Examples of Using NHP Data and Tools

Researcher

Goals

• Identifying ZIPs with low childhood vaccination rates in her health system’s service area
• Learning more about the population in the area
• Identifying barriers to childhood vaccination to address

NHP Data Used

• Neighborhood Health Reports for childhood vaccinations for the ZIP codes in her health system’s service area

Partnerships

• A local immunization coalition and school nurses

NHP Tool Activities to Support the Work

• The researcher had some connections to local clinics, but not with the broader community. She wanted to build partnerships with community leaders, including a local immunization coalition and school nurses, to interpret the vaccination data in context and understand the barriers preventing children from being vaccinated in this community. She wants to connect to the coalition and school community priorities to develop interventions.

Related Policy

• The coalition and researcher collaborate on identifying a policy that removes a barrier to vaccination, such as reducing client out-of-pocket costs

Outcomes

• Strengthened relationships with community partners by sharing data that is relevant to their vaccination improvement efforts
• Learning what the priorities of the community are and potential barriers to vaccination
• Submission of a grant with a community partner to develop an intervention to improve vaccination rates in neighborhoods with high need

Community Pharmacists

Goals

• Identify ZIP codes with lowest blood sugar testing and blood sugar control in diabetes
• Implement additional programming for patients with diabetes in these areas

NHP Data Used

• Neighborhood Health Reports for areas served by the community pharmacies

Partnerships

• Community pharmacists and their patients, pharmacy students, local organization that hosts diabetes self-management classes, health systems

NHP Tool Activities to Support the Work

• Community pharmacists can use a framework to help them understand how to improve diabetes programming to meet the needs of the participants. The pharmacists can hold a community forum with patients, pharmacy students and local health systems to learn their needs and concerns regarding diabetes care in their area. Together they can select a diabetes intervention that helps to meet the goals of all partners and will build and strengthen partnerships to improve health and care for patients with diabetes.

Related Policy

• If the community pharmacists found that fast food consumption was a factor in regulating blood sugar control, the group could advocate to local government to use zoning regulations to limit the number of fast food outlets in an area

Outcomes

• Additional diabetes self-management programs offered in areas of high need
• Increased blood sugar testing and blood sugar control
• Learning opportunities for pharmacy students to help conduct medication reviews in the community

Community Coalition

Goals

• Identify rural underserved ZIP codes in Wisconsin with low colorectal cancer screening rates in the area the coalition serves
• Understand the economic and social environment of the populations living in their ZIP codes
• Distribute colorectal cancer screening test kits to communities with lowest screening rates

NHP Data Used

• Neighborhood Health Reports for colorectal cancer screening
• Sociodemographic Profile Reports
• NHP Navigator maps

Partnerships

• Researchers, Aging and Disability Resource Centers, health insurance companies

NHP Tool Activities to Support the Work

• The coalition is interested in working with researchers to speak at an educational event promoting cancer screening
• Bring data from a successful pilot program distributing test kits to a health insurance company foundation to acquire funding for additional test kits in the future
• When using two types of reports, such as the Sociodemographic Profile Reports and the Neighborhood Health Reports, it’s important to understand the relationship of the data sources to one another. Using these two data sources together provides an opportunity to analyze relationships between factors such as income and screening rates.

Related Policy

• The coalition could advocate for patient financial incentives for preventive care, such as colorectal cancer screening, or increased health insurance coverage for diagnostic colorectal cancer screening to help with costs to participate in the screening

Outcomes

• Analyzed data in the reports
• Strategized as a coalition and created partnerships to identify potential opportunities for action
• Connections with Aging and Disability Resource Centers who serve the counties of the ZIP codes identified as having low colorectal cancer screening rates to distribute the test kits

Community Group

Goals

• Demonstrate why additional parks and sidewalks are needed to help community members exercise safely outside

NHP Data Used

• Neighborhood Health Reports on diabetes and recommended body mass index

Partnerships

• City planners, school board members, local clinicians

NHP Tool Activities to Support the Work

• A lack of exercise is a well known risk factor for developing type 2 diabetes. The community group could use the reports to highlight zip codes that have high rates of diabetes. The group could then use the Action plan to create a detailed plan that clearly describes the steps needed to successfully create additional parks and build sidewalks to help community members exercise safely outside.
• An additional tool that may be useful is the We All Count Funding Web can be used to:
  • Provide information to all project members
  • Provide transparency to the audience when it comes to reporting
  • Identify power gaps and imbalances

Related Policy

The community group looks for funding opportunities to support for additional parks and sidewalks

Outcomes

• The community group uses local data to show how living conditions impact health outcomes

Community Health Workers (CHWs)

Goals

• Gather local data to dig deeper into health trends they are seeing in the community

NHP Data Used

• Neighborhood Health Reports
• Sociodemographic Profile Reports

Partnerships

• Community leaders, organizations and members, health systems

NHP Tool Activities to Support the Work

• CHWs have the power to help prioritize future efforts to improve health for the community. Using the data in both the Neighborhood Health Reports and Sociodemographic Profile Reports and examining the data in a framework, such as The Social-Ecological Model will help partners understand the complex relationship between an individual's health and the external environment. CHWs have a unique perspective as they are often working with community leaders, organizations, members, and health systems to lift up the needs of the community. Digging into the data and pairing that with testimony from community members can set them up to address a range of health and health equity issues

Related Policy

• Institute a Community Health Worker program or expand CHW programming to continue to pair data with personal testimony

Outcomes

• Community Health Workers use the reports to tailor their communication with patients, with more knowledge about the health outcomes affecting the communities they serve
• CHWs bring a broader population health lens to the healthcare setting and help improve patient-provider communication

Health Department

Goals

• Create the annual Community Health Assessment (CHA)
• Learn more about the health of the population they serve
• Add an additional data source on health outcomes and care to their process

NHP Data Used

• Neighborhood Health Reports (for all measures available) for the ZIP codes the health department serves

Partnerships

• Community members, community organizations, health systems, policymakers

NHP Tool Activities to Support the Work

• Use the State of Minnesota’s Department of Health Connecting Communities with Data practical guide for using electronic health

Related Policy

• The health department adapts their organizational level policy on CHA’s to more effectively incorporate data in the CHA process and use it as a tool for shared understanding of the disparities of the health outcomes in their county

Outcomes

• The health department includes data from NHP in their CHA, which will also inform their community health improvement plan

Master of Public Health Student

Goals

• Explore data from NHP on women’s health screening measures in three counties in Wisconsin
• Develop a surveillance report for her MPH capstone project
• Identify best practices to improve screening rates from organizations working in high-performing ZIPs in the counties

NHP Data Used

• Neighborhood Health Reports for breast cancer screening and cervical cancer screening in Racine, Kenosha, and Walworth counties

Partnerships

• Clinics in the ZIP codes with high screening rates

NHP Tool Activities to Support the Work

• She uses the Creating Strong Community-Academic Partnerships section of the Partnerships tool before she reaches out to interview clinics
• The student explores evidence-based actions to improve screening rates

Related Policy

• The student drafts a legislative testimony in support of paid sick leave policies that would allow more people to take time off of work to get to medical appointments

Outcomes

• The student reviews the Neighborhood Health Reports and presents a summary of the data in a surveillance report for her MPH capstone project
• She conducts interviews with clinics in the ZIP codes with high screening rates and conducts a literature review to learn best practices to improve screening rates to include in the capstone report

Health System

Goals

• Learn how many people in their service area do not have internet coverage
• Increase existing telehealth programs to better serve their patients

NHP Data Used

• Sociodemographic Profile Reports for each ZIP code in their service area

Partnerships

• Policymakers, businesses

NHP Tool Activities to Support the Work

• County Health Rankings & Roadmaps’ What Works for Health page on broadband initiatives for unserved and underserved areas

Related Policy

• Advocate to local policymakers about advancing broadband coverage in their communities

Outcomes

• They learn that three of the ZIP codes they serve have many people without internet coverage. They take this information into consideration when developing telehealth programming
  • Short-term: They will prioritize email, phone, and mail outreach to patients in those areas and offer transportation vouchers if needed
  • Long-term: They will work with local policymakers and businesses to advocate for improved broadband coverage in these areas