams for each priority area. These should include the individuals responsible for implementing that priority’s strategies. Most likely, this will primarily be the LPHA staff responsible for the corresponding program. (I.e. Substance Use Prevention Program staff who are implementing components of the CHIP’s Behavioral Health priority.) The Implementation Team may also include representatives from other agencies who have a role in plan implementation, such as a local harm reduction organization or hospital partner. 

Implementation teams should meet regularly to discuss progress, including any potential barriers or challenges to implementing the work.

“Effective community health improvement plans should not be stagnant, but dynamic to reflect the evolving needs of the population served. Health departments should continuously work with multi-sector partnerships to evaluate and improve the community health improvement plan.”  - PHAB Standards and Measures, Version 2022.

As you dive into the work outlined in your action plans, you will need to monitor and revise the content of your action plans at regular intervals. Use the process you developed in Phase 6, Step 5 to keep your action plans accountable, current and responsive to internal and external factors.

Updates will need to be made whenever an objective is completed, a new priority is identified, or a change in circumstances affects previous planning. You may also want to adjust strategies if you find, through your evaluation efforts, that progress is not being made. Changes should be made in partnership with stakeholders through an agreed-upon process.

At least annually, review and make any necessary enhancements to your action plan(s) to ensure:

• Strategies and action plans mirror the actual work being done
• Adaptations are made based on action plan revisions and evaluation results
• Realistic and measurable objectives are related to each strategy
• Responsible individuals/organizations are identified as leads
• Appropriate people and organizations are included for each strategy. If they are not already participating, make plans to recruit them.
• Realistic timelines are set for each strategy
• Necessary and available resources have been identified

It can be challenging to keep stakeholders and partners engaged in the implementation of the plan. Involving a broad array of partners in specific monitoring activities helps sustain their participation and the overall momentum of the process. 

Monitoring and evaluation efforts also can be used to:

• Improve program effectiveness
• Strengthen funding applications
• Increase political support
• Engage community residents
• Improve future assessment and planning processes
• Celebrate your successes!

Evaluation design and resources

Based on what questions you need to answer, determine the optimal type of evaluation. Some communities choose to establish a subcommittee to oversee the evaluation activities, which can be helpful. Tap into staff and stakeholder expertise around evaluation to help guide your process. The process should help you answer the following questions within each area you have chosen to evaluate:

• Did we achieve the goals we set out to?
• What were the impacts of the plan?
• Was there an equity impact?
• What do stakeholders want to know?
• What went well?
• What were the challenges?
• What improvements should we make and how?

You can also check out the following resources for more information on evaluating programs and processes:

• Evaluate actions, County Health Rankings and Roadmaps Action Center
• Measuring Success: Evaluating Comprehensive Community Initiatives, Community Toolbox
• Program Evaluation for Public Health Programs: A Self-Study Guide, CDC

What can you evaluate?

Amongst the advisory group, determine what you would like to evaluate. Two types of evaluation that are recommended in this section. The first is an outcome evaluation, focused on the health outcomes achieved by implementing the plan. The second is a process evaluation, focused on understanding and refining the CHAPS process itself. 

Keep in mind that you do not need to evaluate everything. Choose the most meaningful activities, inputs, outputs, and products of your process and invest time and resources in collecting the data you need to monitor and evaluate them. 

Evaluating the plan’s overall success (end of the cycle)

During the development of the public health improvement plan (Phase 6), you and the advisory group will have outlined potential areas to evaluate, such as:

• Goals and objectives determined in the action plan(s)
• Process or outcome measures/indicators identified in the action plan(s)
• Implementation of strategies (intended and unintended outcomes)

You should already have been doing this work at regular intervals throughout the five year cycle. By the end of the cycle, you will have plenty of information available to you to determine whether or not you have been “successful” in reaching the goals and objectives that your plan set out to achieve.

Use the results 

A final evaluation will allow you to call out areas of success, celebrate these wins and share them with your partners and stakeholders. A final evaluation will also bring to light areas where less progress has been made and can help guide dialogue around why that was. Were there changes in circumstances, resources, etc. that made the goals difficult to reach? Are there changes that should be considered for the next cycle if the same priority area is selected again? Was the indicator that you selected not as helpful as you thought it would be for measuring progress? These are all great questions that an evaluation can get you thinking about. 

Evaluating the CHAPS process 

While you have been continually monitoring your CHIP through the “Monitoring and Revision” steps outlined above and in Phase 6, Step 5, it is also important to evaluate the CHAPS process itself. An ideal time to evaluate CHAPS is in year five, as you are wrapping up one cycle and preparing for the next.

Striving for continuous improvement is a public health best practice, and evaluation of an assessment and planning process is a powerful method to apply it. Including evaluation into your CHAPS process will open up opportunities for further investment in quality improvement, performance management, and strategic planning. Although these are not requirements of the 2008 Colorado Public Health Act, they are key requirements of the PHAB accreditation process and are meant to improve public health programs, policies, processes, and interventions.

Key areas of the process to evaluate: 

• Community engagement throughout the process - from data collection through implementation (satisfaction, inclusivity, quality, reach, etc.)
• Partnership engagement throughout the process (satisfaction, inclusivity, geography, sectors, quality, reach, etc.)
• Public health improvement planning process
• Capacity to address health inequities
• Communication methods and reach

Use the results

Results from your evaluation of the overall CHAPS process can add value the next time you start the cycle. Evaluation results that demonstrate the impact of your improvement plan can be useful in revising action plans and communicating progress. This process can also support documenting what went well and what could be improved the next go-around.

By this point in your process, you should have already communicated the results of your Community Health Assessment as well as the priorities and strategies for your Community Health Improvement Plan to your stakeholders and community members. 
Your communication plan should also include steps for reporting on your progress and/or process to the community. Build off of your work in Phase 6 (Step 7: Share the plan with the community).

Consider the narrative

The community health improvement plan provides an opportunity to choose how you describe public health issues in new ways that connect social, environmental, political, and economic inequities to public and environmental health. This is especially important as Colorado's public health system moves towards addressing issues that are considered upstream or root causes to your communities' health and environmental issues. Think critically and creatively about the story that your assessment and plan is telling. Use the implementation phase to change the narrative around complex health issues, to advance equity, and to address social determinants of health.

Recommended communication resources:

• FrameWorks Institute communication recommendations
• County Health Rankings & Roadmaps communication guidance and tools
   

Communicate progress and evaluation results

The key messages that you share should include findings and lessons learned from your monitoring and evaluation activities. These can be interim findings and preliminary interpretations regarding improvements, since outcomes may take time to occur. These talking points will be valuable when communicating to those who have funded or contributed resources to the process. Likewise, these messages will be important to share with your stakeholders to demonstrate how their contributions - time, perspective, connections, resources - have made a difference.

There are a number of ways to share progress and findings throughout the five years. See the section below titled “Communication as community engagement” for ideas on communications methods and products. Choose one that your agency has the capacity to develop and maintain over the course of the five year cycle. 

Communicating change

Depending on your priorities, strategies, and stakeholders involved, you may have a degree of change that you need to communicate. These plans may represent doing things differently, addressing chronic issues in new ways, and involve new and different partners. Lean on change management principles and tools to further hone your communication efforts to ensure that you are meeting your audiences where they are.

Communication as community engagement

When and how you choose to do this can create two-way conversations. To do this, tailor your message and method depending on your audience and purpose. Differentiate between internal and external communication, and develop products that are appropriate and useful for each audience and communication platform (email, website, social media, presentation, etc.) including:

• Data dashboard
• Agency/partnership/partner website(s)
• Video
• Infographic
• Fact sheets
• Report
• Executive summary of key findings
• PDF for print as needed and electronic dissemination
• PowerPoint slides
• Hard copy, bound publication
• Newsletter
• Webinar
• Hybrid, a mixture of some or all of the above

Use frequent, ongoing, and creative communication approaches to celebrate successes and recognize the hard work of participants and the efforts of the community. This is a multi-year project that you and your stakeholders will have endured together.

Celebrate your wins! 

Use frequent, ongoing, and creative communication approaches to celebrate successes and recognize the hard work of participants and the efforts of the community. This is a multi-year project that you and your stakeholders will have endured together.

Use OPHP networking calls and peer-learning opportunities to share out your local public health improvement process, progress, and impact. CHAPS is co-developed and sustained by local and state public health practitioners.

Share with CHAPS users

• Make sure you’ve submitted your final plan to OPHP! The State uses information in local plans to inform community needs and programming at the state level, including for the State Health Assessment & State Health Improvement Plan 
• Join OPHP’s bi-monthly Public Health Planner networking calls and share your progress, findings, successes, and challenges with peers. It’s also a great place to learn from other agencies that are currently working on CHAPS. Reach out to us at ophp@state.co.us for Public Health Planner call registration information. 
• Reach out to OPHP directly with CHIP progress reports. This is optional but OPHP is interested in receiving updated plans, including action plans, evaluation plans, communication plans and other related materials, to continuously improve Colorado's assessment and planning efforts and to share models with other agencies.

Share with the public health system

Collaborate and network with other counties and partners on implementation efforts by sharing promising practices, collaborating on joint efforts, providing peer support, and networking. OPHP sponsors networking opportunities such as conference calls, webinars, and in-person meetings on a variety of topics. Subscribe to the OPHP newsletter to stay up-to-date on upcoming opportunities. 

Stay connected & continually partner 

The Public Health Act of 2008 also requires CDPHE to develop a state health improvement plan (SHIP) every five years. Similar to local plans, the state plan is based on a comprehensive state health assessment (SHA), requires community engagement, and is used to set priorities and strategies for the public health system.

The act identifies the need to incorporate, to the extent possible, goals and priorities of public health improvement plans developed by county or district public health agencies. It also requires plans to address how local public health agencies coordinate with CDPHE and others to accomplish goals identified in the SHIP. The Public Health Accreditation Board also requires alignment between the state health improvement plan and tribal, local, and national priorities as does Healthy People 2030.

Through CHAPS, local and state public health assessments, improvement plans, and implementation efforts can be coordinated to

• share data collection (qualitative and quantitative) results
• reduce burden of data collection on targeted communities
• inform each other's prioritization processes
• identify and elevate shared priority areas
• share and scale strategies to greater impact
• partner in the implementation of local and state plans, especially when strategies involve a variety of stakeholder levels
• inform monitoring and evaluation efforts to assess the effectiveness and impact of local and state processes

See Phase 1: Plan the Process and Phase 2: Equity and Community Engagement for more information and ideas on partnership and collaboration throughout the CHAPS process. 

Align local and state priorities

The priorities and objectives outlined in the state plan are intended to provide support, guidance, and focus for public health activities throughout the state. This coordinated state and local process enables enhanced management of resources, increased readiness for public health agency accreditation, and a more efficient approach to improving health outcomes.

Often, many of the state priorities are similar to and in alignment with priorities seen across local improvement plans. You can look to the state health assessment & improvement plan for ideas on programming and strategies as well as available data and resources for certain priority areas. 

State Assessment and Planning

Stay connected with OPHP to learn more about opportunities to participate in Statewide Assessment & Planning. Every five years, there are opportunities to participate on the advisory committee for the SHA & SHIP. Information on upcoming planning cycles and opportunities for engagement can be found on the State Assessment and Planning website.