4
A Community Health Improvement Process

Many factors influence health and well-being in a community, and many entities and individuals in the community have a role to play in responding to community health needs. The committee sees a requirement for a framework within which a community can take a comprehensive approach to maintaining and improving health: assessing its health needs, determining its resources and assets for promoting health, developing and implementing a strategy for action, and establishing where responsibility should lie for specific results. This chapter describes a community health improvement process that provides such a framework. Critical to this process are performance monitoring activities to ensure that appropriate steps are being taken by responsible parties and that those actions are having the intended impact on health in the community. The chapter also includes a discussion of the capacities needed to support performance monitoring and health improvement activities.

In developing a health improvement program, every community will have to consider its own particular circumstances, including factors such as health concerns, resources and capacities, social and political perspectives, and competing needs. The committee cannot prescribe what actions a community should take to address its health concerns or who should be responsible for what, but it does believe that communities need to address these issues and that a systematic approach to health improve-



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Improving Health in the Community: A Role for Performance Monitoring 4 A Community Health Improvement Process Many factors influence health and well-being in a community, and many entities and individuals in the community have a role to play in responding to community health needs. The committee sees a requirement for a framework within which a community can take a comprehensive approach to maintaining and improving health: assessing its health needs, determining its resources and assets for promoting health, developing and implementing a strategy for action, and establishing where responsibility should lie for specific results. This chapter describes a community health improvement process that provides such a framework. Critical to this process are performance monitoring activities to ensure that appropriate steps are being taken by responsible parties and that those actions are having the intended impact on health in the community. The chapter also includes a discussion of the capacities needed to support performance monitoring and health improvement activities. In developing a health improvement program, every community will have to consider its own particular circumstances, including factors such as health concerns, resources and capacities, social and political perspectives, and competing needs. The committee cannot prescribe what actions a community should take to address its health concerns or who should be responsible for what, but it does believe that communities need to address these issues and that a systematic approach to health improve-

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Improving Health in the Community: A Role for Performance Monitoring ment that makes use of performance monitoring tools will help them achieve their goals. PROPOSING A PROCESS FOR COMMUNITY HEALTH IMPROVEMENT The committee proposes a community health improvement process (CHIP) 1 as a basis for accountable community collaboration in monitoring overall health matters and in addressing specific health issues. This process can support the development of shared community goals for health improvement and the implementation of a planned and integrated approach for achieving those goals. A CHIP would operate through two primary interacting cycles, both of which rely on analysis, action, and measurement. The elements of a CHIP are illustrated in Figure 4-1. Briefly, an overarching problem identification and prioritization cycle focuses on bringing community stakeholders together in a coalition, monitoring community-level health indicators, and identifying specific health issues as community priorities. A community addresses its priority health issues in the second kind of CHIP cycle—an analysis and implementation cycle. The basic components of this cycle are analyzing a health issue, assessing resources, determining how to respond and who should respond, and selecting and using stakeholder-level performance measures together with community-level indicators to assess whether desired outcomes are being achieved. More than one analysis and implementation cycle may be operating at once if a community is responding to multiple health issues. The components of both cycles are discussed in greater detail below. The actions undertaken for a CHIP should reflect a broad view of health and its determinants. The committee believes that the field model (Evans and Stoddart, 1994), discussed in Chapter 2, provides a good conceptual basis from which to trace the multifactorial influences on health in a community. A CHIP must also 1   The CHIP acronym adopted for this report is not unique to the community health improvement process. In a health context, others use it to refer to community health information programs/partnerships/profiles. See, for example, the discussion of MassCHIP—the Massachusetts Community Health Information Profile—in Chapter 5. The committee anticipates that communities will adopt their own designations for their local community health improvement process.

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Improving Health in the Community: A Role for Performance Monitoring FIGURE 4-1 The community health improvement process (CHIP).

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Improving Health in the Community: A Role for Performance Monitoring adopt an evidence-based approach to determining how to address a health issue. Evidence is needed not only to make an accurate assessment of the factors influencing health but also to select an appropriate process through which to make changes. For example, immunizations are an effective means of preventing some infectious diseases, but many children and older adults have not received recommended doses. Studies show that efforts to raise immunization rates should target both the barriers that keep people from using available immunization services and the provider practices that result in missed opportunities to administer vaccines (IOM, 1994b). As envisioned by the committee, a CHIP can be implemented in a variety of community circumstances. Communities can begin working at various points in either cycle and with varying resources in place. The need to develop better data systems, for example, should not deter communities from using the CHIP framework. Using the process can focus attention on data needs and on finding ways in which they can be met. Participation from both the public and private sectors is needed, and leadership to initiate the process might emerge from either sector. The committee notes, however, that The Future of Public Health (IOM, 1988) suggests that public health agencies have a responsibility to assure that something like a health improvement process is in place. Thus, the committee recommends that local and state public health agencies assure that communities have an effective CHIP. At a minimum, these agencies should be CHIP participants, and in some communities they should provide leadership or an organizational home. Strong state-level leadership in places such as Illinois, Massachusetts, and Washington has helped promote progress at the community level. The ongoing health improvement process must be seen as iterative and evolving rather than linear or short term. One-time activities, briefly assembled coalitions, and isolated solutions will not be adequate. A CHIP should not hinder effective and efficient operation of the accountable entities in the community that are expected to respond to specific health issues, and it must be able to accommodate the dynamic nature of communities and the interdependence of community activities. It should also facilitate the flow of information among accountable entities and other community groups and help them structure complementary efforts. Both community-level monitoring data and more detailed information related to specific health issues must feed back into the system on a continuing basis to guide subsequent analysis and

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Improving Health in the Community: A Role for Performance Monitoring planning. This information loop is also the means by which a CHIP links performance to accountable entities among the community stakeholders. In emphasizing the community perspective, the committee does not want to overlook the broader state and national contexts for community efforts. For example, health policymakers at the federal and state levels could consider community-level performance indicators when planning and evaluating publicly funded health services programs such as managed care for Medicaid populations. Community performance measures could also contribute to state management of federal block grants (e.g., Maternal and Child Health Title V grants or those under the Community Mental Health Services Block Grant program) and the proposed federal Performance Partnership Grants (PPGs) (USDHHS, no date). Some state health departments are prominent participants in community-level health improvement efforts. In Massachusetts, for example, which has only one county health department, the state has taken a lead by establishing 27 Community Health Network Areas (CHNAs; see Chapter 3) to serve as the base for local health improvement activities (Massachusetts Department of Public Health, 1995). Elsewhere, state-level accreditation for local health departments can stipulate measurable targets for performance at the community level and require accountability for achieving targets during the term of accreditation. Illinois, for example, has implemented performance-based state certification of local health departments (Roadmap Implementation Task Force, 1990). Similarly, state agencies that license private-sector health plans or design Medicaid managed care programs have the opportunity to specify performance measures to be used to evaluate the services provided. Origins of the Community Health Improvement Process The committee's proposal for a community-based process for health improvement builds on many other efforts in health care, public health, and public policy, some of which are noted below. The Health Care Sector In the United States, proposals for collaborative community-wide efforts to address health issues date back at least to the early 1930s (Sigmond, 1995). One activity that emerged at this

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Improving Health in the Community: A Role for Performance Monitoring time was comprehensive health planning (CHP), initially a voluntary effort to rationalize the configuration of personal health care facilities, services, and programs, often with a special emphasis on hospitals (Gottlieb, 1974). From the 1960s to the 1980s, the federal government supported formal programs for state- and community-level CHP as a strategy to improve the availability, accessibility, acceptability, cost, coordination, and quality of health care services and facilities (Benjamin and Downs, 1982; Lefkowitz, 1983). At the local level, however, CHP was hampered both by limited control over resource allocation and by its responsibilities to regulate the introduction of new health care facilities and programs (Sofaer, 1988). In addition, local ''ownership" of these activities was weakened by strict federal requirements regarding their organization and operation. Nevertheless, the governing bodies of local planning agencies brought together multiple constituencies, including health care professionals and other "experts," consumers, and in a few cases, private-sector health care purchasers (Sofaer, 1988). CHP efforts also combined data on a community's health care services, epidemiology, and socioeconomic characteristics to identify high priority health problems. Indeed, some planning theorists explicitly based their approach on a model of the determinants of health (Blum, 1981) that might be considered an early version of the field model. Concerns about the quality of health care stimulated measurement and monitoring activities. Evidence of widespread variations in medical practice patterns (e.g., Wennberg and Gittelsohn, 1973; Connell et al., 1981; Wennberg, 1984; Chassin et al., 1986), inadequate information about the outcomes of common treatments (e.g., Wennberg et al., 1980; Eddy and Billings, 1988), and evidence of marked variations across providers in the outcomes of treatment (e.g., Bunker et al., 1969; Luft et al., 1979) prompted increased concern about the effectiveness of care (e.g., Brook and Lohr, 1985; Roper et al., 1988) and a recognition of the importance of monitoring health care practices (e.g., IOM, 1990). Continuous quality improvement (CQI) techniques have been adapted from their origins in industry for use in health care settings (e.g., Berwick et al., 1990; IOM, 1990; Batalden and Stoltz, 1993), and clinical practice guidelines are providing criteria for assessing quality of care (e.g., IOM, 1992; AHCPR, 1995). The basic Plan-Do-Check-Act cycle used in CQI is being applied to community health programs (Nolan and Knapp, 1996; Zablocki, 1996). Health departments are also exploring their role in promoting the quality

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Improving Health in the Community: A Role for Performance Monitoring of health care (Joint Council Committee on Quality in Public Health, 1996). Community-oriented primary care (COPC), which gained increased attention in the 1970s and 1980s, starts from a health care provider perspective to bring together care for individuals with attention to the health of the community in which they live (Kark and Abramson, 1982; IOM, 1984). Although performance monitoring is not an explicit focus of COPC, this approach to health care emphasizes the importance of community-based data for understanding the origins of health problems. The emergence of managed care and various forms of integrated health systems has been another factor that is broadening the health care focus from individual patient encounters to the health needs of a population. Enrolled members are generally the population of primary interest, but many of these organizations participate in activities serving the larger community such as violence prevention, immunization, AIDS prevention, and school-based health clinics. Some have formalized their commitment to community-wide efforts through mechanisms such as the Community Service Principles adopted by Group Health Cooperative of Puget Sound (1996). Nationally, organizations such as the Catholic Health Association (CHA, 1995) and the Voluntary Hospitals of America (VHA, 1992) have adopted community benefit standards that call for accountable participation in meeting the needs of the community. The attributes of a "socially responsible managed care system," proposed by Showstack and colleagues (1996), also support involvement in community-wide health improvement efforts. More generally, financial incentives are encouraging health care organizations to consider community-wide health needs. Nonprofit hospitals and health plans, plus the foundations established by provider organizations and insurers, are responding to the "community benefit" requirements needed to preserve their tax status. In addition, managed care plans are serving an increasing proportion of Medicare and Medicaid beneficiaries (Armstead et al., 1995), whose health may be adversely affected by problems not easily resolved in the health care setting (e.g., violence, poverty, social isolation). Because limited periods of eligibility for Medicaid benefits mean frequent enrollment and disenrollment, health plans may increasing see value in services that improve the health of nonmembers who might be part of their enrolled population in the future.

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Improving Health in the Community: A Role for Performance Monitoring The Public Health Sector Renewed interest in the 1970s and 1980s in a population- and community-based approach to health improvement was also reflected in both national and international activities in the public health arena (Lalonde, 1974; Ashton and Seymour, 1988), including the World Health Organization's Health for All by the Year 2000 program (WHO, 1985). The Healthy Cities/Healthy Communities movement, an international activity that emerged from the WHO and related programs, emphasizes building broad community support for public policies that promote health by improving the quality of life (Hancock, 1993; Duhl and Drake, 1995; Flynn, 1996). In the United States, the first Healthy People report in 1979 helped draw attention to issues of prevention and health promotion (USPHS, 1979). In the early 1980s, the Planned Approach to Community Health (PATCH), was developed to enhance the capacity of state and local health departments to plan, implement, and evaluate health promotion activities (Kreuter, 1992; CDC, 1995b). It emphasizes collaboration both within the community and across federal, state, and local levels. Among other tools that have been developed to guide community health assessment activities is the Model Standards program, which was initiated in 1976. The most recent report, Healthy Communities 2000: Model Standards (APHA et al., 1991), outlines an 11-step community-based process for assessing health department and other community resources, identifying health needs and priorities, selecting measurable objectives, and monitoring and evaluating results of interventions. Another approach, described in APEXPH: Assessment Protocol for Excellence in Public Health (NACHO, 1991), provides an eight-step process for assessing community health, assembling a community-based group through which to work, identifying and prioritizing issues of concern, and formulating a plan for responding. The APEXPH process is designed to begin with action by a local health department, but initial steps can also be taken by others in the community. The Healthy Communities Handbook (National Civic League, 1993b), developed under the auspices of the Healthy Cities/Healthy Communities initiative in the United States, reviews a process divided into a planning phase and an implementation phase. Steps in the planning phase include assembling a stakeholder coalition, (re)defining "community health," assessing influences on health in and beyond the community, reviewing health indicators and community capacities, identifying key per-

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Improving Health in the Community: A Role for Performance Monitoring formance areas, and creating an implementation plan. The implementation phase includes monitoring activities and their outcomes. In a recent survey of local health departments, 47 percent reported using Model Standards for planning activities, 32 percent reported using APEXPH, 12 percent reported using PATCH, and 6 percent reported using Healthy Cities (NACCHO, 1995). Many hospitals and health systems in the private sector also are using the APEXPH model to guide their health assessment activities (Gordon et al., 1996). The interest in community-based health improvement activities also led to several major intervention trials targeting specific health problems. The National Heart, Lung, and Blood Institute (NHLBI), for example, sponsored projects in California (Farquhar et al., 1985), Minnesota (Mittelmark et al., 1986), and Rhode Island (Elder et al., 1986) to test a community-based approach to primary prevention of coronary heart disease. The National Cancer Institute initiated the Community Intervention Trial for Smoking Cessation (COMMIT) in 11 pairs of communities (COMMIT, 1991). Community-based approaches to health improvement also received support from foundations, as in the Henry J. Kaiser Family Foundation Community Health Promotion Grant Program (Tarlov et al., 1987). Health Status and Performance Measurement The committee's proposal draws from a variety of indicator development and performance measurement efforts. Healthy People 2000 (USDHHS, 1991), one of the most prominent, provides more than 300 national health promotion and disease prevention objectives. A smaller set of related indicators was endorsed for use in monitoring key elements of community health status (CDC, 1991). Many states have assembled their own objectives for the year 2000, and Healthy Communities 2000: Model Standards (APHA et al., 1991) specifically addresses how communities can adapt these and other related objectives to their particular circumstances. With stated targets to be achieved, objectives such as these are not only measurement tools but also statements of intended performance. In addition, more specialized assessments are being made such as monitoring the status of children at the state and local levels (Annie E. Casey Foundation, 1996; Children Now, 1996). Interest in performance-based assessments of health care has

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Improving Health in the Community: A Role for Performance Monitoring resulted in the development of "report cards" by some individual health plans and in a variety of nationally used and proposed health care indicator sets (e.g., Nadzam et al., 1993; NCQA, 1993, 1996a; AMBHA, 1995; FAcct, 1995). Individually, many health care organizations are monitoring performance for their internal quality improvement purposes and for tracking community benefit activities. A focus on performance and outcomes also is central to ideas on "reinventing government" (Osborne and Gaebler, 1992; Gore, 1993; Hatry et al., 1994). The Government Performance and Results Act, for example, requires federal agencies to develop annual performance plans and to identify measures to assess progress (GAO, 1996). The proposals to implement PPGs for several health-related block grants would apply a similar approach to state grantees (USDHHS, no date). Some observers, however, caution against an overreliance on measurement in managing government activities, suggesting that many important tasks of government cannot be adequately quantified and that even if measurable may not be adequately insulated from political pressures (Mintzberg, 1996). ADVANCING THE PROCESS The process proposed by the committee reflects the need to combine features of these various activities to produce both a community-wide perspective and the performance measures that support accountability and inform further improvements. The current health planning and health assessment models provide a comprehensive community perspective but generally put less emphasis on the linkage between performance monitoring and stakeholder accountability than either the problem identification and prioritization cycle or the analysis and implementation cycle of the proposed CHIP. The quality improvement and performance measurement activities that have developed in the personal health care sector bring accountability for performance to the fore explicitly. They are, however, generally applied to specific institutions or health plan services for their members, not to activities of many entities responding to the needs of the entire population of a community. Both community-wide and organization-specific performance measurement processes are needed to improve the health of the general population. Applying the field model perspective encourages consideration of the diversity of opportunities and agents, both inside and outside the usual "health" setting, that can con-

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Improving Health in the Community: A Role for Performance Monitoring tribute to health improvement efforts. Although the committee's recommendations for operationalizing a CHIP are based on a variety of theoretical and practical models for community health improvement and quality assurance or performance monitoring in health care, public health, and other settings, the complete set of components of the committee's proposal has not yet been tested in communities. That will be an essential step in validating and improving the process. PROBLEM IDENTIFICATION AND PRIORITIZATION CYCLE As proposed by the committee, the problem identification and prioritization cycle has three main phases: forming a community health coalition; collecting and analyzing data for a community health profile; and identifying high-priority health issues. Community efforts can begin with any phase of the cycle. For example, the availability of data from the health department on various aspects of health status might spark action on a specific health issue before any community-wide coalition is established. Alternatively, efforts around a specific health issue might be the catalyst both for more broadly based activities and for the collection of additional health status data. Form Coalitions A long-term community coalition is an essential element in a CHIP. As noted in Chapter 3, a coalition is an organization of individuals representing diverse organizations, factions, or constituencies who agree to work together to achieve common goals (Feighery and Rogers, 1990). In the context of a CHIP, a coalition provides the mechanism for bringing together the community's stakeholders and accountable entities to develop a broad perspective on health needs and how they might be addressed. Leadership is essential, both to initiate and to maintain a coalition. Many may look to the health department to play this role, but private-sector initiatives or public-private collaborations can also be the motivating force. The coalition's roles include obtaining and analyzing community health profiles, identifying critical issues for action, supporting the development of improvement

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Improving Health in the Community: A Role for Performance Monitoring catalog and convey to communities information on best CHIP practices, specific model performance measures for a variety of health issues, the interpretation of changes in these measures, and available data resources. States and academic institutions should assume a role in using these materials to provide technical assistance to communities. The committee believes that states have a special responsibility to assist communities in obtaining data for community health profiles. There is also a need for further development of performance measurement tools to make the health improvement process more effective. Work is needed on standard measures for both community health profiles and model indicator sets for specific health issues. These measures should be able to perform well in individual communities and be suitable for cross-community comparison. Also necessary are efforts to address both the enhancement of existing measures and the development of valid measures in areas for which they do not currently exist. Measures of quality of life and consumer satisfaction that are suitable for use in community surveys are particularly important. For some health issues, the development of measurement tools cannot proceed until additional research has provided a suitable evidence base. Support should also be given to research to develop and improve the techniques of measurement and analysis that can be applied to community-level performance monitoring (e.g., small area analysis). Technical assistance from federal agencies with health data expertise could be particularly helpful to states and localities in testing and improving the quality of vital statistics and other health data. As with work on other resource materials, this process should bring together federal agencies, national professional organizations, and foundations, in conjunction with state and local health agencies and other community stakeholders. Individuals and organizations with expertise in specific health issues (e.g., injury, reproductive health, environmental and occupational health) might assume leadership for the development of performance measures for those health issues. The indicators proposed by the committee (see Chapter 5 and Appendix A) should be viewed as an initial step in what must be a more extensive indicator development process. Electronic systems have the potential to provide rapid and interactive access to such data, and as has been noted, some states (e.g., Massachusetts) have assigned a high priority to the development of broader electronic health information systems.

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Improving Health in the Community: A Role for Performance Monitoring National leadership and resource support could also be helpful. Some states and communities are using the Information Network for Public Health Officials (INPHO) developed by the CDC (1995a) as a basis for electronic communication and data exchange. Support from foundations and from the CDC is also playing an important role in the development of computerized immunization registries in some states and communities (Faherty et al., 1996). Enhanced public health information resources are also being pursued through the National Information Infrastructure project, which is aimed at enhancing the nation's overall framework for telecommunications and computer technology (Lasker et al., 1995). Work being done to develop more effective and extensive health care information systems is also relevant to the data collection and analysis tasks facing community health coalitions in a CHIP. The IOM report Health Data in the Information Age (IOM, 1994a) outlines the roles and obligations of what it generically calls ''health data organizations" (HDOs), entities that are an anticipated product of the evolution of health and health care information systems. Discussions also refer to "community health information networks" (e.g., see Duncan, 1995). The prototypical HDO is described as operating under a single common authority; serving a specific, defined geographic area; having inclusive population files; having files with person-identified (or identifiable) data; having data covering administrative, clinical, and health status information and on satisfaction with services; acquiring and maintaining information from a variety of sources for multiple uses; having the capability to manipulate data electronically; and supporting electronic access for real-time use (IOM, 1994a). Although this work currently relies primarily on a health care provider perspective, the potential would seem to exist to adopt a broader approach that can support community health improvement activities (Milio, 1995) Professional Training In the long run, effective dissemination of CHIP practices and successful performance monitoring techniques will depend on the development of educational programs that can train a variety of professionals. Because health departments have a responsibility to assure that processes to protect and improve health are available to communities (IOM, 1988), schools of public health should be one of the starting points for such programs. The field model's

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Improving Health in the Community: A Role for Performance Monitoring multidimensional concept of the production of health, which is embedded in the committee's approach to the health improvement process and performance monitoring, suggests that an academic program should introduce CHIP as a way to think about the application of public health as a group of interrelated academic disciplines (epidemiology, biostatistics, environmental health, health behavior, and so on) to the practice of community health improvement (e.g., see Bor et al., 1995). Public health is, however, only one of many fields that can contribute expertise to a community health improvement process and to performance monitoring components. Thus, the committee recommends that educational programs for professionals in fields including, but not limited to, public health, community medicine, nursing, health care administration, public policy, and public administration include CHIP and performance monitoring concepts and practices in their curricula for preservice and midcareer students. Other fields in which CHIP might be addressed include environmental health, mental health and substance abuse counseling and program administration, maternal and child health, and the behavioral sciences. CONCLUSIONS In this chapter, the committee has laid out the framework for an iterative and evolving community health improvement process that relies on collaboration among a diversity of stakeholders and uses measurement as a tool for establishing stakeholder accountability for contributions to that process. The broad perspective that the field model provides on health and the factors contributing to it gives a CHIP a basis for seeking opportunities for health improvement throughout the community, not just within the health department or the health care provider's office. The committee's proposal for a CHIP builds on much other work that has been done in health assessment, community health planning, and performance measurement, but it advances these past efforts in two ways. First, it looks beyond assessments of community health status to accountability for measurable health improvement. Second, it looks beyond performance within an individual organization serving a specific segment of a community to the way in which the activities of many organizations contribute to health improvement throughout the community. The proposed process reflects the committee's judgment based on experience and available evidence, but the CHIP needs to be

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Improving Health in the Community: A Role for Performance Monitoring tested and assessed so that it can be refined and enhanced. Individual communities should look to the national and state levels for these assessments and for the development of tools that can help them use a CHIP. Although the committee views the health improvement process it has described as an essential tool for communities, it emphasizes that attention to using and enhancing this process should not obscure the primary goal of health improvement. REFERENCES AHA (American Hospital Association). 1995. News Release. 25 Partnerships Named to Receive Grants in Community Network Competition. Washington, D.C. August 22. AHCPR (Agency for Health Care Policy and Research). 1995. Using Clinical Practice Guidelines to Evaluate Quality of Care. Vol. 1. AHCPR Pub. No. 95-0045. Rockville, Md.: U.S. Department of Health and Human Services. AMBHA (American Managed Behavioral Healthcare Association). 1995. Performance Measures for Managed Behavioral Healthcare Programs. Washington, D.C.: AMBHA Quality Improvement and Clinical Services Committee. Annie E. Casey Foundation. 1996. KIDS COUNT Data Book: State Profiles of Child Well-Being. Baltimore: Annie E. Casey Foundation. APHA (American Public Health Association), Association of Schools of Public Health, Association of State and Territorial Health Officials, National Association of County Health Officials, United States Conference of Local Health Officers, Department of Health and Human Services, Public Health Service, Centers for Disease Control. 1991. Healthy Communities 2000: Model Standards. 3rd ed. Washington, D.C.: APHA. Armstead, R.C., Elstein, P., and Gorman, J. 1995. Toward a 21st Century Quality-Measurement System for Managed-Care Organizations. Health Care Financing Review 16(4):25–37. Ashton, J., and Seymour, H. 1988. The New Public Health: The Liverpool Experience. Philadelphia: Open University Press. Baker, E.L., Melton, R.J., Stange, P.V., et al. 1994. Health Reform and the Health of the Public: Forging Community Health Partnerships. Journal of the American Medical Association 272:1276–1282. Batalden, P.B., and Stoltz, P.A. 1993. A Framework for the Continual Improvement of Health Care: Building and Applying Professional and Improvement Knowledge to Test Changes in Daily Work. Journal on Quality Improvement 19:424–447. Benjamin, A.E., and Downs, G.W. 1982. Evaluating the National Health Planning and Resource Development Act: Learning from Experience? Journal of Health Policy, Politics and Law 7:707–722. Berwick, D.M. 1989. Continuous Improvement as an Ideal in Health Care. New England Journal of Medicine 320:53–56. Berwick, D.M., Godfrey, A.B., and Roessner, J. 1990. Curing Health Care: New Strategies for Quality Improvement. San Francisco: Jossey-Bass. Blum, H.L. 1981. Planning for Health. 2nd ed. New York: Human Sciences Press.

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