To: County of Sonoma Board of Supervisors
Department or Agency Name(s): Department of Health Services
Staff Name and Phone Number: Tina Rivera, 707-565-4774
Vote Requirement: Majority
Supervisorial District(s): Countywide
Title:
Title
Community Health Assessment and Community Health Improvement Plan
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Recommended Action:
Recommended action
Receive a report on Community Health Assessment and Community Health Improvement Plan progress.
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Executive Summary:
The Department of Health Services (hereinafter “DHS” or “the Department”) is providing a progress report on the Department’s efforts toward completing a Community Health Assessment and Community Health Improvement Plan for the County of Sonoma.
The State Budget Act of 2022 provided $200 million annually through FY 2025-26 (contingent on annual budget adoption) to Local Health Jurisdictions for public health workforce and infrastructure. The County of Sonoma was awarded $2.2 million to invest in the Future of Public Health <https://www.cdph.ca.gov/Programs/RPHO/Pages/All-Local-Health-Jurisdiction-Letters-Notices/FOPH-FY2023-24-FY2025-26_6-30-23.aspx> initiative. The state’s Future of Public Health initiative emphasizes that everyone, regardless of race, ethnicity, gender identity, sexual orientation, geography, or income level, deserves the chance to be healthy - with the aim to close the life expectancy gap by 50% and reduce disease burden by 15% within in the next decade.
The Future of Public Health funding supports local efforts to prepare and submit a Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP). Local Health Jurisdictions are required to submit three-year Local Public Health Workplan and annual Spend Plans. The CHA and CHIP are now standard tools expected from all health jurisdictions and should inform the County’s Local Public Health Workplan.
This report includes preliminary findings and an update on the assessment and development of the Community Health Improvement Plan. The Department will provide annual updates to the Board.
Discussion:
The Budget Act of 2022, included $200 million annually to Local Health Jurisdictions for public health workforce and infrastructure referred to as Future of Public Health funding through FY 2025-26. This initiative directed state funding toward state and local health jurisdictions and was intended to build public health capacity, which had been identified as deficient and lacking sufficient investment and capacity statewide during the COVID pandemic.
The funds are aimed at improving the ability of public health departments to meet the needs of their communities. $100 million was directed towards the California Department of Public Health (CDPH) for internal capacity expansion and enhancement. CDPH was directed by the legislation to pass $200 million onto local health jurisdictions through a non-competitive grant program. Sonoma County received $2.2 million in FY 22-23 and an additional $2.2 million in FY 23-24. The County of Sonoma is to receive this amount as part of the state budget process as the funds are considered a part of the ongoing baseline state budget.
The Future of Public Health funds are intended to increase the capacity and performance of local jurisdictions to apply the latest standards of performance and institute best practices. These actions support an emerging Public Health framework to be implemented nationally. The Future of Public Health funding supports local efforts to prepare and submit a Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP). Local Health Jurisdictions are required to submit three-year Local Public Health Workplan and annual Spend Plans. The CHA and CHIP are now standard tools expected from all health jurisdictions and should inform the County’s Local Public Health Workplan to be prepared and submitted to the California Department of Public Health every three years.
A CHA refers to a state, tribal, local, or territorial health assessment that identifies key health needs and issues through systematic, comprehensive data collection and analysis.
A CHIP is a long-term, systematic effort to address public health problems based on the results of community health assessment activities and the community health improvement process. This plan is used by health and other governmental education and human service agencies, in collaboration with community partners, to set priorities and coordinate and target resources. A CHIP is critical for developing policies and defining actions to target efforts that promote health. It should define the vision for the health of the community through a collaborative process and should address the gamut of strengths, weaknesses, challenges, and opportunities that exist in the community to improve the health status of that community.
Methodology
The Department embarked on the creation of the Community Health Assessment and Improvement Plan in the late fall of 2022, shortly after receiving funding from the state. An internal steering committee of nine staff drawn from the Public Health Division, the Health Data and Evaluation Team, and the Health Policy, Planning and Equity Team was established. They began meeting weekly to develop a work plan, establish deadlines, and assign roles.
The development of the DHS Community Health Assessment and Improvement Plan is a two-phase process. The first phase, which culminated with a draft report (Attachment 1 and 2) submitted to CDPH in December 2023, provides a summary of priority health needs and responsive strategies developed through a thorough data scan and the input of DHS staff and leadership from multiple community sectors (hospitals, clinics, behavioral health, education, housing, etc.).
Phase two, launching in 2024, will focus on revising this initial report and resulting plan to better reflect the needs and goals of community members themselves through community engagement and elevation of the work of Health Action Together. Health Action Together is currently conducting listening sessions with community members who live in the highest need census tracts as identified by the Portrait of Sonoma 2021 Update <https://upstreaminvestments.org/impact-make-a-change/portrait-of-sonoma-county>. These grassroots sessions are community-led and will give voice to experiences and ideas of people and neighborhoods often overlooked. The second phase will continue through 2024 and the final CHA/CHIP will be presented to your Board in early 2025.
The assessment process utilized two significant public health frameworks - the framework designed by the Bay Area Regional Health Inequities Initiative and the Life Course Perspective. The first framework identifies how racism and other forms of discrimination impact health outcomes while the second identifies how events across the life span shape health throughout one’s life and identifies points where large differences can be made in promoting or restoring health and wellbeing.
During the assessment, staff pulled data on Sonoma County from a variety of sources and performed quantitative analyses to discern patterns and significant findings. Staff also utilized qualitative methods because quantitative methods can often fail to provide insight into how people are experiencing their lives and may miss certain demographics. Numerous health systems in the county contributed qualitative data they collected as part of their periodic Community Health Needs Assessments. These are required of all nonprofit health systems and were recently completed by Providence Health System, Sutter, and Kaiser Permanente. In addition, the Department also used data from the Area Agency on Aging 2023 needs assessment, the May 2023 DHS Community Forum on Mental Health, the Mental Health Services Act (MHSA), and Community Program Planning Workgroup studies. It also conducted a series of stakeholder meetings with representatives from numerous community groups and local health systems and DHS staff. Key informant interviews from subject matter experts in critical areas of health rounded out the study phase.
Sonoma County’s Community Health Assessment
The Community Health Assessment organizes its findings across five major areas:
1. Physical Environment
2. Socioeconomic Factors
3. Health Care Access
4. Physical Health
5. Mental Health
Epidemiologists from the Department pulled data in these areas and compared local statistics with those in other parts of the state and nation. It highlighted places where the health of Sonoma County residents fell short of the median or where health risks were elevated in comparison to the rest of the nation or where a concerning trend indicated the situation was worsening.
1. In the area of Physical Environment, the study identified that Sonoma County has been significantly impacted by climate change and that residents face high risk of wildfire. Particulate matter can be worse than other regions. Heat and access to affordable fresh foods is trending negatively.
2. With respect to Socioeconomic Factors, residents of the county are at greater risk of adverse childhood experiences compared to other parts of the state. In addition, in terms of food insecurity, educational attainment, self-sufficiency and housing/ homelessness, Sonoma County experiences significant disparities across racial and ethnic groups. In 2022, only 1 in 5 (22%) Sonoma County children entered kindergarten “ready to go.”
3. In the area of Health Care Access, Sonoma County sees worrying trends in the ratio of providers to residents and, in particular, in the ratio of mental health providers to residents. Emergency department visits and access to primary, preventive care are trending in the wrong direction. Sutter focus group participants described fractured, siloed, and dysfunctional systems; strategic coordination, they noted, is needed among behavioral health providers, hospitals and emergency departments, community-based organizations, the County, and the criminal/legal system. Those answering a survey from the Area Agency on Aging reported not knowing what services were available to them.
4. In regard to Physical Wellbeing, the Department observed several areas of concern. Despite Sonoma County residents having lower rates of pre-term birth, lower levels of obesity and greater levels of physical activity, DHS epidemiologists saw significant disparities across numerous disease areas including diabetes, sexually transmitted infections (STIs), cancer, smoking, and heart disease. Cancer and heart disease are among the leading causes of premature death in Sonoma County. HIV and early syphilis cases are on the rise. The life expectancy of community members has decreased by 1.7 years as compared to the 2017-2019 three-year average. Due to underlying social inequities that increase health risks, COVID-19 was the number one leading cause of death for Latino community members in 2021, while it was the sixth leading cause for the community overall. The picture around Mental Health and Mental Well-being was perhaps most dire. Trends were concerning in the areas of excessive drinking, alcohol involved motor vehicle collisions, adult psychological distress, self-harm among women, and deaths of despair (alcoholism, overdose and suicide).
Having completed the analysis of these areas, the authors of the Sonoma County report, worked with internal and external stakeholders to identify and prioritize areas of need and to craft strategies to influence positive change. These are highlighted in the Community Health Improvement Plan.
Sonoma County’s Community Health Improvement Plan
The Plan which emerged from the assessment process identifies four priority areas. These are the functional areas where the Department will focus its organizational and community health improvement efforts.
The priority areas emerged as the consensus priorities among internal and external stakeholders after the consideration of the analysis in the Community Health Assessment. Under each priority are a set of objectives which outline the strategies the department intends to pursue to address the priority. These are set at a high level as details of the work will be fleshed out on an annual basis. For each objective, there is an indicator which will allow the county to monitor the Department’s progress towards its objectives. The four priorities are:
1. Priority One is to address structural and institutional racism as a critical driver of health as it is the key factor accounting for the disparities noted in Sonoma County’s data. An example of an objective in this area is to establish bi-directional communication that fosters shared decision-making, trust, transparency, and accountability between DHS programs and the populations they serve. An indicator to measure progress in this area is by 2026, Community Health Worker certification, career pathways, training and deployment with DHS are standardized in the County.
2. Priority Two is to improve community members’ connection to resources to support physical and mental health and economic stability. One objective under this area is to assure that all community members are supported in navigating health, social service, and other systems. The indicator identified for this objective is by 2026, the proportion of income-eligible community members enrolled in social service benefit programs will increase as compared to baseline.
3. Priority Three is to improve system of care coordination to address the fragmented systems of care many residents experience, particularly those with lower incomes or severe mental or physical health conditions. An example of an objective under this priority is that health, social service and community resource coordination of care is supported through use of technology. The indicator for this objective is by 2026, FirstWatch data will be actively used as a surveillance tool for drug overdose and other health conditions. FirstWatch is an online tool currently used by the Department to track response time performance and county administrative costs associated with emergency response.
4. Priority Four is to strengthen capacity of mental health and substance use prevention and treatment services. One objective under this priority is that service gaps in the behavioral health landscape are identified through data analysis and community engagement. The indicator for this objective is that by 2026, data and community input are used to inform resource planning for mental health and substance use.
As the Department heads into 2024, it looks forward to launching the second phase of the CHA-CHIP process by taking the draft assessment and plan to communities to delve deeper into the experiences of Sonoma County residents and to examine the resonance of these findings.
The Department will work closely with Health Action Together, in consultation with the Office of Equity, and additional resources to build mechanisms of dialogue with the community to interrogate and investigate the veracity and applicability of this assessment and plan. The Department has learned a good deal from this process and established keen relationships with critical partners. One finding is that there are numerous entities in the county required to complete these studies repeatedly every several years. As a result, some parts of our community are perhaps overstudied and underserved. The Department hopes to work closely with our partners engaged in these studies to find ways to reduce overlap and align work so that communities are not overtaxed by engagement around planning and are instead engaged more appropriately around the design and delivery of interventions and services.
Strategic Plan:
This item directly supports the County’s Five-year Strategic Plan and is aligned with the following pillar, goal, and objective.
Pillar: Healthy and Safe Communities
Goal: Goal 2: Establish equitable and data-driven distribution of services
Objective: Objective 2: Develop and implement dashboard tracking tools to collect data on common outcome measures across Safety Net departments by 2026
Racial Equity:
Was this item identified as an opportunity to apply the Racial Equity Toolkit?
Yes
This item is a report on the development of the County’s Community Health Plan. The plan will inform the County of Sonoma’s delivery of public health programs and services.
The Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP) are critical tools to creating a vision and a roadmap for how a community can determine and achieve its objectives for the health and well-being of the community. The CHIP should define the vision for the health of the community through a collaborative process and should address the gamut of strengths, weaknesses, challenges, and opportunities that exist in the community to improve the health status of that community. Through this process, the Department is committed to a robust and equitable community health planning process.
Data collected in the first phase of the CHA and CHIP development process details multiple areas of disproportionality by race/ethnicity. The CHA used rigorous data from numerous sources. Where possible, these data were disaggregated by race ethnicity. In cases where data could not be disaggregated due to limitations in the data, the Department made efforts to find alternative or complementary data sources, and commits to further examine alternative data sources in the second phase of this work.
By conducting this kind of analysis, the insights, conclusions and improvement plans can be targeted to populations or communities within the county where the disparities in health are greatest or socio-economic needs most profound.
The 2023 DHS Community Health Assessment organizes its findings across five major areas based on places where the health or health risks of Sonoma residents were elevated in comparison to the rest of the nation or where a concerning trend indicated the situation was worsening:
• Physical Environment
• Socioeconomic Factors
• Health Care Access
• Physical Health
• Mental Health
Stakeholders reviewed the data in the above areas and then provided feedback on the areas of greatest need, resulting in the following 4 priority areas of the Community Health Improvement Plan. These are the functional areas where DHS will focus its organizational and community health improvement efforts. These emerged as the consensus priorities among internal and external stakeholders after the consideration of the analysis in the CHA.
• Address structural and institutional racism
• Improve community members’ connection to resources to support physical and mental health and economic stability
• Improve system of care coordination
• Strengthen capacity of mental health and substance use prevention and treatment services
The population level quantitative and qualitative data tell us that, while some health indicators seem to be improving, racial inequities continue to exist (and are even worsening in many cases) in our community. COVID, in particular, had a profound impact on BIPOC young people and their academic readiness and progress.
Social Determinants of Health (i.e., economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context) show us systemic racial inequities that impact opportunity and resource access and contribute to health outcomes. The fact that addressing structural and institutional racism emerged as the top priority area highlights the significant need that exists in our community.
The desired results and outcomes of the CHA/CHIP are to elevate areas of health inequity to help inform awareness and action around structural racism and unequal access to resources to support health and well-being. The CHA/CHIP will be regularly updated to provide an ongoing indication of how Sonoma County is doing in addressing health inequities.
Prior Board Actions:
N/A
Fiscal Summary
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Narrative Explanation of Fiscal Impacts:
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Attachments:
Attachment 1 - CHA/CHIP English
Attachment 2 - CHA/CHIP Spanish
Attachment 3 - Racial Equity Analysis
Related Items “On File” with the Clerk of the Board:
None