Tri-County Health Department
The Metro Denver Partnership for Health
The Metro Denver Partnership for Health (Partnership) is led by the public health agencies serving the seven-county Denver metropolitan region. These counties are Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas and Jefferson. The Partnership, initiated in 2012 and formalized in 2015, collaborates regionally on shared public health priorities.
The Partnership also works with regional leaders in health care, human services, behavioral health, environment, philanthropy, education, business, local government and others to achieve its goals of advancing health equity across the region.
The Metro Denver Partnership for Health (Partnership) is led by the six Local Health Departments (LHDs) serving the seven-county Denver metropolitan region which includes Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas and Jefferson counties. Participating LHDs include Boulder County Public Health, Broomfield County Department of Health and Human Services, Denver Environmental Health, Denver Public Health, Jefferson County Public Health, and Tri-County Health Department.
Public health issue:
Public health issues such as air quality, health inequities, tobacco prevention, obesity, behavioral health, and infectious diseases transcend jurisdictional boundaries. Many public health partners, including health care systems, are regional entities, already working across county boundaries. A regional approach to improving population health makes efficient use of resources by collaborating on common and shared priorities.
Partnership goals and objectives:
1. Create a formal structure to organize collaboration among six LHDs in the seven-county Denver Metro region
2. Develop priority focus areas and identify opportunities to support action in each area.
3. Enhance a culture of collaboration among program leadership in each LHD.
The Partnership also identified goals and objectives in four priority areas for 2015-16:
1. Data sharing
2. Behavioral health
3. Healthy eating active living (HEAL)
4. Partner alignment.
In addition to these four priorities, formal collaboration has been initiated in the areas of radon reduction, promoting health equity, and promotion of early childhood protective factors and reduction of risk factors.
The Partnership was implemented through a series of strategic planning meetings in 2015-2016 facilitated by the Colorado Health Institute, a non-profit health policy research organization and supported by the Office of Planning, Partnerships and Improvement at the Colorado Department of Public Health and the Environment (CDPHE). The directors reviewed models of collaboration in other jurisdictions and met with leaders in health care, higher education, human services and community-based health alliances to discuss their proposed collaboration.
A formal Roadmap outlining the Partnership's structure, goals and activities was prepared in February 2016. The directors and the senior staff from each public health agency convened in May 2016 to discuss the Vision of the Roadmap and identify strategic opportunities for further partnership.
Work groups were established for each of the four priority areas to carry out shared activities.
The Partnership developed a framework for addressing shared priority health issues regionally resulting in three grants to support their work.
1. Data sharing. A two-year, $1.9 million award from the Colorado Health Foundation (CHF) to increase access to the Colorado Health Observation Regional Data Service (CHORDS). CHORDS is a network that uses electronic health record data to support public health evaluation and monitoring.
2. Behavioral health. A three-year federal grant through Colorado's State Innovation Model (SIM) with funds from the Center for Medicaid and Medicare Innovation to address behavioral health (estimated annual award $500,000).
3. HEAL. A three-year, $ 3 million grant from the CDPHE to reduce obesity and chronic diseases across the region.
The fourth priority, partner alignment, has not received grant funding, although our collaborative team has successfully worked with the region's largest not-for-profit hospital system, Centura Health, to inform development of the current cycle of their Community Health Needs Assessments (CHNAs).
The Partnership also secured a CDPHE grant to develop and promote policies to reduce radon exposures across the region.
The Partnership has been successful based on several factors. The LHDs have committed leadership at the highest levels to participate and to develop strong, collaborative relationships with one another. The Partnership was built on an existing track record of informal collaboration over the years. The LHDs all share priorities HEAL and behavioral health as identified in their respective Public Health Improvement Plans (PHIPs).
Public health impacts of practice:
The Partnership is an efficient use of limited resources, extending the reach of public health interventions by increasing available investments.
The Partnership does not yet have a dedicated website; however, LHD members are in the process of including the Roadmap on their individual websites, now completed for Tri-County Health Department (http://www.tchd.org/517/Agency-Planning-Efforts) and Denver Public Health.
Multiple issues and conditions impact the public's health. They cannot be improved by one public health agency or a single health care agency. Change requires effective, mutual partnerships that align efforts to improve public health collectively. Effective regional collaboration needs to be broad-based, involving multiple sectors. The Partnership is a first step in this process, by aligning our LHDs so we can approach other partners (health care, housing and human services, education, business, foundations) in a cohesive, strategic way.
Nearly 3 million people, approximately 57% of Colorado's population, reside in the region's seven counties which includes Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas and Jefferson counties.
Colorado's racial and ethnic make-up is mirrored in the seven-county region, with nearly six percent of residents being African American, around two percent Native American, over four percent Asian, and more than 20 percent Hispanic. Over 10 percent of residents in the region are foreign-born, and there are over 100 languages spoken by students in some of the school districts within the region.
The percentage of residents in the region with incomes below the Federal Poverty Level ranges from four percent in Douglas County to 19 percent in Denver County; however, in some census tracts within the region, over 60 percent of families live in poverty.
What has been done in the past:
Our LHDs have collaborated for years but on an ad hoc basis when an opportunity arose (e.g., regional TB control). However, collaboration among the LHDs across the region was not a defaultâ€ consideration. More commonly, our LHDs worked separately, competing for resources to improve the health of our communities, which often resulted in developing duplicative systems and programs that included siloed efforts to engage community partners (eg, health care systems).
Why the Partnership is better:
The U.S. Department of Health and Human Services' Public Health 3.0 (https://www.healthypeople.gov/sites/default/files/Public-Health-3.0-White-Paper.pdf) calls on public health departments to form vibrant, structured, cross-sector partnershipsâ€ and to foster shared funding, services, governance and collective actionâ€. As a tangible example. some of our LHDs would not have been successful in securing funds on their own. It was because of the Partnership, its reach, and the anticipated health impacts from a coordinated regional strategy that yielded success in securing and sharing resources.
Partnership as innovation:
The Partnership is an innovative, cross-jurisdictional effort in Colorado that impacts the health and well-being of over half of the Colorado population. Two other public health partnerships have been formed in Colorado to address rural needs and LHD capacity. Our Metro Denver Partnership is unique in that it covers an area where individual LHD capacity is already at a high level and the incentive to collaborate is based on expectations of enhanced synergy and regional impact..
Guided by the lessons learned and resources available from the Center for Shared Public Health Services, the Partnership's efforts cut across the spectrum of cross-jurisdictional sharing arrangements (http://phsharing.org/what-we-do). Each public health agency is autonomous, responsible for its own jurisdiction, while also working together. The Partnership follows an informal governance structure, using the principles laid out in the Roadmap to guide efforts.
The Partnership's evidence-basis:
Collaborative frameworks such as that embodied in the Partnership are not based on formally collated evidence. They are, however, endorsed in multiple influential documents developed over the past several years. These include broad approaches such as Kania and Kramer's Collective Impact model (2011) (https://ssir.org/images/articles/2011_WI_Feature_Kania.pdf). This concept is at the core of the notion of LHDs serving as Chief Community Health Strategists (Resolve, 2014) (http://www.resolv.org/site-healthleadershipforum/files/2014/05/The-High-Achieving-Governmental-Health-Department-as-the-Chief-Health-Strategist-by-2020-Final1.pdf). NACCHO endorsed this concept in a Statement of Policy (http://www.naccho.org/uploads/downloadable-resources/15-11-LHD-as-Community-Chief-Health-Strategist.pdf)and it was also incorporated into the Public Health 3.0 framework.
Nutrition, Physical Activity, and Obesity
Partnership goals and objectives:
The Partnership's mission is to improve population health regionally with collective action. We have identified four areas of common purpose to prioritize for regional work
1. Data sharing. The Partnership's goals are to use, share and analyze cross-jurisdictional data and to gain access to a local resource that uses electronic health records for public health surveillance (CHORDS).
2. Healthy eating active living (HEAL). The Partnership's goals and objectives include reducing consumption of sugar-sweetened beverages, identify data sources to inform efforts and engage non-profit hospitals in promoting HEAL.
3. Behavioral health. The Partnership is targeting stigma reduction and improved coordination between systems of care and prevention of behavioral health issues.
4. Partner alignment. The Partnership set goals for meaningfully engaging the region's non-profit health systems in conducting CHNAs and health improvement activities.
Steps taken to implement the Partnership:
The directors contracted with an external partner (Colorado Health Institute, a non-profit health policy research organization) to conduct a facilitated process for assessing whether a more formal collaborative structure between the six public health agencies in the metro Denver region was needed. The process included four planning meetings and was finalized with a document outlining our process and priority areas of focused collaboration (Metro Denver Partnership for Health Roadmap [http://www.tchd.org/517/Agency-Planning-Efforts]).
While developing the collaborative framework, the LHDs identified opportunities for collective efforts in the four areas of priority focus. These opportunities included grant writing to secure funding as well as supporting the region's non-profit hospitals develop CHNAs. The Colorado Health Institute also provided administrative support for scheduling meetings, notes and follow up activities that resulted from planning meetings.
The Executive Directors of our collaborating LHDs began quarterly information sharing meetings in 2012. When we recognized the possible synergies among our independently developed Public Health Improvement Plans in 2014, we decided to explore a path toward a more formal framework of collaboration.
Facilitated planning meetings were held during 2015-2016. An initial version of the Roadmap was finalized in February 2016. The LHD's senior staff and directors convened in May 2016 to review Roadmap, discuss shared priorities and establish the vision for collaboration as a default approach among our LHDs.
Work groups that address the four priority areas meet monthly or as needed to accomplish goals and objectives and provide formal updates to the Partnership directors during conference calls or bimonthly meetings.
The directors hold standing bimonthly meetings and schedule phone calls between meetings as needed. Ongoing bimonthly meetings provide opportunities to consider new areas of collaborative focus. Recent examples from the fall of 2016 include the creation of a new Health Equity workgroup and consideration of a regional approach to developing LHD Community Health Assessments.
Stakeholder Involvement and Roles:
Colorado Health Institute conducted key informant interviews with community partners and jurisdictions already collaborating regionally to explore the successes and challenges of current collaborative efforts; identify and prioritize activities and issues for regional action; assess interest in varying levels and models of collaboration; and consider opportunities for regional public health collaboration and leadership. Stakeholders who participated in these interviews included representatives of local health alliances, human services, behavioral health, academia, state organizations (Department of Health Care Policy and Finance, Department of Human Services, Colorado Department of Public Health & Environment) and health care providers.
Partnership directors met with senior leadership from local non-profit health care systems to discuss how they can continue to partner and work together with community agencies and LHDs.
Fostering collaboration with community stakeholders:
The Partnership is oriented around and rooted in collaborative efforts. It places public health collaboration at its core, with members serving as Chief Health Strategists for the region.
The Partnership is providing a foundation for expanding beyond public health to include relevant partners â€“ human services, health care, behavioral health, business, philanthropy, education â€“ to engage on priority initiatives.
The Partnership secured funding awards in 2015-16 to work together regionally on a broad range of topics, including radon exposure prevention, early childhood toxic stress, obesity prevention, behavioral health and data sharing. The last three grants support the Partnership's priority areas, facilitating relationship-building activities with organizations and partners throughout the region including behavioral health providers, health care providers and community organizations, providing opportunities for addressing another Partnership priority around partner alignment.
Directors have shared the Roadmap with leaders in Colorado's health care partners, philanthropy community and state agency directors for Medicaid, public health and human services, with a goal of soliciting feedback on how they can be engaged in Partnership work and how the Partnership can support their efforts.
Partnership start-up or in-kind costs and funding services:
Funding to support LHD implementation of Public Health Improvement Planning has been provided to the Partnership by the CDPHE Office of Planning, Partnerships and Improvement. The substantial overlap between the LHDs' PHIPs identified in 2014 led to formalizing the Partnership's development.
Substantial in-kind funding was provided by each LHD through the involvement of their Executive Directors in developing the Partnership and establishing the four priority areas of focus. Significant additional in-kind funding was provided to staff working in each priority area prior to the grant funding for the first 3 areas. In-kind funding of staff involved in hospital partnerships has been ongoing for two years.
What was learned?
The Partnership is a work in progress and like any collaborative effort, our members are learning along the way. Key lessons learned to date include:
Collaboration takes vision and leadership effort by top LHD executives.
A compelling vision and supportive leadership can inspire staff.
There is no free lunch. Collaboration takes time and effort and requires administrative capacity, which is currently supported with resources provided by CDPHE and provided by the Colorado Health Institute.
LHDs can be more impactful on specific priority areas of focus and in creating momentum for our work as chief community health strategists by working together.
Regional collaboration is perceived as an efficient and important orientation among targeted funders.
The Partnership's progress to date on stated goals is described below.
1. Establish a formal structure of collaboration.
The Partnership Roadmap outlined a process for working together and created a structure for considering new collaborative efforts. Of note, while trusting relationships among the directors was important in initiating the Partnership, there have already been two changes in leadership among the six LHDs with no diminution of our collaborative energy.
2. Identify priority areas of focus and resources to support action in each area.
The Partnership identified a manageable number of important priority areasâ€” Data sharing, Behavioral health, HEAL, and Partnership alignmentâ€”and has secured external grant funding for the first three from state, federal, and foundation sources. In addition, possible support or aligned collaborative effort by not-for-profit hospitals in Behavioral health or HEAL seems likely.
3. Enhance a culture of collaboration among program leadership in our LHDs.
Creating culture change takes time but programs across a range of health topics (tobacco prevention, immunization, radon policy development, health equity, early childhood development, air quality) are beginning to spontaneously seek opportunities to work together and to gain endorsement by the Partnership. The Partnership's vision that collaboration not competition should be our default approachâ€ is moving along faster than almost any of the LHD directors anticipated.
Key milestones of progress in the Partnership's four priority areas are described below.
1. Data sharing
A Colorado Health Foundation grant to expand access to CHORDS among Partnership members was written in 2015 and awarded in 2016. LHDs are currently signing data use agreements with CHORDS data partners and will complete user training by the end of 2016. A work group has also identified an internet-based common work space to share regional data and is developing its uses and functions.
2. Behavioral health
The Partnership received funding through the State Innovation Model (SIM) grant to collaborate with community partners, businesses, and other organizations in the development of a common messaging campaign designed to reduce stigma around mental and behavioral health so that people and providers will know that it's ok for those who need treatment to seek it. The team is working with these partners to develop a messaging campaign for the region.
The Partnership secured a three year, $3 million award from the CDPHE through the Cancer, Cardiovascular and Pulmonary Disease Grants Program to reduce obesity and chronic diseases in seven counties in the Denver metropolitan area. It created the Healthy Beverage Partnership (HBP), a regional effort made up of the Partnership's LHDs. Each county is facilitating local coalitions to engage the greater community in this effort to improve dietary habits and shift norms. The HBP coordinates with 11 local coalitions, which all contribute to a regional steering committee. To date, 318 nutrition environment and policy assessments have been conducted in public venues such as government, hospital, school, daycare, recreation and museum settings. More than 48 policy and practice changes have been adopted since the initiation of this effort.
4. Partner alignment
Partnership members experienced in assessment and health data partnered with the seven not-for-profit hospitals of Centura Health across our region by joining hospital assessment committees, providing local data and information and training hospital assessment leadership in prevention, life course perspective, and population health. To build momentum between hospital and PHIP efforts, the team also developed a menu of evidence based strategies to inform hospital planning efforts and identify opportunities for cooperation.
While the Partnership did not establish a formal evaluation framework, we will evaluate our efforts over time by our ability to secure funding for and to make measurable differences in our current and future areas of priority focus.
Lessons learned in relation to practice:
Staff have limited capacity to expand their work portfolios and regional activities can be additive to existing tasks. Establishing regional collaboration as a leadership priority was helpful for our staff when allocating their time. Also, the Partnership needed adequate administrative support to ensure smooth, consistent communication.
Lessons learned in relation to partner collaboration:
Local concerns do not always align with regional priorities. Limiting the Partnership's activities and regional collaboration to issues with greatest alignment and allowing each LHD to establish unique parameters for participation can alleviate these concerns.
Stakeholder commitment to sustaining the Partnership:
LHD directors are committed to working together regionally through formal collaboration. The Partnership members have already seen definite gained benefits in sharing resources, approaches, the increased collaboration and sharing of information that comes from relationship development and the increased ability to leverage the resources across the Partnership.
It will be important for the Partnership to demonstrate benefit to the additional stakeholders/partners it desires to engage and involve in its efforts. These stakeholders include health care systems, human/social services organizations, education partners, business and others who, by aligning with the Partnership, can yield greater impact around shared goals.
The Partnership directors are planning a retreat in January 2017 is to discuss long term sustainability, including how to support future Partnership activities if CDPHE resources are no longer available at some future point.