Health Policy and Community Based Organizations: From Analysis to Data to Influence

1. Health Policy and Community Based Organizations: From Analysis to Data to Influence Data & Democracy Statewide Training Initiative: Fresno Regional Convening April 18, 2007 John Capitman, Central Valley Health Policy Institute, California State University Fresno

2. Central Valley Health Policy Institute at Fresno State receives core support from

3. Overview Definition of Health Social Determinants of Health Definition of Health Policy Influence and Analysis Implications for Community Needs Assessment Example: Home Garden Community Needs Assessment

4. What is Health? Traditional Definitions: Absence of disease, normal age-appropriate functioning, focus on individual biology and behavior Emerging Definitions: Wellness, well-being, optimal (age-appropriate) functioning, focus on individual and community Social Determinants of Health: New Consensus: physical and social environments, social solidarity and public safety shape individual and community health.

5. What is Health Policy? Private and public financing of health care Private and public delivery of health care Public oversight of financing, provider organizations, and professionals Publicly subsidized professional training Public health education in multiple contexts Public health oversight of indoor and outdoor environments and products Public and private policies and practices that create and sustain opportunity, power, exposure, and resistance at individual and macro-individual levels (taxes, monetary, military, immigration, industrial, environmental etc.) Have some conversation----what’s really health policy? Is everything health policy?Have some conversation----what’s really health policy? Is everything health policy?

6. From Analysis to Influence: five ways to think about change Focus on Inclusion: How do we work together? Focus on Power and Fairness: What are our interests? What outcomes do we want? How does this differ from other actors? Focus on Resources: How does the money flow? How does this impact outcomes? Focus on Delivery Systems: How are provider organizations working? How does this impact outcomes? Focus on Opportunities for Change: Can we address root cause of poor outcomes? How can outcomes be improved in the short run?

7. How does the money flow? Howdoes this impact outcomes? Health care financing/regulation is complex: Multiple private, federal, state, and county payers, have differing roles in setting policies Payers impose different requirements on providers and health care users Decision-making on payments may be influenced at different points in system Reimbursement rates and rules vary by payer and may create perverse incentives Allocated dollars may be sufficient but difficult to access or just not enough

8. How are provider organizations working?How does this impact outcomes? Health outcomes are as often determined by how care is organized as by financing. Provider relationships (MCOs/specialists) Barriers to care access (transpo,hours etc) Eligibility and payment process Quality assurance systems (care management) Language and cultural match

9. Basic questions about how care is organized and delivered* Are there organizational barriers to access for primary or specialty care? Are there clinic barriers to access? Does provider maximize payment sources? How does provider address medical debt? Do quality assurance systems work? Does provider assist with behavior change? Does provider attend to linguistic and cultural factors? Does provider partner with others to address community-level determinants of health? * LOOK for Individual Stories and Available Data. Consider how to use data to gain power.

10. How can outcomes be improved in the short run? Policies change in response to perceived crisis. Use media and public events over time to create consistent community message on needs/costs. How “crisis” is framed determines range of policy and program options. Seek a framing that emphasizes specific harm from current and broad benefits from change. Framing “crisis” in terms of individual knowledge, attitudes, and behavior can shift blame to target communities. Seek a framing that emphasizes access to appropriate services and community assets Short-run solutions at local level can be applied to provider-linked problems. Access and quality improvement may be within reach of providers but they need community partners and financing changes to sustain changes. State-level financing/regulatory changes arise through interest-group pressure on particular legislative and beauracratic proposals Develop relationships with decision-makers that cross multiple issues, raise awareness of breadth of group interests, and help legislators focus on local implications.

11. Needs Assessment vs. Strategic Planning Needs Assessment Population problems and policy solutions Values Target population Unmet needs—quantitative and qualitative Program evaluation Planning and politics Strategic Planning Organizational success Mission Market Composition and External assets/liabilities Internal assets/liabilities Short and long term objectives Implementation plan

12. Formulating Questions Traditional Framing Framing value choices Establishing person-level indicators—need/health measures, process measures---and person-level need moderators Establishing numerical and process goals Comparing indicators and goals—how much difference matters Identify and evaluate interventions Emergent Frameworks Contextual/macro-individual determinants Social/cultural/political/economic Historical/time series Spatial/environmental Intersection of program values, experiences and expectations Intervention logic models—recognition of multiple pathways and mechanisms

13. Needs Assessment Rationale “Needs” = values + evidence + intervention potential Needs Assessment Asks and Answers 5 basic questions: What is the target population? What is known about their need-related features (demography, geography, health and social status)? How are we addressing unmet needs? What are the Process, Efficacy, Effectiveness, Efficiency of these interventions? What are the Opportunities to address unmet need? What are the Barriers to addressing unmet need? What Resources need to be mobilized to move forward? Quick round----everybody just quickly says who they areQuick round----everybody just quickly says who they are

14. Needs Assessment: Process is Paramount Who is at the table? Broad inclusion of stakeholders Who sets the table? Timing, location, invite, format determine level of participation What to prepare? Formulating questions, finding and preparing evidence. My view: narrower is better and less is more How to serve? Avoiding “mock democracy” by clarifying what different stakeholders can influence. My view: evidence in/values, evidence critique, and options out. What comes next? Extended process; summary of possibilities; barriers, resources; quick turn-around, additional input process; political process

15. Home Garden Community Assessment John Capitman, Ph.D., Executive Director Alicia González, Research Assistant March 27, 2007

16. Project Goals Increase knowledge of the KPC Board, staff and community of the health needs and access issues through the collection of local data Identify and prioritize physical and mental health needs through a grass roots community engagement process Support creation of community strategies to address identified needs

17. Data Collection Surveys Face-to-Face Survey Interviews August - October 2006 Family Surveys = 183 Elder Surveys = 53 Total = 236 Photovoice 10 Youth Total Photographs = 46

18. Photovoice (Wang, 1992) Community Based Participatory Research Three main goals: Enable Promote dialogue Inform decision-makers

19. Photovoice Method (Wang, 1992) What do you See here? What is really Happening? How does this relate to Our lives? Why does this problem or strength exist? What can we Do about it?