It was also suggested that the committee's work might encourage collaboration among key stakeholders on data issues. Standardized performance indicators would establish common ground for data collection and assessment. Reaching agreement on electronic data interchange standards would facilitate the transfer of data among health departments, health plans, and other contributors to the assessment process. The successful development of community-wide data systems will also require resolving confidentiality concerns that arise in combining data from different sources.

ACTIVITIES AT THE NATIONAL LEVEL

A variety of federal agencies and private-sector organizations have programs that address, directly or indirectly, monitoring and improving community health. The workshop gave the committee an opportunity to learn more about the work being done by some of these groups. Comments during these presentations indicated substantial interest in and support for the work being done by the committee.

Federal Agencies

Office of the Assistant Secretary for Health12,13

The Office of the Assistant Secretary for Health in the U.S. Department of Health and Human Services (DHHS) has had broad responsibilities and interests in both health care and public health. Three activities have special relevance to the committee's work on monitoring and improving community health: (1) a proposal for performance partnership grants to states, (2) bringing the public health sector into the National Information Infrastructure (NII) initiative, and (3) developing comprehensive information on the nation's public health infrastructure.

Performance partnership grants Performance partnership grants (PPGs), which are proposed in legislation now before Congress, are intended to provide states with funding for 3 to 5 years to achieve specific and measurable health status improvements. PPGs are planned for six areas: mental health, substance abuse, HIV/STD/TB, chronic diseases and prevention of disabilities, immunizations, and preventive health and health services.

12  

This section is based on a presentation by Roz Lasker.

13  

Following the workshop, a reorganization in the U.S. Department of Health and Human Services placed the activities described in this section under the direction of the Office of the Assistant Secretary for Planning and Evaluation.



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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary It was also suggested that the committee's work might encourage collaboration among key stakeholders on data issues. Standardized performance indicators would establish common ground for data collection and assessment. Reaching agreement on electronic data interchange standards would facilitate the transfer of data among health departments, health plans, and other contributors to the assessment process. The successful development of community-wide data systems will also require resolving confidentiality concerns that arise in combining data from different sources. ACTIVITIES AT THE NATIONAL LEVEL A variety of federal agencies and private-sector organizations have programs that address, directly or indirectly, monitoring and improving community health. The workshop gave the committee an opportunity to learn more about the work being done by some of these groups. Comments during these presentations indicated substantial interest in and support for the work being done by the committee. Federal Agencies Office of the Assistant Secretary for Health12,13 The Office of the Assistant Secretary for Health in the U.S. Department of Health and Human Services (DHHS) has had broad responsibilities and interests in both health care and public health. Three activities have special relevance to the committee's work on monitoring and improving community health: (1) a proposal for performance partnership grants to states, (2) bringing the public health sector into the National Information Infrastructure (NII) initiative, and (3) developing comprehensive information on the nation's public health infrastructure. Performance partnership grants Performance partnership grants (PPGs), which are proposed in legislation now before Congress, are intended to provide states with funding for 3 to 5 years to achieve specific and measurable health status improvements. PPGs are planned for six areas: mental health, substance abuse, HIV/STD/TB, chronic diseases and prevention of disabilities, immunizations, and preventive health and health services. 12   This section is based on a presentation by Roz Lasker. 13   Following the workshop, a reorganization in the U.S. Department of Health and Human Services placed the activities described in this section under the direction of the Office of the Assistant Secretary for Planning and Evaluation.

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary The PPG should combine the benefits of specificity and accountability in categorical grant programs with the flexibility of block grants, and avoid some of the problems in each of those funding mechanisms. The program will preserve funding specifically for surveillance and evaluation. It can also encourage states to integrate data systems that may originally have developed for specific categorical programs. For each funding area, the proposal calls for states to reach an agreement with DHHS on specific targets for improvement and the degree of improvement sought. The mix of objectives and targets will vary among states. For each funding area, a menu of health status objectives from which states can choose will be developed in a collaborative effort organized by DHHS. Possible objectives will be identified through regional meetings and work with national associations representing state and local health agencies with responsibilities in the areas to be covered by the PPGs. A National Research Council panel will review technical measurement issues and areas where data system improvements may be needed. Several factors will be considered in selecting PPG objectives: links to Healthy People 2000 (USDHHS, 1991); issues that are important and understandable to policymakers and the public; aspects of health status on which states can be expected to have an impact and for which change can be measured during the grant period; a focus on results with measures for outcomes and for processes and capacities with clear links to outcomes; clearly specified measures; and the timely availability of sound and comparable data to all grantees at reasonable cost. The menu of PPG objectives is expected to change as the capabilities of data systems improve. National information infrastructure Another important activity (see Lasker et al., 1995) is bringing public health interests into the National Information Infrastructure (NII) initiative, which is promoting the enhancement of the nation 's computing and telecommunications infrastructure. Public health professionals are bringing to these discussions a familiarity with and interest in data issues that has not always been found in work with the health care community. Through its participation in the NII initiative, the public health community is gaining knowledge of and access to computing resources that often are not available to public agencies. Trying to bring a broad range of interests together around the NII may help identify common needs and more cost-effective solutions than could be achieved individually. Information on the public health infrastructure The lack of, and need for, comprehensive information on the nation 's public health infrastructure became clear during the development of health care reform proposals in 1993 and 1994. DHHS is funding a project to assemble a database on public health resources at the national, state, and local levels (e.g., organization, services provided,

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary funding, expenditures). Part of this effort will include bringing together individuals and organizations already looking at these issues to develop a consensus on definitions and typologies for the elements of such a database. It is expected to aid a variety of policymakers in assessing the impact of changes in organization and delivery of health care on the public health infrastructure. Agency for Health Care Policy and Research14 The primary activities of the Agency for Health Care Policy and Research (AHCPR) relevant to performance monitoring include the development of clinical practice guidelines, technology assessment, support for outcomes research, and applied research on health care quality measurement and improvement. Two projects may have special relevance to community health assessment and improvement. The first project is collecting and classifying clinical performance measures being used by health care providers in the public and private sectors (Center for Health Policy Studies and Center for Quality of Care Research and Education, 1995). This “typology project” is producing a database with information on about 1,300 individual measures found in 40 measurement systems. The database is intended to allow users to explore specific measures within the project's classification system and to identify measures linked to specific clinical conditions or patient populations. The structure of the database facilitates comparisons among measures and is intended to foster greater uniformity in the development and description of measures. The second project was aimed at producing information that can help consumers make choices among health plans (Research Triangle Institute, 1995). It focused on developing questionnaire modules that could be used to collect information from and for health care consumers. Specific areas of attention include access to care, use of services, health outcomes, and satisfaction with care. The results of this initial effort are being further developed, tested, and refined in the Consumer Assessments of Health Plans Study. Centers for Disease Control and Prevention: Activities in Managed Care15 Changes in the organization and delivery of health care are changing some of the expectations regarding responsibility and accountability for health and health care. Public health agencies have generally been responsible for broad community health needs but in many communities have also been providing 14   This section is based on a presentation by Linda Demlo. 15   This section is based on a presentation by Randolph Gordon.

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary personal health services. In the private sector, the growth of managed care organizations is shifting attention from individual patients to entire enrolled populations, including groups formerly served by public health agencies. The Centers for Disease Control and Prevention (CDC), guided by a Managed Care Working Group, is examining its role in a changing health care environment. CDC is encouraging managed care organizations and other private-sector health care providers, in collaboration with public health agencies, to give greater attention to prevention and community health. Concerns about the profitability of those activities may, however, encourage private sector health care organizations to focus their attention on their enrolled populations. This drew the observation at the workshop that there is a need to create a new view of prevention as an investment in the quality of health services and not simply a means of avoiding treatment costs. Among CDC's priorities is an effort to identify effective forms of community-based prevention and compile a guide to those interventions (similar to the report of the Clinical Preventive Services Task Force). With more and more states seeking Medicaid managed care waivers, CDC has as another priority trying to address public health concerns by encouraging greater participation by state health agencies in the development and implementation of those waiver programs. Research on issues related to health reform and managed care also is a priority. For example, as Medicaid managed care alters the structure of community health care and the delivery of services, CDC is assessing the impact of those changes on public health programs ranging from tuberculosis clinics to lead abatement. CDC is also working with managed care organizations to enhance their contribution to public health efforts through activities such as participation in community health planning, development of assessment skills in environmental and occupational health, and collaboration on disease surveillance and other public health information needs. In collaboration with organizations such as the Group Health Association of America, the Joint Commission on Accreditation of Healthcare Organizations, and the National Committee for Quality Assurance, CDC is exploring how to bring attention to prevention in reporting on health plan performance. Also being studied is whether data collection tools such as the Behavioral Risk Factor Survey can be adapted for use by health care organizations. National Center for Health Statistics16 Although it has not always been called “monitoring health status indicators,” the National Center for Health Statistics (NCHS), a component of 16   This section is based on a presentation by Ronald Wilson.

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary CDC, has been collecting and reporting national health data for many years. Recently, NCHS has given greater attention to obtaining data for states and even counties. In addition to its role in assembling vital statistics data and conducting several longstanding surveys such as the National Health Interview Survey (NHIS), NCHS also has major responsibilities associated with Healthy People 2000 (USDHHS, 1991). A particular focus is the set of 18 health status indicators selected in response to the Healthy People 2000 objective 22.1, which calls for “a set of health status indicators appropriate for Federal, State, and local health agencies,” and the summary indicator of years of healthy life (CDC, 1991; Erickson, Wilson, and Shannon, 1995). NCHS is working with states and communities to improve the comparability of data and data collection for many Healthy People 2000 objectives. NCHS is also working on indicators suitable for monitoring health care. A recent report prepared for NCHS compiled information on several sets of health or health care indicators, some of which are currently in use (see Lewin-VHI, 1995). Some specific comments and suggestions were offered to the committee. Particular emphasis was put on making a careful assessment of data needed for performance monitoring. The cost of data collection could become a constraint as could the burden on those providing the data. Collecting some data less frequently or from a more limited population may be adequate. In assessing the need for data it also may be helpful to consider whether any action can or will be taken based on the information produced. A final comment emphasized the need to consider whether changes in some health-related indicators signal real changes in health status. Changes in social or economic context or in values or perceptions may affect how individuals report their health status. Private Sector Organizations American Public Health Association17 Healthy Communities 2000: Model Standards (American Public Health Association et al., 1991), is a tool specifically designed to help communities and local public health agencies monitor and improve health by translating the national health promotion and disease prevention objectives of Healthy People 2000 into local objectives and developing community action plans to achieve those objectives. Use of Model Standards in conjunction with APEXPH: Assessment Protocol for Excellence in Public Health (NACHO, 1991), produced by the National Association of County and City Health Officials, has been 17   This section is based on a presentation by Claude Hall.

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary encouraged. The emphasis on public health structure and process in APEX PH complements the emphasis on health outcomes in Model Standards. Although the Model Standards project is based at the American Public Health Association (APHA), it is a collaborative effort with the Association of Schools of Public Health, the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, and the CDC. The two previous editions of the Model Standards report were linked to the 1990 national health promotion and disease prevention objectives. In contrast to these earlier versions, Healthy Communities 2000 has built more directly on the national objectives of Healthy People 2000 to provide an explicit link from the national level to state and local efforts. It also has expanded on some areas, such as environmental health, that received limited attention in Healthy People 2000. APHA is trying, through Model Standards and other activities, to provide a bridge to resources in the larger community that can promote health. Community hospitals and the American Hospital Association and the Voluntary Hospital Association have been a particular focus of attention. There has also been collaboration with the National Civic League. Within APHA, the Model Standards project has been brought into a new organizational unit on scientific, professional, and sectional activities. This group will be pursuing activities to promote priority setting and action on public health improvement, implementation of strategies to improve public health decisionmaking, and enhancement of information and communication systems. Through these activities, the Model Standards project will be able to collaborate with a broader range of organizations. Several suggestions about performance monitoring were offered to the committee. In developing indicators that need to bridge public health and health care, the relationship in the computer industry between the separate but linked fields of hardware and software development might offer insights. Fields such as sociology and political science might provide helpful models for defining communities and interest groups. It was noted that the recent collaboration among major businesses to negotiate with managed care organizations illustrates the diversity of perspectives on “community” health and the complexities in identifying relevant stakeholders for health improvement efforts (residents, employees, enrollees, purchasers/employers, providers, etc). Also stressed was seeing performance measures as part of larger picture that includes other tools, such as practice guidelines and model standards, that can help guide community decisionmaking. As a final point, the committee was encouraged to establish a broad range of “partnerships” to promote full development and implementation of its work.

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary National Association of County and City Health Officials18 As was noted above, the National Association of County and City Health Officials (NACCHO) is responsible for producing APEXPH: Assessment Protocol for Excellence in Public Health (NACHO, 1991). This workbook for local health officers has two parts. Part one is an organizational capacity assessment that helps an assessment team identify strengths and weaknesses in their health department and develop a responsive action plan. The second part guides health departments in developing a community health planning committee that can identify health problems of concern to the community and mobilize the community to address them. The committee also is responsible for balancing community interests against possibly conflicting priorities suggested by available data. In many communities and health departments, these APEXPH-guided activities have prompted constructive change. Also available to health departments is APEXPH in Practice (NACCHO, 1995a), which provides various tools to facilitate use of APEXPH. NACCHO recently published a profile of local health departments that presents, in the aggregate, information on their organization, resources, and activities (NACCHO, 1995b). NACCHO also is beginning to gather comments from health departments that will help shape a revision of APEXPH. Plans include enhancing the limited environmental health component. 19 The new version of APEXPH may offer one means of disseminating and operationalizing the recommendations of this IOM committee. Earlier APEXPH work was able to play a similar role for the IOM report The Future of Public Health (IOM, 1988). Members of the committee suggested that the revision include input from local health departments in two particular areas: (1) narrative material that examines factors that contributed to success or failure in using APEXPH and (2) observations on the usefulness of APEXPH for health departments of varying sizes, with particular attention to whether small departments find it useful (or feasible) to collaborate with other departments or organizations. NACCHO also is working through the Joint Council of Governmental Public Health Agencies on a project on the role of state and local public health departments in issues of quality assurance and accountability as they affect population groups. The project's advisory committee is expected to consider strategies that state and local health departments can use to assure the quality and effectiveness of population-based services. Previously NACCHO collaborated with CDC to produce Blueprint for a Healthy Community (NACHO and CDC, 1994), which outlines 10 elements needed to protect and promote community health and which local health departments should assure are available. 18   This section is based on a presentation by Nancy Rawding. 19   Since the workshop was held, a NACCHO committee has started this work.

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary National Committee for Quality Assurance20 The National Committee for Quality Assurance (NCQA) focuses on quality in health care and on providing purchasers and consumers of health care services with information that helps them select among health plans offering those services. It uses accreditation to establish that health plans have structures and processes that should enable them to meet the needs of their enrolled populations. Performance measurement provides information that can be used to assess health plans' effectiveness in providing services and to identify areas for improvement. NCQA has three aims for performance measurement. First, there should be national standardization of measures. Measurement, however, should be a local or market-based process where comparisons among health plans are meaningful for purchasers and consumers. Second, application of those measurement standards should be documented. Third, performance measurement should produce information that promotes quality improvement. NCQA is addressing these aims with HEDIS—the Health Plan Employer Data and Information Set—which provides a standard set of measures that helps purchasers compare health plans and helps health plans assess their own performance (National Committee for Quality Assurance, 1993). HEDIS encompasses measures in several categories including quality of care for both prevention services and treatment, utilization of services, members' access to and satisfaction with services, and organization and operation of the health plan. NCQA is working with many health plans to help them improve their data collection and analysis capabilities for both external reporting and internal assessment. A pilot project involving 21 health plans with varying characteristics (size, structure, location) has demonstrated the feasibility of producing “report cards” but also has shown that the process is not easy and is vulnerable to problems. The cost to produce the report cards ranged from $100,000 to $1,000,000, some of which represents start-up costs. The cost of adding data elements is not yet known but is likely to depend on the nature of the added reporting. NCQA is exploring what information to present to consumers and how to present it but finds that there is little basis for knowing what information consumers want. Work is beginning on the next HEDIS update (version 3.0). Workshop participants expressed interest in the possibility that HEDIS could be expanded or adapted to meet community health information needs in addition to those of health plans and employers/purchasers. It was suggested that health plans could be gathering more information relevant to community health than they are currently asked to do. NCQA has included a public health representative on the committee overseeing the HEDIS revision and anticipates the addition of some 20   This section is based on a presentation by Cary Sennett.

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary measures of interest for community health assessment (e.g., prevalence of smoking). Meeting the needs of health plans and employers will, however, remain HEDIS's principal role. NCQA questions what contribution health plans and HEDIS should be expected to make toward collecting data on community health and where responsibility should lie for paying costs health plans would incur in collecting the data. A specific suggestion offered to the committee was to focus on performance measures for public agencies and institutions. The group was urged not to try to duplicate the work already being done in the private sector. Joint Commission on Accreditation of Healthcare Organizations21 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) assesses the qualifications and performance of hospitals and numerous other types of health care facilities. Performance indicators are not considered sufficient by themselves since they can provide only an after-the-fact report. Standards for organization and operation, which are set with the expectation that they increase the likelihood of good outcomes, are also considered essential. Among the Joint Commission activities related to the committee's work is the development of preventive services standards, which extends the scope of the continuum of care beyond JCAHO's traditional focus on diagnosis and treatment. Primary, secondary, and tertiary prevention services are all within the scope of the new standards. Work is beginning with health care networks, but JCAHO expects to extend these standards to other kinds of health care organizations over time. The standards for these services call for health networks to provide preventive services that are appropriate for their mission, that are considered efficacious, that are appropriate to the needs of the population they serve, and that are provided in an effective manner. If prevention is seen as an appropriate network service, a network will be expected to define the role it plays in delivering that service in the community. It will also be expected to conduct a needs assessment in the community to determine what services should be provided. The importance of working with public health agencies and other community resources, including other health care organizations, will be emphasized. As this process moves forward various issues of accountability will need to be resolved. In a “capacity-building ” effort, JCAHO will be holding workshops in conjunction with the American Hospital Association and CDC to better inform hospitals and other clinically focused health care organizations about issues such as health promotion and preventive services, 21   This section is based on a presentation by Margaret VanAmringe.