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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