Evidence-based population health improvement plan

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For this assessment, you will create a 5-7 slide PowerPoint presentation about a population health improvement plan. You will then record a video of no more than five minutes presenting your PowerPoint.


Master’s-level nurses need to be able to think critically about the evidence, outcomes data, and other relevant information they encounter throughout their daily practice. Often the evidence or information that a nurse encounters, researches, or studies is not presented in the exact context of that nurse’s practice. A key skill of the master’s-level nurse is to transfer evidence from the context in which it was presented and apply it to a different context in order to maximize the benefit to patients in that new context.

Professional Context

Master’s-level nurses need to be able to think beyond the bedside. It is important to be able to research, synthesize, and apply evidence that will result in improved health outcomes for the communities and populations that are part of your care setting. Improving outcomes at a community or population level, even incrementally, can create noticeably significant, aggregate health improvements for patients across all of a care setting.


Your organization has created an initiative to improve one of the pervasive and chronic health concerns in the community. Some examples of possibilities for health improvement initiatives include type 2 diabetes, HIV, obesity, and communicable diseases. You will need to do your own research to gather and evaluate the relevant data for your chosen issue.

Once you have created a presentation for the initiative, you have been asked to present to a group of community stakeholders. The purpose of your presentation is to inform and enlist support for the initiative from your audience.


The optional Evidence-Based Population Health Improvement Plan Presentation Template [PPTX] is provided to help you prepare your slides. If you choose to work without the template, consider referring to Creating a Presentation: A Guide to Writing and Speaking and Guidelines for Effective PowerPoint Presentations.

The suggested headings for your presentation are:

  • Community Data Evaluation.
  • Meeting Community Needs.
  • Measuring Outcomes.
  • Communication Plan.
  • Evidence.

In your presentation, you will:

  • Evaluate the environmental and epidemiological data about your community to determine a population-focused priority for care.
    • Identify the relevant data. This can be communicated in a table or chart. 
    • Describe the major population health issue suggested by the data within your community.
    • Explain how environmental factors affect the health of community residents.
    • Identify the level of evidence, validity, and reliability for each source.
    • Explain what evidence in the current literature (within the last 5 years) supports your evaluation of the data and the population focused priority of care you have selected.
  • Develop an ethical health improvement plan with outcome criteria that addresses the population health priority that you identified in your evaluation.
    • Consider the environmental realities and challenges existing in the community.
    • Include interventions that will meet community needs.
    • Address potential barriers or misunderstandings related to various cultures prevalent in the community.
    • Propose criteria that can be used to evaluate the achievement of the plan’s outcomes for your population health improvement.
      • Explain why your proposed criteria are appropriate and useful measures of success.
  • Explain a plan to collaborate with a specific community organization to support the implementation of the population health improvement in an ethical, culturally sensitive, and inclusive way.
    • Identify the community stakeholders that are relevant to your Population Health Improvement Plan.
    • Develop a clear communication strategy that is mindful of the cultural and ethical expectations of colleagues and community members regarding data privacy.
    • Ensure that your strategy enables you to make complex medical terms and concepts understandable to members of the community regardless of disabilities, language, or level of education.
  • Explain the value and relevance of the evidence and technology resources used as the basis of a population health improvement plan.
    • Explain why the evidence is valuable and relevant to the community health concern you are addressing.
    • Explain why each piece of evidence is appropriate and informs the goal of improving the health of the community.
  • Communicate the Evidence-Based Population Health Improvement Plan in a professional, effective manner that engages the community organization stakeholders and the community-at-large to implement and sustain change.
    • What specific actions can the community stakeholders take themselves to build a feeling of community ownership in your plan?
  • Integrate relevant sources to support assertions, correctly formatting citations and references using APA style.

Submission Requirements

  • Length of submission: 5–7 slides. Balance text with visuals. Avoid text-heavy slides. Use speaker’s notes for additional content.
  • Length of Video Presentation: No more than five minutes.
  • Font and font size: Appropriate size and weight for a presentation, generally 24–28 points for headings; no smaller than 18 points for bullet-point text. Use a suitable professional typeface, such as Times or Arial, throughout the presentation.
  • Number of references: Cite a minimum of 3–5 sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work.
  • APA formatting: Resources and citations are formatted according to current APA style.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

  • Competency 1: Apply evidence-based practice to plan patient-centered care.
    • Explain a plan to collaborate with a specific community organization to support the implementation of the population health improvement in an ethical, culturally sensitive, and inclusive way.
  • Competency 2: Apply evidence-based practice to design interventions to improve population health.
    • Develop an ethical health improvement plan with outcome criteria that addresses the population health priority for care identified in the evaluation.
  • Competency 3: Evaluate the value, relevance, and ethics of available evidence upon which clinical decisions are made.
    • Evaluate the environmental and epidemiological data about your community to determine a population-focused priority for care.
    • Explain the value and relevance of the evidence and technology resources used as the basis of a population health improvement plan
  • Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with organizational, professional, and scholarly standards.
    • Communicates the Evidence-Based Population Health Improvement Plan in a professional, effective manner that engages the community organization stakeholders and the community-at-large to implement and sustain change.
    • Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.

2020 vol. 44 no. 5 Australian and New Zealand Journal of Public Health 331
© 2020 The Authors

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is
properly cited, the use is non-commercial and no modifications or adaptations are made.

Despite the benefits of conducting
evidence-based practice, many
public health initiatives remain

unsupported by evidence1 and public
health policies and practices that have been
shown to improve health outcomes are
not routinely implemented.2,3 Maximising
the impact of public health interventions
requires policy-makers and practitioners to
use robust evidence to consider both ‘what’
interventions are effective in addressing
public health issues and ‘how’ such
interventions can best be implemented
into practice. However, organisations that
deliver public health initiatives face a range of
barriers including a lack of skills and capacity
when using and generating evidence to aid
such decision-making.4,5 The development of
decision support tools has been suggested
as a useful strategy to help overcome such

Decision trees are frequently used tools
in health care to assist clinicians to
make evidence-based diagnostic and
therapeutic decisions.7 Such tools may
also be useful for public health policy and
service delivery organisations to aid their
selection of evidence-based interventions
and implementation strategies, and also to
identify where further evidence needs to
be generated. While a number of process
models and decision trees for the medical
and nursing field have been published,3,8 few
of these address consideration of evidence-
informed implementation strategies or
evidence generation needs.

In this editorial, we describe a decision tree
(Figure 1) developed and utilised in a large
public health organisation in NSW, Australia.9

The decision tree tool aims to assist in the
application of research evidence to maximise
the impact of public health programs and
services. The tool helps identify when there
is sufficient evidence to support the delivery
of particular services, and when there is not.
The latter outcome provides an indication
of where further research may be needed,
identifying opportunities to undertake policy
and practice relevant research. At each step in
the decision tree, users are posed a question,
and based on their response, a service and/or
research action is suggested. Health services
may have the capacity and expertise to
conduct research actions or they may need
to commission, partner or collaborate with
researchers to do so. This tool should be used
with other resources such as the Intervention
Scalability and Assessment tool to determine
intervention suitability for scaling up.10 Such
assessments need to consider end-user
values, resource, capability and context.

Step 1. Assessment of intervention
options to address health problem

The Public Health Research and Practice
Decision Tree starts at the point where the
public health service organisation requires
information regarding effective interventions
to address an identified health problem.
Systematic reviews are a recommended
source of such evidence.11 Health services
could employ or train staff, or engage a
research organisation to critically appraise the
findings of such reviews where they exist, or
undertake a review where a contemporary
review does not meet their needs. If a review
identifies that effective interventions exist,
the decision-maker moves to Step 2 of the
tree. If the review identifies either: i) an
absence of evidence regarding the impact
(adverse or beneficial) of interventions on
the health issue; ii) insufficient evidence;
or iii) effective interventions that are not
suitable for implementation in the local
context, (e.g. cannot feasibly be delivered
at scale), the conduct of further research is
desirable to support intervention selection.
Other frameworks have described factors that
need to be considered when determining
the suitability of an intervention for scaling
up, including the severity of the problem
it is seeking to address, the strategic/
political context, the intervention costs and
benefits to the organisation, fidelity and
adaptation to the original program, reach
and acceptability, delivery setting and
workforce, implementation infrastructure
and sustainability.12 To meet this evidence
need, public health service organisations

doi: 10.1111/1753-6405.13023

Improving the impact of public health
service delivery and research: a decision
tree to aid evidence-based public health
practice and research
Luke Wolfenden,1,2 Christopher M. Williams,1,2 Melanie Kingsland,1,2 Sze Lin Yoong,1,2
Nicole Nathan,1,2 Rachel Sutherland,1,2 John Wiggers1,2

1. School of Medicine and Public Health, The University of Newcastle, New South Wales

2. Hunter New England Population Health, New South Wales

Figure 1: Public Health Practice and Research Decision Tree.


332 Australian and New Zealand Journal of Public Health 2020 vol. 44 no. 5
© 2020 The Authors


could undertake research, partner with a
research organisation, or commission such a
trial to test the impact of a new or adapted
intervention that aligns with the health
service values, capability, infrastructure and

Step 2: Assessment of evidence-
practice gaps

Once an effective intervention option
has been identified or developed, an
assessment of the extent to which it is
currently being implemented in practice
is required (evidence-practice gap
assessment).13 Such assessments identify
service delivery gaps that may benefit
from investment in strategies to improve
intervention implementation. Given the
importance of equity for many service
organisations, this assessment should
address gaps in implementation across
population sub-groups. Evidence-practice
gap assessments can be conducted by
service delivery staff or in partnership with
researchers through an analysis of routinely
collected administrative or service data,
or by purpose-specific data collection
activities including surveys, stakeholder
engagement processes, or service delivery
observations. If an evidence-gap assessment
reveals effective interventions are being
routinely implemented, and according to a
sufficient standard across population sub-
groups, no further investment in enhancing
implementation is required. Nonetheless,
a monitoring strategy is recommended
to ensure implementation is maintained.
Existing public health surveillance systems
could be used for this purpose,14 or local
monitoring or data collection systems could
be developed.

Step 3: Assessment of implementation

When an evidence-practice gap for a suitable
and effective intervention is identified,
the service organisation needs to identify
effective strategies to ensure adequate
implementation of the intervention.
Again, systematic reviews can be used or
undertaken to assess the effectiveness of
implementation strategies. However, the
effects of implementation strategies are likely
to be contextually dependent, and so the
selection of appropriate strategies should also
be guided by local data on implementation
barriers. Together with systematic review
evidence, the use of theoretical frameworks

can help to select potentially effective
strategies to overcome implementation
barriers that have been identified locally.15
Effective and contextually relevant strategies
that can be feasibly delivered within the
resources and infrastructure available
should be preferenced and employed to
implement the intervention. Ongoing
monitoring is also recommended to: i) ensure
the implementation occurs as planned; ii)
afford early identification and response to
implementation or sustainability challenges;
and iii) provide a mechanism for performance

If no effective and contextually appropriate
implementation strategies are identified
through this process, public health services
may undertake, partner or commission an
implementation trial to test the impact of an
appropriate implementation strategy.


The decision tree is a simple resource
intended to assist health service practice and
to foster the conduct of practice relevant
research. The tree has the potential to
improve the impact of public health research
by identifying opportunities where the
enhanced alignment of research with the
evidence needs of end-users is needed.

1. Indig D, Lee K, Grunseit A, et al. Pathways for scaling

up public health interventions. BMC Public Health.

2. Wolfenden L, Nathan N, Janssen LM, et al. Multi-
strategic intervention to enhance implementation of
healthy canteen policy: A randomised controlled trial.
Implement Sci. 2017;12:6.

3. Hills A, Nathan N, Robinson K, et al. Improvement in
primary school adherence to the NSW Healthy School
Canteen Strategy in 2007 and 2010. Health Promot J
Austr. 2015;26:89-92.

4. Oliver K, Innvar S, Lorenc T, et al. A systematic review
of barriers to and facilitators of the use of evidence by
policymakers. BMC Health Serv Res. 2014;14:2.

5. Tabak RG, Padek MM, Kerner JF, et al. Dissemination
and implementation science training needs: Insights
from practitioners and researchers. Am J Prev Med.

6. Yost J, Dobbins M, Traynor R, et al. Tools to support
evidence-informed public health decision making.
BMC Public Health. 2014;14:728.

7. Podgorelec V, Kokol P, Stiglic B, et al. Decision trees:
An overview and their use in medicine. J Med Syst.

8. Titler MG, Kleiber C, Steelman VJ, et al. The Iowa model
of evidence-based practice to promote quality care. Crit
Care Nurs Clin North Am. 2001;13:497-509.

9. Wolfenden L, Yoong SL, Williams CM, et al. Embedding
researchers in health service organizations improves
research translation and health service performance:
The Australian Hunter New England Population Health
example. J Clin Epidemiol. 2017;85:3-11.

10. Milat A, Lee K, Conte K, Grunseit A, Wolfenden L, van
Nassau F, et al. Intervention Scalability Assessment Tool:
A decision support tool for health policy makers and
implementers. Health Res Policy Syst. 2020;18(1):1.

11. Chambers D, Wilson PM, Thompson CA, et al.
Maximizing the impact of systematic reviews in
health care decision making: A systematic scoping
review of knowledge-translation resources. Milbank
Q. 2011;89:131-56.

12. Milat AJ, Bauman A, Redman S. Narrative review of
models and success factors for scaling up public health
interventions. Implement Sci. 2015;10(1):113.

13. Kitson A, Straus SE. The knowledge-to-action cycle:
Identifying the gaps. Can Med Assoc J. 2010;182:e73.

14. Conte KP, Groen S, Loblay V, et al. Dynamics behind
the scale up of evidence-based obesity prevention:
Protocol for a multi-site case study of an electronic
implementation monitoring system in health
promotion practice. Implement Sci. 2017;12:146.

15. French SD, Green SE, O’Connor DA, et al. Developing
theory-informed behaviour change interventions
to implement evidence into practice: A systematic
approach using the Theoretical Domains Framework.
Implement Sci. 2012;7:38.

Correspondence to: A/Prof Luke Wolfenden,
Hunter New England Population Health,
Locked Bag 10, Wallsend, 2287 NSW;
e-mail: [email protected]

© 2020. This work is published under
http://creativecommons.org/licenses/by-nc-nd/4.0/(the “License”).

Notwithstanding the ProQuest Terms and Conditions, you may use this
content in accordance with the terms of the License.


Public Health Reports
2022, Vol. 137(3) 471 –478

© 2021, Association of Schools and
Programs of Public Health

All rights reserved.
Article reuse guidelines:

DOI: 10.1177/00333549211002767



1 Cancer Prevention Fellowship Program, Division of Cancer Prevention,
National Cancer Institute, Rockville, MD, USA

2 Herschel S. Horowitz Center for Health Literacy, School of Public Health,
University of Maryland, College Park, MD, USA

Corresponding Author:
Heather Platter, PhD, MS, National Cancer Institute, Division of Cancer
Prevention, Cancer Prevention Fellowship Program, 9609 Medical Center
Drive, Rockville, MD 20850, USA.
Email: heather. platter@ nih. gov

The Value of Community Health
Literacy Assessments: Health
Literacy in Maryland

Heather Platter, PhD, MS1,2 ; Katya Kaplow, BS2 ; and Cynthia Baur, PhD2


Objective: Community health assessments have typically not measured health literacy at the community level. We developed the
Community Health Literacy Assessment (CHLA) framework to describe county and regional health literacy activities, assets, gaps,
and opportunities in Maryland.

Methods: We implemented the CHLA framework in Maryland from January to August 2018. We conducted an environmental
scan of Maryland’s 24 counties to identify community resources, health indicators, and organizations. We targeted local health im-
provement coalitions and health departments for interviews in each county. We conducted qualitative interviews to understand
what key community organizations throughout Maryland are doing to implement health literacy best practices and policies. We used
summative content analysis to review, quantify, and interpret interview data.

Results: We conducted 57 interviews with participants from 56 organizations representing all 24 counties in Maryland. We cap-
tured data on multiple dimensions of health literacy and identified 3 main themes: health literacy assets and activities, health literacy
gaps, and health literacy opportunities. The most cited asset was collecting data to inform health literacy practices, the most cited
gap was using jargon with community members, and the most cited opportunity was increasing public awareness of existing health
programs through improved outreach and teaching health information–seeking behaviors.

Conclusion: A systematic community health literacy assessment is a feasible way to collect a large amount of health literacy data,
which can inform strategic planning, determine community interventions, and ultimately lead us toward a health- literate society. We
recommend that others replicate the CHLA framework to operationalize health literacy as a health indicator and include it as a
community health assessment measure.


health literacy, community health assessment, community health literacy assessment, systematic framework, public health

The Healthy People 2030 Secretary Advisory Committee states
that health literacy occurs when a society provides accurate
health information and services that people can easily find,
understand, and use to inform their decisions and actions.1 This
description shifts the focus of health literacy work from measur-
ing and intervening to change people’s health literacy skills to
measuring and changing professional, organization, and
community- level practices and policies to address health liter-
acy problems and barriers. The 2030 description aligns with rec-
ommendations in the National Action Plan to Improve Health
Literacy, which outlines ways to improve the nation’s health lit-
eracy and create a health- literate society by having public and
private sector organizations, community- based organizations,
health care and education professionals, and policy makers work
together to develop and use health literacy best practices.2 A

focus at the professional, organization, and community level
suggests the need for assessment tools and data that identify
activities and gaps in these contexts and indicate opportunities
for improvement. Although some state- level health literacy data
on people’s health literacy skills are available in the 2003 State

472 Public Health Reports 137(3)Public Health Reports 00(0)2

Assessment of Adult Literacy3 and, more recently, the 2016
Behavioral Risk Factor Surveillance System survey,4 these
population- level data do not characterize what professionals,
organizations, and communities are doing to address health liter-
acy in their own geopolitical areas.5

Organizations can choose from several tools to assess their
internal health literacy practices and policies, such as the Agency
for Healthcare Research and Quality Health Literacy Universal
Precautions Toolkit,6 the Ten Attributes of Health Literate
Health Care Organizations,7 the HLE2 Assessment Tool,8 and
the Health Literacy Champions Toolkit.9 However, the health
literacy field lacks frameworks and assessment tools that extend
beyond single organizations to facilitate descriptions, data col-
lection, and analysis of multiple organizations, communities, or
even geopolitical areas (ie, county) that often share public health
responsibilities and resources that could affect health literacy.10
To address this gap, a team from the University of Maryland
Horowitz Center for Health Literacy, which included the authors
(H.P., K.K., C.B.), adapted the standard community health
assessment process to create a Community Health Literacy
Assessment (CHLA) framework. Maryland was an ideal state in
which to test the framework because some organizations in the
state have made health literacy a priority. Maryland has state
laws encouraging health literacy education and training for stu-
dents and practicing health professionals, and the Center for
Health Literacy leads a statewide coalition. The CHLA frame-
work, which is described elsewhere,11 allowed our team to cap-
ture data on multiple dimensions of health literacy at the county
and local coalition levels and across jurisdictions.

Previously, our team11 proposed that the community health
assessment model used by public health departments and hospi-
tals to gather important community health data in a geographi-
cally defined area could be adapted for health literacy work.12

The framework has 7 steps that organizations can follow to col-
lect health literacy information at the community, county, region,
or state level (Figure). We found that the adapted framework
gives local and county organizations the opportunity to charac-
terize health literacy both internally and across organizations,
and we described participant descriptions of health literacy and
organizational rankings on the use of health literacy best prac-
tices.11 This study reports the results of qualitative analyses of
our Maryland assessment in more detail using the adapted


We conducted an environmental scan to gather background data
on Maryland’s 24 counties. The study team created a template
for each county in Maryland to methodically record important
information found through internet and database searches. The
environmental scan included a review of publicly available
community health assessment reports, county indicators, popu-
lation demographic data, and local health organizations. The
team examined available community health assessments to
understand county health priorities and determine whether
counties were implementing health literacy activities. After the
environmental scan, the team developed an interview protocol,
which included an email template for scheduling interviews and
for talking with local health improvement coalition (LHIC) staff
members to gain access to their membership list to schedule
additional interviews with community leaders, and a semi-
structured interview guide. We pilot- tested the semi- structured
interview guide with 2 health department staff members to
assess question flow, clarity, and understandability. After updat-
ing the interview guide, the team conducted semi- structured

Figure. Community Health Literacy Assessment framework.

Platter et al 473Platter et al 3

interviews with community partners and leaders from
community- based organizations, health departments, health
care facilities, and LHICs throughout Maryland. We used a
qualitative approach to understand what key community organi-
zations, health care facilities, and health departments throughout
Maryland are doing to implement health literacy best practices
and policies to improve individual, community, and population
health literacy.

Our team used purposive sampling to identify and select partic-
ipants who were able to provide information about the health
literacy activities, assets, gaps, and opportunities within their
organization, county, or region. We used information from the
environmental scan of Maryland’s 24 counties (Baltimore City
counted as a 24th county per state guidelines) to create a priority
list for recruiting potential participants. We targeted LHICs first,
because they include local leaders and community partners who
determine and address public health priorities in their communi-
ties. It was also valuable to connect with participants from local
health departments because they often lead community health
assessments in their county. We also contacted hospitals, public
libraries, federally qualified health centers, faith- based organiza-
tions, and nonprofit organizations, although not in any particular
order. We used snowball sampling methods to identify addi-
tional potential participants.

The University of Maryland Institutional Review Board
determined this project to be exempt before data collection. We
contacted participants and asked them to participate in a semi-
structured in- person or telephone interview. Participants gave
verbal consent to participate and allow the research team to tran-
scribe detailed notes during the meeting. Interviews ranged in
length from 30 to 60 minutes, and no compensation was offered.
We used the tested interview guide to facilitate each interview.
Trained team members who conducted the interviews updated
and cleaned the interview notes, which were similar to a tran-
script, and then uploaded and stored them in password- protected
files. Additional details about the methods can be found

Data Analysis
We used summative content analysis to review, quantify, and
interpret interview data.13 We individually reviewed and com-
pared interviews to create codes for health literacy activities,
assets, gaps, and opportunities. A code is a label that represents
a group of similar interview statements or phrases. For example,
we coded a discussion about gaining community input for health
material development through the use of evaluation surveys as
“asset of community input.” We quantified codes by the number
of participants who mentioned a phrase in an interview that
matched the code. We counted interviews with organizations
that serve multiple counties, such as a tri- county LHIC, for each
county served by the organization. The unit of analysis for this

study was the county, providing a denominator of 24. Codes
were open to revision and updated after every few interviews
because the coding process took place while interviews were
still occurring. Interviews concluded when saturation was
reached for each county or no other participants for the county
were available for interviews.

To assess reliability, the first author (H.P.) met biweekly with
the second author (K.K.) to create and review codes. After the
codebook was created and interviews were completed, 2 inde-
pendent coders (H.P., K.K.) coded 6 of the same interviews and
compared codes, which were consistent. To further enhance reli-
ability, member checking was performed with participants (n =
10) and other community members who attended a community
results forum (n = 30), to determine their agreement with inter-
preted results.


We completed 57 interviews with participants from 56 organiza-
tions representing all 24 counties in Maryland during a period of
7 months. Eighteen counties were represented by interviews
with a leader from their county LHIC, and a minimum of 2 inter-
views were completed with organizations per county or LHIC,
ensuring that all 24 counties in Maryland are represented in the
sample and results. Multiple types of organizations were
included in the study (Table 1). Three themes arose during our
analysis of the interviews: health literacy assets and activities,
health literacy gaps, and health literacy opportunities. We com-
bined activities and assets into 1 theme because we considered
health literacy activities to be assets.

Health Literacy Assets and Activities
Participants mentioned 5 key health literacy–oriented activities
or assets currently implemented in their communities (Table 2).
Participants representing all 24 counties in Maryland mentioned
collecting data to inform health literacy practices and discussed

Table 1. Types of organizations participating in interviews about
health literacy best practices and policies, Maryland, 2018

Organization type
No. of counties

(N = 24)

No. of

(N = 57)

Local health improvement

18 21

Health department 7 12

Hospital 6 7

Community health center 5 6

Literacy council, public
school, and public library

5 5

Nonprofit organization 3 3

Faith- based organization 2 2

Cooperative extension 1 1

474 Public Health Reports 137(3)Public Health Reports 00(0)4

community outreach and educational materials, such as sharing
health education print or digital materials to improve patients’
ability to manage their own health.

Another common activity and asset mentioned by partici-
pants representing 23 counties was community outreach and
education materials, where organizations provide in- person
health education to community members in a way that they
understand. Navigation services was another asset described by
participants representing 21 counties and defined as an activity
to improve a person’s ability and efficacy to take control of their
own health. Participants representing 21 counties mentioned
evaluating their materials for health literacy, although most par-
ticipants did not specify a tool or technique for evaluation. Only
1 participant mentioned using the CDC Clear Communication
Index14 to evaluate materials.

Health Literacy Gaps
Participants identified 5 health literacy gaps (Table 3). Jargon
was a prevalent gap mentioned by participants representing 19
counties. Participants defined jargon as words used by medical
providers, programs, or health care workers that may be difficult
to understand, and no explanation of these words is provided in
plain language to community members. One participant repre-
senting several counties said that “[e]veryone is using acronyms,
[which is] so confusing.”

Another gap, mentioned by participants from 17 counties,
was limited funds dedicated to health literacy activities. One
participant from a rural county shared that there are “no separate
funds related to health literacy incorporated into the budget.”
Seventeen participants also noted that no staff members were
dedicated to conducting health literacy–related work in the

Participants from 13 counties stated that they had no process
in place to evaluate the effectiveness of their programs or mate-
rials in relation to health literacy. Participants from 8 counties
mentioned a lack of advocacy for the importance of health liter-
acy and the improvement of programs through implementing
health literacy techniques and best practices.

Health Literacy Opportunities
Participants identified 5 opportunities to improve health lit-
eracy within their organization, community, or county
(Table 4). Participants representing 21 counties discussed the
need to increase public awareness of existing health pro-
grams and services through improved outreach and by teach-
ing better health information–seeking behaviors. Participants
from organizations in 19 counties mentioned the need to
bring health literacy into discussions at organizational meet-
ings to raise awareness of the importance of health literacy in
all aspects of the health care system. Participants

Table 2. Health literacy assets and activities reported by interviewees (N = 56), Maryland, 2018a

No. of counties

(N = 24) Quotes

Data collection to inform health
literacy practices

24 Through the needs assessment, we know education and literacy levels are lower
than the state average. We did do a survey of clinics and health departments
5 years ago to ask about health literacy and found that patients don’t get help
filling out forms or understand[ing] prescriptions.

—Local health improvement coalition

Community outreach and
education materials

24 [The] county gave [the] workgroup money to print pamphlets that give patients
resources, hotlines, and community services, in Spanish on the back. They
printed another card that talks about how the language used by family and
support members can cause stigma and how stigma can prevent people from
seeking help.

—Local health improvement coalition

In- person community outreach
and education

23 A lot of the people we serve are in their homes; community health workers
go over discharge papers with clients. Community health workers will also
rewrite meal plans with clients and teach them about medication safety.

—Community health center

Navigation services 21 During health literacy classes at the hospital, one of our tutors works with
groups to discuss health and why it’s important. She gave them a tour of the
hospital and taught them how to navigate the hospital over a few weeks.

—Literacy program

Health literacy material evaluation 21 We have the public relations department and patient advisory council review
things like opioid use education flyers. We also use our education advisory
and quality management group.


aInterviewees were from local health improvement coalitions, health departments, hospitals, community health centers, literacy councils, public schools,
public libraries, nonprofit organizations, faith- based organizations, and a cooperative extension.

Platter et al 475Platter et al 5

representing 19 counties also noted that increasing or
improving current collaborations and partnerships to address
health literacy was an opportunity to improve health

Participants from 17 counties suggested offering health
literacy training to all staff members. A participant from a
rural county said, “[m]y greater hope is not so much for the
populations, but for the awareness of clinicians, nurses, and

Table 3. Health literacy gaps reported by interviewees (N = 56), Maryland, 2018a

No. of counties

(N = 24) Quotes

Jargon 19 Vocabulary level on the provider end is not the same as anyone else; even
educated people have trouble understanding providers or dentists.

—Community health center

Limited health literacy funding 17 We need more funding toward initiatives to address health literacy

—Health department

No dedicated health literacy staff

17 It is difficult to keep up with the health literacy information in the county
because there are only 5 community health workers in the entire county
to collect data on health literacy.

—Health department

No health literacy evaluation 13 In our Health Wellness Division, [we have] family services and literacy efforts
around those programs. But that doesn’t tell you about the impact we are
having because we are not measuring. No ways to measure health literacy
… gaps [and the] stratification of our population.

—Health department

Lack of health literacy advocacy 8 [There is] no statewide health literacy program or overall initiative so all
of Maryland could align themselves around the goal to improve health

—Health department

aInterviewees were from local health improvement coalitions, health departments, hospitals, community health centers, literacy councils, public schools,
public libraries, nonprofit organizations, faith- based organizations, and a cooperative extension.

Table 4. Health literacy opportunities reported by interviewees (N = 56), Maryland, 2018a

No. of counties

(N = 24) Quotes

Increase public awareness of existing
health programs

21 It’s because people don’t understand what each organization does
and how it can help them. People don’t know the services that are
provided through these resources.

—Local health improvement coalition

Raise health literacy awareness 19 The first part is to establish very specific goals. What do we mean by
health literacy and how do we know if we’ve achieved it? Break down
into actionable steps. Work groups that cross many categories of
populations and get stakeholder input.

—Health department

Enhance partnerships to address health

19 Hospital outreach liaison should build relationships with providers
so they will be willing to help [improve the health literacy of their

—Health department

Increase health literacy training 17 Health literacy training for community partners, especially for rural and
low- income audiences.

—Local health improvement coalition

Require health literacy in funding,
programs, curricula, and trainings

16 Include health literacy in our strategic plan . . . so we can really monitor
how people are applying it in their activities.

—Local health improvement coalition

aInterviewees were from local health improvement coalitions, health departments, hospitals, community health centers, literacy councils, public schools,
public libraries, nonprofit organizations, faith- based organizations, and a cooperative extension.

476 Public Health Reports 137(3)Public Health Reports 00(0)6

staff to think twice, slow down, and use teach- back methods.
We need the providers to improve their health literacy tech-
niques.” Finally, participants from 16 counties discussed the
need to standardize and require the implementation of health
literacy principles as part of funding requirements, program
assessments, education curriculums, and required training.


To our knowledge, this study is the first to gather data sys-
tematically on community health literacy in a heterogeneous
state that includes urban, suburban, and rural areas. The
CHLA framework that the team created allows organiza-
tions, communities, regions, and states to enrich their current
community health assessments with new information by
documenting and examining health literacy activities and
assets, opportunities, and gaps, which can be prioritized in
comprehensive health improvement plans. The project team
used the CHLA framework to standardize data collection,
identify and analyze themes in the responses, and character-
ize health literacy at the local and state level. We tested the
framework by collecting preliminary data on health literacy
assets and activities, gaps, and opportunities in Maryland.11

Fifty- seven participants representing 56 organizations in
Maryland identified 15 health literacy assets and activities,
gaps, and opportunities, demonstrating how counties in 1
state address health literacy. This study revealed the impor-
tance of asking how organizations address health literacy in
their communities. The team learned that almost all Maryland
counties used many positive steps to address health literacy.
Respondents for all 24 counties reported that they use data to
inform health literacy practices and that community outreach
and education occur in all counties. Respondents from almost
all counties noted providing navigation services and evaluat-
ing materials for health literacy, although only 1 participant
mentioned using the CDC Clear Communication Index14 as
an evaluation tool.

The gaps and opportunities listed by our respondents
align with literature on the persistence of jargon in public
information, the need for more accessible information, and
the need for trained, dedicated staff members. Jargon as a
routine part of health communication with the public was
confirmed by participants from most Maryland counties,
demonstrating the need for plain language15 and teach-
back training16 for health care, public health, and other
organizations that work with the public. Limited funds and
no dedicated staff members available to conduct health lit-
eracy–related work were 2 widely shared gaps, despite the
need to teach the public better health information–seeking
behaviors and increase outreach to improve public aware-
ness of existing health programs. Participants indicated
that they recognize the importance of internal work to edu-
cate and train staff members and external partnerships to
share resources and best practices and engage in advocacy.

Respondents in 19 counties discussed raising health liter-
acy awareness at organizational meetings, which was also
related to a gap noted in 8 counties about the lack of advo-
cacy for the importance of health literacy. Despite
Maryland’s laws promoting health literacy education and
free courses, toolkits, and readings to train staff members
in the teach- back technique,16 the Health Literacy
Universal Precautions Toolkit,6 the Ten Attributes of
Health Literate Health Care Organizations,7 and the CDC
Clear Communication Index,14 respondents still reported
the need for more staff awareness and training. The last
opportunity noted by 16 counties was to standardize the
implementation of health literacy principles. Organizations
can start a health literacy committee internally or as part of
a coalition to provide training, establish a material review
process, agree on principles, and address other gaps.

The initial application of the CHLA had some limitations.
First, it is a new method and required a new questionnaire
not used in previous studies. Although the concepts used to
generate questions for this first iteration came from the well-
established community health assessment process, and the
items were pilot- tested with 2 health department staff mem-
bers, any new questionnaire requires additional testing,
refinement, and validation. Repeated use of the questionnaire
may identify additional factors or issues not covered by the
questionnaire. The Center for Health Literacy team intends
to use and refine the questionnaire and hopes that other teams
will also test the questionnaire and report their results so that
the field can confirm and build consensus on core validated

A second limitation was the sampling method and unit of
analysis. Although we spoke with participants from organi-
zations of all 24 counties, we were not able to gather the
same level of detail for each county. In addition, we were
unable to speak to an LHIC representative from all 24 coun-
ties because some county LHICs were not very active and
other (more rural) counties had collaborative LHICs that
conducted strategic planning for an entire region. To address
this limitation, the team focused on speaking with partici-
pants from organizations responsible for strategic planning
in the counties, even when the participant was not represent-
ing an LHIC.

A third limitation was that interview data could have been
missed when a single research team member was taking
detailed notes while interviewing. However, two- thirds of
interviews were completed by at least 2 team members (n =
37, 65%), team members were trained on interview tech-
niques, and interviewers could finish taking notes before
advancing to the next question.

A fourth limitation of this project was the inherent bias
associated with self- reported measurements. All interview
responses were self- reports of health literacy efforts in

Platter et al 477Platter et al 7

participants’ organizations and counties. Responses could
have been biased by participants’ lack of knowledge on
improvement efforts, over- or under- describing efforts, not
being able to remember the health literacy tools used in
efforts, or trying to present a positive view of their contribu-
tions. This limitation, however, is the same for organiza-
tional self- assessment tools, such as the Health Literacy
Universal Precautions Toolkit,6 and the team mitigated the
bias with independent background research, a review of pre-
viously completed public community health assessments,
and supplemental interviews with organizations and experts
familiar with Maryland as a whole.


This project offers an initial example to public health practi-
tioners, health care professionals, and researchers about how
to assess community health literacy issues using a standard
framework based on well- established community health
assessment principles. We prioritized LHICs, health depart-
ments, and hospitals because these groups are typically the
ones that decide what should be measured in a community
health assessment. The project team recommends that health
literacy become a part of regular community health assess-
ment measures because results can inform broader commu-
nity health assessments and allow teams to address
community health literacy issues within comprehensive
health improvement plans. Health literacy assessments can
also provide data for health departments’ Public Health
Accreditation Board applications, which require documenta-
tion of health literacy efforts.

The Horowitz Center for Health Literacy intends to repli-
cate this project to refine the data collection process, track
changes in improvement efforts, and deepen our understand-
ing of how community health literacy functions. We recom-
mend that other teams replicate the CHLA framework to
identify similar geopolitical health literacy assets and activi-
ties, gaps, and opportunities. These assessments need to be
repeated periodically before health literacy can be operation-
alized in the same way as other population health indicators,
such as obesity or vaccination rates, and to provide a reliable
account of health literacy at the state and local level.

Authors’ Note

The opinions expressed by the authors are their own, and this
material should not be interpreted as representing the official
viewpoint of the US Department of Health and Human Services,
the National Institutes of Health, or the National Cancer Institute.


The authors acknowledge Neha Trivedi, PhD, MPH; Bridget
Higginbotham, MPH; and Lauren Levy, BS, all former students
from the University of Maryland, College Park, School of
Public Health, for their contributions to instrument creation, data
collection, and data analysis; and the participants who completed

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.


The authors received no financial support for the research,
authorship, and/or publication of this article.


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ED606503. pdf

published: 19 February 2021

doi: 10.3389/fpubh.2021.595786

Frontiers in Public Health | www.frontiersin.org 1 February 2021 | Volume 9 | Article 595786

Edited by:

Hajo Zeeb,

Leibniz Institute for Prevention

Research and Epidemiology

(LG), Germany

Reviewed by:

Lira Pi,

BioStat Solutions, Inc. (BSSI),

United States

Lauren Houghton,

Columbia University, United States

Hande Gencer,

Leibniz Institute for Prevention

Research and Epidemiology

(LG), Germany


Carmen E. Guerra

[email protected]

Specialty section:

This article was submitted to

Life-Course Epidemiology and Social

Inequalities in Health,

a section of the journal

Frontiers in Public Health

Received: 17 August 2020

Accepted: 26 January 2021

Published: 19 February 2021


Guerra CE, Verderame E,

Nicholson A, Wan L and Brooks AD

(2021) A Plan-Do-Study-Act

Approach to the Development,

Implementation and Evaluation of a

Patient Navigation Program to Reduce

Breast Cancer Screening Disparities in

Un- and Under-Insured, Racially and

Ethnically Diverse Urban Women.

Front. Public Health 9:595786.

doi: 10.3389/fpubh.2021.595786

A Plan-Do-Study-Act Approach to
the Development, Implementation
and Evaluation of a Patient
Navigation Program to Reduce
Breast Cancer Screening Disparities
in Un- and Under-Insured, Racially
and Ethnically Diverse Urban Women
Carmen E. Guerra 1,2,3*, Emily Verderame 2, Andrea Nicholson 4, LiYea Wan 2 and

Ari D. Brooks 2,5

1Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States,
2 Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, United States, 3 Leonard Davis Institute for Health

Economics, University of Pennsylvania, Philadelphia, PA, United States, 4MD Anderson Cancer Center at Cooper, Cooper

University Hospital, Camden, NJ, United States, 5Department of Surgery, Perelman School of Medicine, University of

Pennsylvania, Philadelphia, PA, United States

Introduction: For the over 28 million Americans without health insurance, there is a great

need to develop programs that help meet the health needs of the uninsured population.

Materials and Methods: We applied the Plan-Do-Study-Act (PDSA) quality

improvement framework to the development, implementation, and evaluation of a breast

cancer screening navigation program for un- and under-insured women.

Results: Six critical steps emerged: (1) obtain program funding; (2) navigator training;

(3) establish a referral base network of community partners that serve the un- and

under-insured women; (4) implement a process to address the barriers to accessing

mammography; (5) develop a language- and culturally-tailored messaging and media

campaign; and (6) develop measures and process evaluation to optimize and expand

the program’s reach.

Discussion: A Plan-Do-Study-Act approach allowed identification of the key

elements for successful development, implementation and optimization of a breast

cancer screening navigation program aimed at reaching and screening un- and

underinsured women.

Keywords: breast cancer screening, neoplasm, patient navigation, Plan-Do-Study-Act, uninsured, low SES


Breast cancer is the most common cancer and second leading cause of cancer death among women
in the United States (U.S.). Despite a reduction in breast cancer mortality by 40% from 1989 to
2016, breast cancer continues to pose a significant public health burden (1). It is estimated that
in 2020, there will be approximately 276,480 cases diagnosed in women and about 42,170 deaths

Guerra et al. Breast Cancer Screening Navigation Program

due to breast cancer in the U.S. (1). Furthermore, the rate of
decline in death rates has not been equitable. Breast cancer death
rates are approximately 40% higher in Black women compared
to white women, despite similar incidence rates (2). Racial
and ethnic minority groups in the U.S are more likely to be
medically underserved and live in poverty compared to their
White counterparts (2). Racial disparities in breast outcomes
exist due to social, economic, and cultural factors such as
socioeconomic status, employment status; and limited access
to healthcare, safe housing and affordable nutritious food (2).
Although breast cancer screening reduces breast cancer mortality
and thereby remains the cornerstone of breast cancer control (3),
screening remains underutilized in the U.S. (4). In 2018, 73% of
women aged 50–74 years reported having had a mammogram
within the past 2 years (5). However, according to the Center for
Disease Control (CDC), several subpopulations of patients have
lower screening rates (6). In particular, only 30% of uninsured
women over age 40 had undergone a screening mammography
within the past 2 years compared to 69.7% of insured women (6).
Uninsured women are also 2.6 times more likely to be diagnosed
at a later stage of disease and 60% more likely to die from breast
cancer compared to women with health insurance (7). While
there have been recent improvements in access to insurance in
the U.S., 28.5 million individuals living in the U.S., or 8.5% of
the population, did not have health insurance at any point during
2018 (8). Regardless of race/ethncity, for Americans without
health insurance, there is a great need to develop programs that
help meet the health needs of the uninsured population.

Patient navigation programs have been reported to reduce
barriers to care and improve access to services. Navigation
programs have also been shown to improve the quality
measures including increasing the receipt of timely screening
and diagnostic services and treatment after a suspicious
finding, adherence to treatment, and patient satisfaction (9).
Furthermore, such programs are cost-effective (9). In order to
encourage others to design and implement navigation programs
in diverse, un- and under-insured communities that meet
the needs of their communities, we describe the use of the
Plan-Do-Study-Act (PDSA) Framework, first proposed by W.
Edwards Deming and popularized by the Institute for Health
Care Improvement (10), to the process of developing a breast
cancer screening navigation program for un and under-insured
women, its key successes, as well as the challenges and how
these challenges were overcome. This project and all procedures
performed in studies involving human participants were in
accordance with the ethical standards and approved by the
University of Pennsylvania’s Institutional Review Board (IRB).


Below we describe the development of the Penn Medicine Breast
Health Initiative (PBHI), a breast cancer screening navigation

Abbreviations: ACC, Abramson Cancer Center; FQHC, Federally Qualified

Health Center; HPC, Health Promotion Council; DOH, Department of Health;

LCWH, Ludmir Center for Women’s Health; MPH, Master of Public Health;

NBCCEDP, National Breast and Cervical Cancer Early Detection Program; PBHI,

Penn Breast Health Initiative; PDSA, Plan, Do, Study, Act.

program, created to increase access to free, high-quality
mammography for un- and underinsured women and reduce
breast cancer mortality among this underserved group, using
the PDSA framework. The Initiative is based at the Abramson
Cancer Center (ACC) of the University of Pennsylvania, a
National Cancer Institute Comprehensive Cancer Center, located
in Philadelphia. The ACC is also home to the Rena Rowan
Breast Center and the Pennsylvania Hospital Integrated Breast
Center which are accredited by the American College of Surgeons
National Accreditation Program for Breast Centers. We first
describe the needs assessment that led to the program’s creation,
then apply the PDSA model to establishing, evaluating and
optimizing the program.

Needs Health Assessment
Understanding the health need from the perspective of the
community is the critical step to designing a successful navigation
program. It informs the purpose and goals of the navigation
program. Similar to national data (6), data from the Public
Health Management Corporation’s Southeastern Pennsylvania
Household Survey indicated that, in 2015, nearly four in ten
(38%) uninsured women in Philadelphia between the ages of
50–74 reported not having a mammogram in the past year;
this figure represents an estimated 462,200 women (11). The
lower screening rates among uninsured women contribute to
Philadelphia’s breast cancer mortality rate of 28.2/100,000 which
is significantly higher than the state and national rates of
22.8/100,000 and 21.5/100,000, respectively (12). The un- and
under-insured population in Philadelphia, thus, represented one
of the populations with the greatest need for interventions to
increase access to screening mammography.

Plan-Do-Study-Act Framework
There are multiple steps to developing a successful patient
navigation program (13). Using the Plan-Do-Study-Act (PDSA)
Framework (10), we discuss several critical components to the
development of a breast cancer screening patient navigation
program for diverse, un- and under-insured populations. In the
“Plan” stage, the critical elements are: (1) securing the funding
to establish a cost-free screening mammography program; (2)
selection, training and defining the functions of the breast
cancer screening navigator; and (3) establishment of a network
of community partners that serve the un and under-insured
and provide a referral base. The “Do” stage is focused on the
implementation of a navigation process to address the barriers
to accessing mammography including using language and
culturally-tailored messaging and media campaign. The “Study”
stage is defined by tracking enrolled patients and evaluating
program measures that include completion of screening and
diagnostic services and, then, in the “Act” stage, optimizing the
program to expand the reach of the program to serve greater
proportion of un- and under-insured women.

Development of a Breast Cancer Screening
Navigation Program
In the “Plan” stage, the critical elements are: (1) securing
the funding to establish a cost-free screening mammography
program; (2) selection, training and defining the functions of

Frontiers in Public Health | www.frontiersin.org 2 February 2021 | Volume 9 | Article 595786

Guerra et al. Breast Cancer Screening Navigation Program

the breast cancer screening navigator; and (3) establishment of
a referral network of community partners that serve the health
needs of un and under-insured women.

Securing the Funding to Establish a
Cost-Free Screening Mammography
The PBHI program costs include: (1) patient care costs for
screening and diagnostic mammography, breast ultrasounds,
office visits and biopsies which result from both professional and
facility fees; (2) patient navigator salary, benefits and training
costs; (3) program costs include routine administrative costs
such telephone services, mail and postage, program promotional
and educational materials, as well as the costs to overcome
patient barriers including transportation and interpreters. A
combination of contractual, grant and institutional funding
covered the total costs of the program as described below.

In 2014, the ACC became a designated Pennsylvania
Department of Health (DOH) Healthy Woman Program site.
The Pennsylvania DOH Healthy Woman Program is funded by
the CDC National Breast and Cervical Cancer Early Detection
Program (NBCCEDP), a nationwide, comprehensive public
health program with the mission of increasing access to breast
and cervical cancer screening for women who are medically
underserved. Established in 1990, one of the objectives of the
program is to target the racial/ethnic disparities in screening,
diagnosis, and treatment of breast and cervical cancers. The
program provides funding in all 50 states, the District of
Columbia, 6 US territories, and 13 American Indian/Alaska
Native tribes or tribal organizations. Program sites are allocated
slots based on the demonstrated need in their communities.
Many large metropolitan cities have dozens of BCCEDPs to meet
the needs of their large un- and underinsured populations. Of
the 1,309,350 women undergoing breast screening or diagnostic
services through NBCCEDP between July 2013 and 2018 across
the U.S., almost 70% were from racial/ethnic minority groups
(14). The NBCCEDP strategies to increase screening and
breast cancer treatment among racial/ethnic minorities include
reminders for patients, culturally-tailored programs that address
specific beliefs or knowledge gaps, and programs addressing
financial or logistical barriers to screening (15). An analysis of
the NBCCEDP estimated that the number of life-years saved
between 1991 and 2006 was 100,800 compared with no program
and 369,000 life-years compared with no screening (16).

Through a combination of this contract and a portfolio of
grants including from the Susan G. Komen Foundation and
other foundations as well as institutional funding from the ACC,
the program has been able to provide an increasing number
of free breast screening services to eligible women. The ACC
and the Rena Rowan Breast Center provided additional funding
for personnel costs and Penn Medicine has provided support
through office space and translation services.

By contract with the Pennsylvania DOH, Medicaid rates (and
currently Medicare rates) were the maximum reimbursable rates.
The PBHI established a billing contract with Penn Medicine

that allowed the program to charge the Medicaid and Medicare-
adjusted rates for all breast services provided by the PBHI (rather
than commercial rates) which allowed the program an even
greater capacity to support and serve the greatest number of
women possible.

Patient Navigator Selection, Training, and
The PBHI navigator is a Masters of Public Health (MPH)-trained
individual who acts as bridge between the community and the
health care system. The PBHI navigator had to be proficient at
creating community partnerships that permit the identification
of un- and under-insured women in communities, lead and
participate in community educational and outreach events and
navigate patients through a complex health care system. The
navigator received further training at the Harold P. Freeman
Patient Navigation Institute in New York, New York, which
focuses on teaching skills to maximize retention, diagnostic and
treatment resolution rates, cancer navigation best practices and
the conduct of navigation research (17).

The primary function of the navigator is to create a referral
base from community partners and navigators and facilitate
access to screening, diagnostic or treatment care by addressing
language, literacy and cultural barriers, provide emotional
support to patients to reduce fear and improve patient–provider
communication. To overcome communication challenges posed
by differences in language, culture and limited interactions
with health care, communication via the referring community
navigators and partners was determined to be most effective to
establish contact with patients.

The navigator also coordinates the administration, financial
and reporting responsibilities of the program. The navigator
collaborates with radiology departments to implement the
program’s enrollment protocols into the registration and check-
in process. In addition, the navigator also works with the financial
department to create corporate guarantor accounts and prevent
the direct billing of services rendered to patients. It is imperative
to avoid directly billing patients which can create a record of debt
for patients and even jeopardize their credit records. Finally, the
navigator is responsible for maintaining detailed records to allow
for call backs for screening or diagnostic testing when medically
necessary, for administrative reporting to grant sponsors and for
internal quality improvement and program evaluation purposes.

Establishing a Referral Base From a
Network of Community Partners That
Serve the Health Needs of Un- and
Under-Insured Women
Since un- and under-insured patients are unlikely to seek
a screening mammography due to its prohibitive costs and
lack of access, it was critical for the navigator to develop a
robust network of community partners which serve the un-
and underinsured communities in the region. Since a portion
of the target population is already accessing primary care
through Federally Qualified Health Centers (FQHCs), the PBHI
partners with multiple primary care clinics at FQHCs and

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Guerra et al. Breast Cancer Screening Navigation Program

TABLE 1 | Penn Medicine breast health initiative community partner network.

Organization Type of


Organization description Location Primary population


Health Promotion Council Non-profit An affiliate of Public Health Management Corporation


Center City West Hispanic/Latinx

Southeast Asian Mutual

Assistance Association

Coalition (SEAMAAC)

Non-profit One of the oldest and largest refugee founded agencies

in the region

South Philadelphia Asian

Congreso de Latinos Unidos Non-profit,


FQHC in partnership with PHMC Fairhill Hispanic/Latinx

BEBASHI Non-profit Services for breast health, sexual health and hunger relief Kensington Black

Health Annex FQHC An affiliate of Family Practice & Counseling Network, a

program for Resources of Human Development



African, White, Black

National Black Leadership

Initiative on Cancer (NBLIC)

Non-profit Greater Philadelphia Chapter, launched as the first

minority outreach project of the National Cancer Institute

under the leadership of Louis W. Sullivan, M.D.,

Morehouse School of Medicine President Emeritus and

Former Secretary of the US Dept of Health and Human


Poplar Black

African Family Health

Organization (AFAHO)





A non-profit organization that connects African and

Caribbean immigrants and refugees to health care

Belmont African and Caribbean

immigrants and refugees

Puentes de Salud Non-Profit A non-profit focused on health, education and

community building

Center City Hispanic/Latinx

Greater Philadelphia Health

Action (GPHA)

Non-profit A non-profit to increase access to health care for un and

underinsured families

12 locations

throughout the

Greater Philadelphia


White, Black, Asian,


Maria de los Santos Health



Health Center

Part of Delaware Valley Community Health, Inc., the

largest provider of primary health care services to Latinos

in Philadelphia

Fairhill Hispanic/Latinx

Norristown Regional Health


FQHC Part of Delaware Valley Community Health, Inc.,

Montgomery County’s first FQHC providing health,

behavioral and dental services to communities

Norristown Hispanic/Latinx, African


Ludmir Center For Women’s



Health Clinic

Based at Penn Medicine’s Pennsylvania Hospital and a

Healthywoman program provider for obstetrics and

gynecology services


Square/Center City



Rising Sun Health Center Non-profit Program of Philadelphia Health Management


Olney Hispanic/Latinx

Cambodian Association of

Greater Philadelphia

Non-profit Philadelphia’s foundation of social, health and education


Olney Cambodian

Horizon House Health Center Primary Care


First behavioral health care center in Philadelphia to

integrate medical care and behavioral health

Fairmount White, Black, Asian,


Philadelphia Corporation for

Aging (PCA)



One of the largest non-profit organizations in the region Fairmount Seniors, people with


non-profit community organizations to identify and refer the
target population for breast cancer screening services (Table 1).
During the time this program was planned, over 300,000 patients
made visits to Philadelphia area FQHCs and other community
health centers with 97% of patients reporting incomes <200%
of the Federal Poverty level (18). Subsequently, the program
has established and maintained over a dozen partnerships with
FQHCs in the Philadelphia area which have been critical in the
development of the program’s referral base and reaching the
target population.

On the other hand, many un-and underinsured women are
not accessing care at all. To reach this portion of our target
population, the PBHI partners with community-based, non-
profit organizations that employ community lay navigators that
can identify and refer patients to the program. One example of
such a partner organization is the Health Promotion Council of
Southeastern Pennsylvania (HPC), an affiliate of the Philadelphia
Health Management Corporation, a non-profit corporation that
conducts community-based outreach, education and advocacy
for vulnerable populations. Through a subcontract funded by

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Guerra et al. Breast Cancer Screening Navigation Program

the Susan G. Komen National Foundation, HPC employed
two community navigators that helped to identify women in
need of breast cancer screening in the community and linked
these women with the PBHI navigator. These agencies organize
many different free community events which helps the HPC
community navigators identify women overdue for breast cancer
screening and connect them with the PBHI navigator. The
navigator also attends and leads outreach and educational events,
health fairs and breast symposiums regularly to engage women
in need of breast health services. The navigator follows up with
these women by phone to enroll patients in the program and
schedule screenings.

The navigator also receives referrals from word of mouth, as a
result of marketing and advertising efforts and through internal
daily requests via other Penn Medicine health care providers and
employees such as patient service associates, radiology managers,
when patients are deemed un- and underinsured. Referrals are
made through a HIPAA-compliant form containing patient’s
contact information that is securely faxed to the navigator.

Establishing a Navigation Process to
Address the Barriers to Accessing
We developed a step-by step process for breast cancer screening
navigation (Appendix 1) to outline the “Do” component of
the PDSA cycle. The navigator must first confirm patient
eligibility for enrollment in the PBHI. Patients must be of the
guideline-recommended screening age and due for a screening
mammogram or be experiencing a new breast problem, such
as a breast lump, nipple discharge, breast mass or breast pain.
To be enrolled in the Healthy Woman Program, patients must
be a Pennsylvania resident, un-insured or under-insured (i.e.,
have a high co-pay or deductible they cannot afford) and meet
household income guidelines (at or below 250% of the Federal
Poverty Income level).

Un- and underinsured patients who are ineligible for the
Healthy Woman Program and in need of breast services are
enrolled in the PBHI and their services are covered using
alternative grant or philanthropic funding. The additional
funding also allows the program to serve New Jersey residents
who are within the ACC’s catchment area, but do not qualify for
the Pennsylvania-funded program and to males experiencing a
breast problem.

Over half (58%) of the PBHI’s patient population speaks a
language other than English (Table 2). To bridge language and
communication barriers, the navigator has a dedicated phone
line that patients can contact directly and uses a hospital-
provided translational service when communicating with non-
English speaking patients over the phone. In-person language
interpreters and on-demand video interpretation via Martii
devices are available to non-English speaking patients at their
appointments. To further address language barriers, program
promotional materials and breast health educational materials
are available in a variety of languages including Spanish,
Mandarin, and Vietnamese. Result and reminder letters are also
translated for non-English speaking patients.

TABLE 2 | Demographics (n = 1,974).

Age, mean (s.d.) 48 (9.7)

Age distribution

<40 15%

40–49 45%

50–64 37%

65+ 3%


White 44%

Black 27%

Other 17%

Unknown 12%


Hispanic/Latino 53%

Non-Hispanic/Latino 36%

Unknown 11%


English 42%

Non-English 58%

Spanish 78%

Mandarin 11%

Other 11%

Likewise, cultural barriers are prominent among the PBHI
population and important to address. Differences in cultural
beliefs between the provider and the patient affect how
patients perceive medical information and the concept of health
and illness in general. The PBHI navigator works closely
with our diverse group of partner organizations to provide
culturally-tailored messages and appropriate care. To improve
cross–cultural communication, the navigator expresses any
patient concerns to the point of contact from the patient’s
referring organization and seeks guidance about how to more
effectively communicate with patients in light of differences in
cultural beliefs.

Language and cultural barriers are linked with low health
literacy (19). In addition to having program and educational
materials in various languages, the PBHI ensures that all
information is written for individuals with lowest literacy levels
(6–8th grade) in order to effectively reach our target population.
The navigator also offers patients help with completion of any
forms needed to access care.

Transportation was also reported as a barrier by PBHI
patients. To address transportation barriers, the PBHI offers
public transportation vouchers to help patients and their
caregiver travel to and from appointments.

Patients frequently report fear of a cancer diagnosis as
a barrier in accessing care, especially after receiving an
abnormal mammogram result. The PBHI navigator responds to
statements about fear with information, emotional support and
encouragement to patients. The navigator also provides patients
with her direct land and cell phone numbers which allows
patients to reach the navigator at their convenience if they had
any questions or concerns.

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Guerra et al. Breast Cancer Screening Navigation Program

In an effort to best accommodate patients, minimize
travel and maximizing convenience, the program’s services are
available to patients at a variety of Penn Medicine’s community
radiology locations in the Greater Philadelphia region including
Pennsylvania Hospital (Center City), The PerelmanCenter (West
Philly), Radnor Hospital, Valley Forge, Bucks County,Woodbury
Heights, NJ and Cherry Hill, NJ.

Furthermore, in addition to offering cost-free breast cancer
screening services, the navigator offers referrals for free
cervical cancer screenings at the Ludmir Center for Women’s
Health (LCWH), a Penn Medicine, Pennsylvania’s DOH Breast
and Cervical Cancer Early Detection Program/HealthyWoman
program provider located at Pennsylvania Hospital, that offers
gynecology and obstetrics services. This partnership involves
close communication between the PBHI navigator and LCWH
staff to ensure that new and existing un- and underinsured
patients are receiving comprehensive women’s health services.

One of the most important functions of the navigator and
a measure of success of a breast cancer screening navigation
program is follow up of patients with abnormal results to assure
that they receive the necessary follow up diagnostic testing. The
navigator has a detailed protocol for following up patients with
abnormal results, that begins by contacting the program co-
director via the electronic record (EPIC) with the imaging result
and schedules further radiologic workup or an office visit for
each patient. The navigator also generates daily work queues
from EPIC to identify patients enrolled in the program who
have abnormal screening results. The radiology departments also
have a dual process for following up abnormal findings that also
applies to the patients of our program. This includes an attempt
to call the patient, a mailed letter notifying the patient to return
for additional imaging with a telephone number to schedule the
appointment, a reminder letter after 15 days as well as a second
reminder letter and a letter to the referring physician after 30
days. If still unsuccessful in reaching the patient after six attempts,
the navigator reaches out to the referring clinic, provider or
community partner to ensure that the patient is not lost to follow
up. For example, the PBHI partners with community navigators
at the HPC who are available to visit patients’ homes, if needed,
to provide further education and explain the importance of
follow-up studies to patients.

Patients who complete a diagnostic mammogram receive the
results immediately after their test directly from the radiologist
reading the studies, using translation services if necessary.
Patients that require a biopsy are scheduled for appropriate
follow-up studies immediately after receiving their results, and,
if needed, arrangements are made so that they are accompanied
by our partners’ community navigators. This removes any
uncertainty regarding appropriate follow-up and contact.

If a woman is diagnosed with breast cancer, the PBHI
also offers assistance with enrolling women in the state health
insurance plan. Immediately preceding a patient’s office visit
with a new diagnosis of breast cancer, the navigator initiates the
first steps in obtaining coverage to minimize delays in receiving
treatment. The navigator works with the Pennsylvania County
Assistance Offices, chooses the office that is in closest proximity
to the patient’s home and gathers all the necessary documents

that are needed to produce an effective application for obtaining
coverage. Upon diagnosis, women are enrolled in the State Breast
and Cervical Cancer Treatment Program and, if ineligible, for
example if the woman is undocumented, then she is enrolled
in Emergency Medical Assistance. The navigator also makes
additional referrals to the ACC’s Financial Advocacy team that
determines if the patient may be eligible to enroll in a health
insurance plan through the marketplace. After securing health
coverage, the navigator transitions the patient into treatment at
the ACC where the Initiative’s co-director, and the ACC’s team of
cancer specialists and nurse navigators continue to support the
patient throughout their treatment.

Developing Culturally-Tailored Messaging
and a Media Campaign
Another important component of the “Do” stage in developing
this program was the development of a multilingual messaging
and media campaign tailored to the needs of the diverse
patients served by the program. According to the Pew Charitable
Trusts’ Philadelphia Research Initiative, in the last 10 years
there has been significant growth in Hispanic communities in
Philadelphia (20). Moreover, 319,310 of Philadelphia residents
speak a language other than English with the most common
foreign language being Spanish (20). Limited English proficiency
is a major barrier in the delivery of medical care among the
uninsured: women who speak Spanish are less likely to be
screened for breast cancer (21). In an effort to develop culturally-
tailored messaging to decrease breast screening disparities
among the Latina population in our community, the PBHI
partners with the American Cancer Society and Univision 65
to hold an annual, “Amate a ti Misma” or a “Love Yourself,”
campaign to encourage women to undergo an annual screening
mammography. The campaign messages, delivered in Spanish
by Univision newscasters, focuses on an all-day screening event
located at the Pennsylvania Hospital. The message addresses the
prevalent cultural beliefs in Latin cultures rooted in Marianismo,
specifically Familismo, that encourage women to care for other
members of her family and dissuade Latinas from putting their
needs first. The message asks Latinas to love themselves by
undergoing a mammogram. The month leading up to the event,
Univision airs public service announcements which include the
PBHI navigator’s phone number. Patients interested in attending
call the navigator to schedule an appointment. If women are
unable to attend the event, they are scheduled for another more
convenient day and time.

Program Evaluation and Optimization
Patient navigation process measures are carefully captured by
the patient navigator to allow us to “Study” the program and
then “Act” to more effectively and efficiently accomplish the
goals of the program. The program tracks the number of
patients referred for services, appointments made and kept,
type of service(s) rendered and their date, screening results,
follow up recommendations, demographic information (race,
ethnicity, age, zip code, city and state, insurance status), referral
information (for breast cancer screening and treatment services
and for cervical cancer screening), navigation services received,

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Guerra et al. Breast Cancer Screening Navigation Program

TABLE 3 | Mammography results by breast imaging reporting and data system (BI-RADS) category (n-1,974 unique patients).

BI-RADS Screening


(n = 1,761)

Screening mammograms with

incomplete follow-up

(n = 11)



(n = 654)

Diagnostic mammograms with

incomplete follow-up

(n = 31)

Cat 0 – Incomplete Exam 167 7 16 5

Cat 1 – Negative 1,194 – 123 –

Cat 2 – Benign 363 – 287 –

Cat 3 – Probably Benign 15 4 118 22

Cat 4 – Suspicious 19 – 95 4

Cat 5 – Highly Suspicious 3 – 15 0

TABLE 4 | Stages of breast cancer diagnosed (n = 25).

Stage n

0 3

I 6

II 7


IV 3

and barriers addressed (including transportation and language
support), among others (this data not shown). The Initiative
also tracks patient outcomes including mammogram and biopsy
results, time to diagnostic resolution, cancer diagnoses, stage of
cancer at diagnosis and cancer treatment (some of this data is
discussed below and shown in Tables 3, 4).

Finally, patients enrolled in the HealthyWoman program are
required to complete the Pennsylvania DOH HealthyWoman
Program enrollment forms before appointments. Patients
complete the forms at check-in and the radiology check-in staff
is required to fax the forms to the navigator and scan the form
in the patient’s electronic medical record. The navigator later
enters all forms into the DOH’s data management system, Med-
IT, a requirement for reimbursement of services rendered. Med-
It is a web-based health screening information database system
that includes demographic information, automatic eligibility
computation, billing and much more. The navigator is able to
query the Med-IT database for clients by provider reports, billing
reports and demographic reports, which allows the evaluation of
the HealthyWoman program’s data separately.

The Initiative measured patient satisfaction in an initial subset
of 90 patients that enrolled in the program using an adapted,
previously published instrument (22). The adapted instrument
which was made available via a translator in the patient’s native
language, consists of 9 items with a 5-point Likert response scale
with anchors very satisfied to very dissatisfied. The mean scores
for each of the 9 items ranged from 4.68 to 4.95 out of amaximum
of 5.00 indicating that patients were generally very satisfied with
the services offered by the program (Table 5).

The ability to capture and analyze all of these measures
allowed us to reflect and innovate (“Act”) to optimize the
program and more effectively and efficiently reach its goals of

TABLE 5 | Patient satisfaction with patient navigation services (n = 90)*.

For each problem, indicate whether you were

very satisfied (very happy), a little satisfied

(happy for the most part), or not satisfied (not

happy) with the help you received from your



1. Making medical appointments 4.95

2. Getting results of tests you had 4.80

3. Dealing with financial concerns related to getting

the care you need


4. Getting transportation to the doctor’s office 4.72

5. Giving you emotional support 4.86

6. Dealing with fears related to your health issues 4.91

7. Getting the health information you need 4.88

8. Understanding the medical tests you got 4.68

9. Dealing with doctors, nurses, and other health

care workers who do not speak your language


*Adapted from Patient satisfaction with logistical aspects of navigation (PSN-L) scale (20).

increasing access to screening and diagnostic mammography
and ultimately reduce the burden of breast cancer among un-
and under-insured women. Our multidisciplinary team met
regularly to map and measure the program’s processes, identify
barriers to accessing the program and redefine our work. The
PDSA model allowed us to strengthen the program over time
by allowing us the ability to reflect on populations that we
were not able to initially reach and then adjust the program to
better serve those populations. For example, initially, there were
women who needed screening or diagnostic mammography,
but who did not meet the eligibility for the Pennsylvania
DOH Healthy Woman Program because they fell out of the
eligible age range and resided in an adjacent state. This led our
team to apply for a Susan G. Komen grant that allowed us
to serve these women. In another example, the PDSA model
allowed us to recognize that the program was not fully reaching
Asian women. Consequently, we sought to develop additional
partnerships with community organizations that serve the Asian
community and grant support to expand our outreach and
engagement with this community. Below we describe some of
the program’s results and key successes that resulted from the

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Guerra et al. Breast Cancer Screening Navigation Program

iterative application of the PDSA cycle to the PBHI as well as
program challenges.


A key success is that over the past 5 years since the program’s
inception (June 2014–June 2019), the Initiative has navigated
1,974 racially and ethnically diverse women providing over 2,000
high quality breast services to women who were previously
unable to access mammography (Table 2). Table 2 also shows the
diversity of the race and ethnicity of the women enrolled in the
program: 10% Asian, 27% Black, 7% other, 12% Unknown, 44%
White; 53% Hispanic. Over half (58%) of women who participate
in the program speak a language other than English, with 78%
Spanish as the most common, 11% speak Mandarin; 11% speak
other languages. Similar to prior research, this work shows
that breast cancer screening navigation programs for uninsured
women are effective and lead to increased screening rates and the
detection of previously undetected breast cancers (23).

Table 3 demonstrates that among 1,974 unique patients,
the program delivered 1,761 screening and 654 diagnostic
mammograms. Among these 11 patients who completed
screening mammograms and 31 patients who completed
diagnostic mammograms did not complete follow-up diagnostic
images. Despite multiple attempts by our navigator by telephone
and mail, via the Health Promotion Council Navigators and the
radiology providers and/or staff, these women were lost to follow
up. In a few of these cases, familymember or community partners
or navigators confirmed that the woman refused additional
images, sought care elsewhere or returned to her native country,
but the reason for incomplete studies was unknown for the
majority of patients and they were classified as lost to follow up.

Another important success of the program is the diagnosis
of breast cancer in 25 patients – all of whom were enrolled in
health insurance and treated at the ACC (Table 4). The majority
of these were diagnosed at a localized stage and that all patients
have received high quality treatment at and support from an
NCI-Comprehensive Cancer Center.

As shown in Table 5, yet another success is the high patient
satisfaction reported among an initial subset of women enrolled
in the programwhich wasmeasured using the Patient Satisfaction
with Logistical Aspects of Navigation Scale (20). However, this
subset represents a group that was slightly older and had half the
proportion of Hispanic patients than the larger cohort we report
here (data not shown). Therefore, the satisfaction results may not
be generalizable to the results of the cohort reported here.


For the over 28 million Americans without health insurance (8),
hospitals often represent their only source of care. Consequently,
there is a great need to develop programs that help meet the
health needs of the uninsured populations and deliver high
quality care. We describe the development of a program that
could be replicated to meet the breast cancer screening needs of

un- and under-insured women. The application of the Plan-Do-
Study-Act quality improvement framework to the development,
implementation, and optimization of a breast cancer screening
navigation program for racially and ethnically diverse un- and
under-insured women and outline the critical elements to guide
this work. Among the critical steps ascertained through this
process are: procurement of program funding from the DOH,
grants and philanthropic sources; training of a navigator in the
establishment of a referral network of community partners that
serve the un and under-insured; establishment of a navigation
process that can overcome barriers to screening and care; design a
language and culturally-tailored messaging and media campaign;
and establishment of clear process measures and evaluation that
can further inform the optimization of the program.

The Penn Medicine Breast Health Initiative was created using
this framework and this analysis summarizes the program’s reach
and impact. In the first 5 years of this program, it reached almost
2,000 women and identified 25 cases of breast cancer. Among the
25 women, only three were identified at stage 4. All 25 women
were enrolled in health insurance and provided with high quality
care at an NCI comprehensive cancer center. Patient satisfaction
with the program, measured in a small subset of 5% of patients,
was high.

The major challenges to establishing a breast cancer screening
navigation program for un- and under-insured diverse patients
include securing the funding for the program’s operating support
which includes the navigator salary, benefits and training
which can be secured through grant, philanthropic and/or
institutional funding. There are also logistical challenges to
reaching this difficult-to-reach population both before engaging
in the program and after for follow up care. This population
generally has transient phone and sometimes housing access.
Traditional methods of communication by telephone and mail
fail these individuals. During situations where patients have an
abnormal finding and require additional follow up, the navigator
works with the referring center that women trust and, at times,
community navigators, to locate the patient. Potential future
strategies for reaching women might include contacting them
at their place of employment or other faith-based and non-faith
based community organizations. There is also the challenge of
securing insurance for patients in a timely manner once they are
diagnosed with cancer. This challenge can be overcome assigning
a case worker or financial advocate to the patient and having this
individual work closely with the navigator who already has an
established relationship and trust with the patient. Furthermore,
under the Protecting Access to Medicare Act of 2014, in order to
expedite insurance coverage and obtain access card information
for any patients enrolled in emergency medical assistance, the
navigator must also complete a waiver to allow the navigator to
retrieve the patient’s coverage information on the patient’s behalf.

Despite these challenges, the BCCEDP program provides
funding to meet the breast cancer screening needs of un- and
under-insured women. We have demonstrated that the Plan-
Do-Study-Act quality improvement framework can be used to
develop, implement, and optimize a breast cancer screening
navigation program that can identify and reduce the burden of
breast cancer in women at risk.

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Guerra et al. Breast Cancer Screening Navigation Program


The raw data supporting the conclusions of this article will be
made available by the authors, without undue reservation.


The studies involving human participants were reviewed and
approved by University of Pennsylvania Institutional Review
Board. Written informed consent for participation was not
required for this study in accordance with the national legislation
and the institutional requirements.


All authors take responsibility for the manuscript, have directly
participated in the planning, development, writing of the article,
read and approved the final version, and consent to our names
on the manuscript. CG have full access to all aspects of the review
and writing process and take final responsibility for the paper.


The Penn Medicine Breast Health Initiative is supported
from the Pennsylvania DOH’s Breast Cancer and Early
Detection/Healthy Woman Program as part of the National

Breast and Cervical Cancer Early Detection Program
(NBCCEDP), Susan G. Komen Foundation National, Susan
G. Komen Foundation Philadelphia, the Allergan Foundation,
the First Hospital Foundation, the Harrison Memorial Fund,
Brander Beacons Cancer Research Foundation, Holman
Enterprises Community Grants program, Penn Medicine
Cares Grant Program, the Rena Rowan Breast Center, and the
Abramson Cancer Center.


The authors also are grateful to Dr. Kevin Fox, Marianne T., and
Robert J. MacDonald Professor in Breast Cancer Care Excellence
at the Abramson Cancer Center, Christina Miller, Marla Vega,
andMaria Barrera, as well as the many community health centers
and organizations in Philadelphia (Table 1) that partnered with
us to reach and deliver screening and care to our un- and
under-insured communities.


The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fpubh.


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at: http://www.pewresearch.org/fact-tank/2016/09/21/unauthorized-

immigrant-population-stable-for-half-a-decade/ (accessed May 23,


21. Coren JS, Filipetto FA, Weiss LB. Eliminating barriers for patients with

limited english proficiency. J Am Osteopath Assoc (2007). 109:634–40.

doi: 10.7556/jaoa.2009.109.12.634

22. Carle AC, Jean-Pierre P, Winters P,Valverde P, Wells K, Simon M, et al.

Psychometric evaluation of the patient satisfaction with logistical aspects of

navigation (PSN-L) scale using item response theory. Med Care. (2014) 52:4.

doi: 10.1097/MLR.0000000000000089

23. Simon MA, Tom LS, Nonzee NJ, Murphy KR, Endress R, Dong XinQi,

et al. Evaluating a bilingual patient navigation program for uninsured women

with abnormal screening tests for breast and cervical cancer: implications

for future navigator research. Am J Public Health. (2015) 105:e87–94.

doi: 10.2105/AJPH.2014.302341

Conflict of Interest: The authors declare that the research was conducted in the

absence of any commercial or financial relationships that could be construed as a

potential conflict of interest.

Copyright © 2021 Guerra, Verderame, Nicholson, Wan and Brooks. This is an open-

access article distributed under the terms of the Creative Commons Attribution

License (CC BY). The use, distribution or reproduction in other forums is permitted,

provided the original author(s) and the copyright owner(s) are credited and that the

original publication in this journal is cited, in accordance with accepted academic

practice. No use, distribution or reproduction is permitted which does not comply

with these terms.

Frontiers in Public Health | www.frontiersin.org 10 February 2021 | Volume 9 | Article 595786

  • A Plan-Do-Study-Act Approach to the Development, Implementation and Evaluation of a Patient Navigation Program to Reduce Breast Cancer Screening Disparities in Un- and Under-Insured, Racially and Ethnically Diverse Urban Women
    • Introduction
    • Materials and Methods
      • Needs Health Assessment
      • Plan-Do-Study-Act Framework
      • Development of a Breast Cancer Screening Navigation Program
      • Securing the Funding to Establish a Cost-Free Screening Mammography Program
      • Patient Navigator Selection, Training, and Functions
      • Establishing a Referral Base From a Network of Community Partners That Serve the Health Needs of Un- and Under-Insured Women
      • Establishing a Navigation Process to Address the Barriers to Accessing Mammography
      • Developing Culturally-Tailored Messaging and a Media Campaign
      • Program Evaluation and Optimization
    • Results
    • Discussion
    • Data Availability Statement
    • Ethics Statement
    • Author Contributions
    • Funding
    • Acknowledgments
    • Supplementary Material
    • References

published: 31 March 2020

doi: 10.3389/fpubh.2020.00088

Frontiers in Public Health | www.frontiersin.org 1 March 2020 | Volume 8 | Article 88

Edited by:

Simone Rauscher Singh,

University of Michigan, United States

Reviewed by:

Jason Scott Turner,

Rush University, United States

Berkeley Franz,

Ohio University, United States

Judith Connell,

George Washington University,

United States

Kelly Kelleher,

The Research Institute at Nationwide

Children’s Hospital, United States


Sue A. Kaplan

[email protected]

Specialty section:

This article was submitted to

Public Health Policy,

a section of the journal

Frontiers in Public Health

Received: 13 November 2019

Accepted: 03 March 2020

Published: 31 March 2020


Kaplan SA and Gourevitch MN (2020)

Leveraging Population Health

Expertise to Enhance Community

Benefit. Front. Public Health 8:88.

doi: 10.3389/fpubh.2020.00088

Leveraging Population Health
Expertise to Enhance Community

Sue A. Kaplan* and Marc N. Gourevitch

Department of Population Health, NYU Grossman School of Medicine, NYU Langone Health, New York, NY, United States

As the Internal Revenue Service strengthens the public health focus of community

benefit regulations, and many states do the same with their tax codes, hospitals are

being asked to look beyond patients in their delivery system to understand and address

the needs of geographic areas. With the opportunities this affords come challenges to

be addressed. The regulations’ focus on population health is not limited to a defined

clinical population—and the resulting emphasis on upstream determinants of health

and community engagement is unfamiliar territory for many healthcare systems. At

the same time, for many community residents and community-based organizations,

large medical institutions can feel complicated to engage with or unwelcoming.

And for neighborhoods that have experienced chronic underinvestment in upstream

determinants of health—such as social services, housing and education—funds made

available by hospitals through their community health improvement activities may

seem insufficient and unreliable. Despite these regulatory requirements, many hospitals,

focused as they are on managing patients in their delivery system, have not yet

invested significantly in community health improvement. Moreover, although there are

important exceptions, community health improvement projects have often lacked a

strong evidence base, and true health system-community collaborations are relatively

uncommon. This article describes how a large academic medical center tapped into the

expertise of its population health research faculty to partner with local community-based

organizations to oversee the community health needs assessment and to design,

implement and evaluate a set of geographically based community-engaged health

improvement projects. The resulting program offers a paradigm for health system

investment in area-wide population health improvement.

Keywords: hospital community benefit, health systems and community partnerships, hospitals addressing social

determinants of health, community health improvement plan, departments of population health


On March 23, 2010, the Patient Protection and Affordable Care Act (ACA) added a
new section 501(r) to the Internal Revenue Code creating “Additional Requirements
for Charitable Hospitals” (1). Pursuant to these provisions, not-for-profit hospitals
are required to undertake a community health needs assessment (CHNA) every 3
years and then develop an implementation strategy—a set of “community health
improvement” activities—to address priorities that are identified through that process (2).
A number of states have similar policies in their tax codes. For example, the New York

Kaplan and Gourevitch Population Health Expertise for Community Benefit

State Department of Health for many years has mandated
that every not-for-profit hospital submit a Community Service
Plan (CSP) to the State. Beginning with the CSPs that were
due in the fall of 2013, the State sharpened its public health
focus, requiring hospitals to align their plans with local health
department priorities, which, in turn, were to align with the
State’s “Prevention Agenda” (3).

These federal and state regulations have been designed to: (a)
open healthcare systems to greater community input; (b) foster
“greater collaboration between state and local health agencies
and hospitals serving the region;” (4) and (c) leverage hospital
resources to advance area population health (3). Yet effective
implementation of these requirements is typically challenging
both for hospitals and for the community organizations with
which they seek to partner. For many health care systems,
focused as they are on the complexities of managing care
within their walls, engaging with community partners and
developing programs to improve population health call upon
unfamiliar skills (5). At the same time, for many community
residents and community-based organizations, large medical
institutions can feel bewildering or unwelcoming. And for
neighborhoods that have experienced chronic underinvestment
in the upstream determinants of health—social services, housing,
and education—the funds made available by hospitals through
these community health improvement activities may seem
insufficient and unreliable.

Community health improvement resources are one of the
myriad assets that healthcare systems have—as clinical providers,
employers, educational institutions, purchasers, and investors—
that can be leveraged to strengthen the drivers of health in
the communities in which they are located (6). Over the past
few years, innovative health systems have begun to recognize
these levers and look upstream to address social determinants of
health—whether out of a sense of mission, to be in compliance
with state regulations, to enhance reputation, to attract and
maintain staff and patients, or to prepare for anticipated changes
in reimbursement (7). Examples are beginning to emerge for how
these efforts can be structured and sustained (8–10).

Based on the experience of one major academic health
system—New York University Langone Health (NYULH)—we
describe a model of how population health expertise can be
brought to bear to address community health improvement
requirements as part of a community-engaged approach that
results in sustainable improvements in population health.



For academic medical centers, particularly those located in cities
dense with other healthcare systems, defining a “community”
can present a challenge. NYULH serves a broad geographic area:
its primary service area includes the New York City boroughs
of Manhattan, Brooklyn, and Queens, and its secondary service
area extends into the borough of Staten Island, as well as
Long Island, Westchester, and New Jersey. To enhance the
impact of the CSP and create opportunities for synergy across

programs, NYULH in 2013 narrowed the geographic scope of
its CSP (previously the entire lower third of Manhattan) to
focus on the closest areas of greatest need: the Lower East Side
and Chinatown (together comprising Manhattan Community
District 3). Following merger in 2017 with a community hospital
(Lutheran Medical Center) and associated network of Federally
Qualified Health Centers in Brooklyn, the CSP extended into the
Sunset Park neighborhood of Brooklyn.

The three neighborhoods comprising NYULH’s CSP
catchment area—the Lower East Side, Chinatown and Sunset
Park—share many characteristics and face similar challenges.
Each is a microcosm for the social, economic, and linguistic
diversity of New York City and has served as a first destination
for immigrants, with high percentages of residents who are
foreign born and with large Latino and Asians populations.
Even as these neighborhoods gentrify, residents continue to
experience high levels of poverty, low educational attainment,
and health disparities.

At the same time, each neighborhood benefits from strong
networks of community-based organizations (CBOs) that
provide services and support for residents. Information about
health status and trends in these communities, as well as our
process for assessing assets and needs and setting priorities,
can be found in our comprehensive Community Health Needs
Assessment and Implementation Plan at https://nyulangone.org/

Aligning with the New York State and New York City public
health and community priorities, the NYULH Community
Service Plan engages multiple sectors (e.g., healthcare, education,
social service, faith-based organizations, and housing providers)
in its goals of: (a) preventing chronic diseases by reducing
tobacco use and preventing and addressing obesity, and
(b) promoting healthy women, infants and children through
programs focusing on parenting and teen health. These
goals were selected based upon the CHNA we conducted,
which analyzed and presented to the community primary
and secondary data about community needs and priorities in
Manhattan Community District 3 and in Sunset Park, including
data from the New York City Department of Health and
Mental Hygiene’s Community Health Survey and the New
York City Department of City Planning, as well as focus
groups, surveys, interviews and meetings with residents and
other community stakeholders. The priorities selected reflect
continued community concern about ongoing health disparities,
including tobacco use, obesity, early childhood development,
and teen health. In addition, the connection between housing
quality/security and health emerged as a growing concern, which
led to the formation of the Brooklyn Health and Housing
Consortium described below.

To oversee the need and asset assessments, priority setting,
and implementation of the CSP, we formed a Coordinating
Council led by the Department of Population Health and
composed of NYULH faculty and staff, leadership and
staff of partnering CBOs, community leaders (including
community health workers, faith-based leaders, Community
Board members), and a growing group of other stakeholders
including researchers and policymakers. Beginning in 2017,

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Kaplan and Gourevitch Population Health Expertise for Community Benefit

we fully integrated partners from the NYULH Brooklyn-based
system, including its affiliated network of Federally Qualified
Health Centers, the Family Health Centers at NYU Langone,
which now co-leads the group.

Each CSP initiative has at least one faculty partner and one
community partner. To enable full participation of community
partners, we have sought to ensure that the CSP program
budgets cover not only the time of CBO staff who work
directly on the project but also a portion of senior management
time, recognizing the importance of their supervisory roles and
their participation as leaders on the Coordinating Council. As
one community partner observed, in partnering with academic
institutions, senior staff of community organizations are often
asked to contribute their time pro bono, straining already
tight budgets.

The Coordinating Council serves as the forum for
coordinating across the CSP initiatives, identifying shared
challenges and emerging community needs, and grounding
the work in a community based participatory approach
(CBPA). In the first year of the CSP, we reviewed principles
of community engagement and sought to anticipate potential
causes of tension (11). From our previous experience in
community based participatory research (12–14), and from
early conversations with key informants as part of the CHNA,
we were acutely aware of the potential for misunderstanding
between academic institutions and community partners. A small
group of faculty and community leaders drafted a memorandum
of understanding, which provided detailed language about
collaboration in program development and implementation,
data sharing, and the development of presentations and
publications, including the expectation of co-authorship. More
recently, growing out of two CBPA projects (an assessment of
the health needs and priorities of the Arab American community
in southwest Brooklyn and an asset and needs assessment of Red
Hook, a neighboring community in Brooklyn) the Coordinating
Council revisited and revised its guiding CBPA principles and is
in the process of identifying the capacity building activities and
skills that are needed to support the movement of our projects
further along the spectrum of community engagement (15). The
principles, which grew out of a review of the extensive literature
on CBPA and academic-community partnerships (16–23), are
currently being reviewed and revised by our community partners
and with community residents, and will then will be posted and
shared as a possible starting place for other community health
improvement plans.




State and federal regulations governing community
health improvement projects require that hospitals
select evidence-informed interventions that meet the
needs identified in the CHNA, describe their anticipated
impact, and set forth a measurement and evaluation
plan (2, 3, 24). To take advantage of expertise in the

design, implementation and evaluation of evidence-
based programs, beginning in 2012, NYULH transferred
responsibility for the CHNA and the development of its
CSP from its corporate office of Strategy, Planning and
Business Development to its academic Department of
Population Health.

In developing an initial portfolio of community health
improvement projects, faculty with population health expertise
drew upon existing grant-funded evidence-informed programs
designed to address the health needs of underserved populations,
primarily low-income Latinx and African Americans. Building
on this foundation, faculty partnered with community-based
organizations to adapt those programs, tools and materials
for implementation in their settings and to reflect the needs
and preferences of their diverse populations, leveraging, and
enriching faculty’s understanding of cultural and linguistic
translation, behavior change, and implementation science.
The following two examples illustrate this process (A fuller
picture of these and other CSP projects can be found
at https://nyulangone.org/our-story/community-health-needs-

ParentCorps, an evidence-based program developed byNYULH’s
Center for Early ChildhoodHealth andDevelopment, is designed
to buffer the adverse effects of poverty and related stressors
on early child development by engaging and supporting both
parents and teachers at children’s transition to school. The
program is implemented in early childhood education or
childcare settings and includes professional development for
teachers and other caregivers and a 14-session weekly group
educational series for parents and children. Two federally-
funded, randomized controlled trials with more than 1,200
poor, minority children found that ParentCorps results in more
supportive and nurturing home and early childhood classroom
environments, higher kindergarten achievement scores (reading,
writing, and math) and, among the highest-risk children, lower
rates of obesity, and mental health problems (25). A benefit-cost
analysis indicates that ParentCorps has the potential to yield cost
savings of more than $2,500 per student (26).

Through the CSP, ParentCorps has partnered with University
Settlement Society, a large social service agency with three
early childhood sites, and with elementary schools located in
the CSP catchment area, training nearly 200 teachers and
teaching assistants and over 100 other professionals including
mental health professionals, social workers, and administrators.
In addition, ParentCorps staff have implemented seventeen 14-
session series of the Parenting Program in English, and in
Mandarin and Cantonese for the first time, reaching 555 families,
in the process translating and adapting materials so that they are
culturally tailored and acceptable to this new population. Based
on earlier studies, we estimate that the program will increase
parent knowledge, skills, and engagement in school; decrease
the percentage of children with behavior problems; increase
healthy eating and physical activity; and decrease the percentage
of children who are overweight/obese.

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Kaplan and Gourevitch Population Health Expertise for Community Benefit

Tobacco Free Community
Despite the availability of safe and effective treatment for tobacco
dependence, only a small proportion of smokers who try to quit
each year use cessation therapies. This is particularly true among
low-income adults and for non-English language speakers,
contributing to growing disparities in smoking prevalence (27).
The CSP navigator program is designed to address this gap, with
a particular focus on Chinese American men, who have among
the highest smoking rates in New York City. In partnership
with Asian Americans for Equality (AAFE) and the Asian
Smokers’ Quitline (ASQ), experts from the Department of
Population Health’s Section on Tobacco, Alcohol, and Drugs are
implementing a community navigator model that mirrors the
patient navigator model developed, studied and implemented by
the American Cancer Society (28). Results of this program have
been comparable to other navigator programs (34% self-reported
quit rate) and unusually, because of its roots in the community,
AAFE has been able to reach many smokers who had never
previously tried to quit or cut down.


Neither the Internal Revenue Service nor the Affordable Care
Act mandate a dollar amount or percentage of operating
budget that not-for-profit hospitals are required to allocate
to their community health improvement projects. Indeed, it
has been estimated that nationally only about five percent
of community benefit dollars are allocated to community
health improvement programs (29). Although a large figure
when aggregated nationally, locally, the modest scope of such
funds can limit their impact, particularly when viewed in the
context of longstanding, unmet community needs. Fostering
the sustainability of initiatives launched through community
health improvement efforts is a way of extending the impact of
limited funds. There are several strategies that health systems can
use to advance this goal: (a) building capacity among partners
and within the healthcare system; (b) integrating programs into
operational flow and procedures; (c) supporting public policies
that maintain initiatives and facilitate their diffusion; and (d)
leveraging existing or new funding and resources that can be
braided into the stream of support (30).

Building Capacity
Academic medical centers can provide a wide array of capacity-
building resources to CBOs in addition to providing direct
funding for programs. For example, NYULH experts on tobacco
cessation have led several in-depth training programs, reaching
community health workers across the Community Service Plan
partnership. Tobacco cessation experts from the medical center
have also partnered with the Chinese American Medical Society
to provide lectures on smoking cessation to their members for
continuing medical education credit.

Through the Community Service Plan, the Family Health
Centers at NYU Langone have also championed capacity
building to support child development and school readiness.
The ParentChild+ program (formerly known as the Parent-
Child Home program), a national, evidence-based early literacy,

parenting and school-readiness program, offers year-long
training and support to Family Child Care (FCC) providers
to promote school readiness for all children in their care. The
impact of the program extends beyond the FCC environment.
Parents whose children are enrolled at an FCC have reported
changes in language and literacy behaviors at home, such as
replacing screen time with book reading.

Academic medical centers can also support capacity-building
by offering access to educational and professional development
opportunities. Community partners are routinely invited to
conferences to present their CSP-supported work, often with
faculty co-authors; and NYULH faculty provide technical
assistance and consultation on data analysis to support program
evaluation and needs assessments. Recently, the CSP staff
launched a series of monthly workshops inviting faculty, staff,
and community experts to present on topics that reflect shared
program needs and interests. The workshops have addressed
survey development, in which partners were invited to bring
draft instruments for review and discussion; m-health strategies
in community settings; approaches to health literacy; and
mindfulness for health professionals. As we have deepened our
focus on CBPA, these sessions will be used to build capacity
across all current, planned and future projects to do more deeply
engaged community work. Emerging topics include: how to
define the relevant community or communities; understanding
community organizing principles and strategies; and tools and
processes to promote trust, engagement, self-reflection, and
equity. In addition, our quarterly Coordinating Council meetings
foster cross-project learning, for example through discussion
of strategies and approaches for community engagement and
facilitating behavior change across cultures (31). These forums
also provide an opportunity for CBOs to network with other
organizations and with policymakers and potential funders.

As others have noted, the CHNA provides an opportunity
for “community-engaged, health equity research” (32). Indeed, in
partnering with community-based organizations, it is important
for hospitals to recognize that, done right, capacity building
is bidirectional. Through the discussions in our Coordinating
Council, we are able organically to identify issues that have not yet
emerged through more formal needs assessments or in existing
data. These have included, for example, the intergenerational
needs of Chinese American families in which children are raised
abroad in their early years (33), and very early on we learned
of the growing concern among undocumented immigrants who
fear seeking care and accessing entitlements. These insights have
generated new program approaches and opportunities for timely
and important responses and research. In addition, partnerships
can provide an opportunity to collect pilot data to support
collaborative grant development. For example, as part of our
Tobacco Free Community initiative, we conducted focus groups
with residents in public housing about their attitudes toward
the federally-mandated smoking ban being implemented in their
apartment buildings, providing helpful information to the New
York City Housing Authority as it rolls out its program and
serving as pilot data for a large collaborative study (funded
by the National Institutes of Health) of the impact of this
new regulation.

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Kaplan and Gourevitch Population Health Expertise for Community Benefit

Relationships with partners can also provide educational
opportunities, including site visits for medical students and
student research projects. Finally, an unexpected consequence of
the Coordinating Council structure has been that it has facilitated
productive relationships across divisions within the Department
of Population Health, across departments within the medical
center, and with other schools across the university.

Integrating Programs Into Operational

Programs are more likely to be sustained if they are aligned
with organizational culture and priorities and integrated into
operational flow and standard operating procedures (34). For
this reason, in implementing the Greenlight program, a practice-
based obesity prevention program, we worked closely with
colleagues at the Charles B. Wang Community Health Center
to minimize burden on health care providers and to integrate
the program into the flow of the busy pediatric practice of this
Federally QualifiedHealth Center. This hasmeant collaboratively
designing program implementation with administrators to take
advantage of patient waiting times and working with existing
staff who provide materials and coaching. The successes and core
insights from the Manhattan implementation are being used to
align the program with the pediatric workflow in the Seventh
Avenue Family Health Center site in Sunset Park.

Similarly, AAFE now screens for tobacco use on all of its
intake forms (for example, for housing, insurance, small business
development) and provides information about smoking cessation
at community meetings on a wide array of topics, having
learned that people are more amenable to hearing about tobacco
cessation when other services are being provided and other
problems solved.

Promoting Policy Change and Program

Engaging policymakers has been a core strategy of the Tobacco
Free Community initiative. Growing out of and supported by the
CSP partnership and the RCHNCommunity Health Foundation,
the Charles B. Wang Community Health Center spearheaded the
creation of a City-wide anti-smoking coalition, which helped field
a street intercept survey in Chinese American neighborhoods,
testified before the City Council, and worked with the New York
City Department of Health and Mental Hygiene in developing
and publicizing an Epi Data Brief that highlights cancer as
the leading cause of death for Chinese New Yorkers, reflecting
the persistently high rates of smoking among Asian American
men (35). In response, the City Health Department launched an
Asian language public awareness campaign. One of the Coalition
partners, Korean Community Services, received funding from
the City Council to support a tobacco navigator program in
the Korean American Community, and the effort is now being
expanded to include other immigrant-serving CBOs.

Leveraging Resources
Although the scale of community health improvement funding
alone is insufficient to support sustainable and long-term change,
these dollars can be used to leverage other resources. Some have

suggested creating pooled “community health trusts” that might
attract broader investment (36). Others have used community
health improvement dollars to “unlock” capital investments (37).
At a programmatic level, we have sought to pool support by
linking to a wide range of resources. For example, the smoking
cessation program uses existing relationships and forums to
direct people to available resources: the New York State Smokers’
Quitline and to the Asian Smokers’ Quitline, both of which offer
free coaching and nicotine replacement therapy. In addition,
the Robin Hood Foundation provided substantial supplemental
funding for the CSPHealth+Housing Initiative, a pilot housing-
based community health worker project in two affordable
buildings on the Lower East Side (38). The initiative is now
being sustained and expanded in two additional buildings by
the owners of one of the buildings in which it was piloted,
in continued collaboration with our community partner, Henry
Street Settlement. This not only provides a potentially sustainable
and replicable funding source, but it also gives our partners
ownership over the initiative and allows them to tailor the
program to meet ongoing needs.

Similarly, the Family Health Centers’ Project SAFE, a
peer education program employing an evidence-based
youth development approach to prevent teen pregnancy
and HIV/AIDS, was able to deepen their reach in schools
through the Community Service Plan, which was then leveraged
to acquire federal Substance Abuse and Mental Health Services
Administration grant funding. Leveraging community health
improvement funding to access outside support not only
increases the pool of available dollars, but also helps to increase
visibility and demonstrate program value to internal and
external audiences.


In launching the CSP, we experienced a number of challenges.
Within our own institution, there were tensions as the
Department of Population Health applied a more rigorous set of
criteria to the programs that would be funded through the plan.
This meant eliminating some projects that had deep institutional
roots but lacked a strong evidence base or were more focused
on data collection and research than on service delivery. In
addition, as noted above, we brought to the CSP a set of
expectations about community engagement that differed from
the traditional academic approach. We have found, however, that
faculty and staff have relished the deep community relationships
and the egalitarian nature of the Coordinating Council, which
brings together community health workers and senior faculty,
policymakers and staff (31).

Developing trusting relationships with community partners
presented another challenge. The CHNA regulations are
specifically designed to require that hospitals open their doors
to community input. Our initial foray into the community
was revelatory—and sometimes painful. Overtures to some
prospective partners were met with a high degree of skepticism.
Several were critical of the medical center and the university’s
role in the community, noting a previous lack of engagement.

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Kaplan and Gourevitch Population Health Expertise for Community Benefit

Significant time was spent assuring community leaders of our
commitment to true partnership. Fostering a strong community-
based culture and identity within the Coordinating Council has
been critically important to maintaining credibility with our
partners and in the communities in which we are working.

The challenge of matching evidence-based community-
oriented programs with community priorities has meant that our
work is held together more by a set of principles and an approach
than by a defined goal or outcome. Although each project has
an evaluation component, “moving the needle” at a population
level remains an elusive goal. This is complicated further by
our geographic spread, spanning several diverse communities. A
more laser-like focus on an issue or geographic area might have
aligned our projects toward a single measurable outcome. But
our approach has helped build the partnership and has allowed
us to be responsive to needs and to generate new and promising
initiatives as opportunities arise. For example, growing out of
our work and deep community engagement, we have developed
the Brooklyn Health and Housing Consortium, which engages
health care providers, CBOs, and housing providers with the
goal of developing relationships and infrastructure, and building
capacity to support people with complex health and housing
needs. Similarly, we have created a Community Health Worker
Research and Resource Center to serve as a resource to CBOs,
health systems, municipal agencies, and research organizations
that are planning, or seeking to strengthen, initiatives that use
lay health workers to enhance care, link services, and improve
community health. These more recent efforts are evidence of
a deeper level of engagement and lasting contribution to local
health improvement capacity. The value of these initiatives would
not likely be captured in a traditional cost-benefit approach.


Community health improvement funding provides an important
resource to support community-based population health
initiatives. But the absence of a required funding threshold
and general lack of hospital expertise in partnering to address
the upstream determinants of health, threaten to limit its
impact. Despite the ACA requirement for a thorough needs
assessment and implementation plan, and similar mandates in
many state tax codes, many hospitals have not invested deeply in

community health improvement. Moreover, although there are
important exceptions, community health improvement projects
have often lacked a strong evidence base, and true community
collaborations are difficult to achieve and sustain (39).

As hospitals begin to develop departments of population
health (40), they can leverage that growing expertise—in data
collection and analysis, in implementation science, in partnering
to promote health and wellness outside their walls—to guide
their community health improvement programs and widen
the lens from patients in the delivery system to residents in
the community. In this way, community benefit resources can
be deployed more effectively to address important community
health priorities, build community and institutional capacity, and
lay a foundation for long-term sustainable change.


The raw data supporting the conclusions of this article will be
made available by the authors, without undue reservation, to any
qualified researcher.


SK and MG contributed to the design and implementation of the
programs described and to the writing of the manuscript.


Support for the work described in this paper was provided by
NYU Langone Hospitals’ Community Health Improvement
funding as part of its Community Benefit spending.
Supplemental funding for the Health + Housing Project
was provided by the Robin Hood Foundation. Initial support
for the city-wide tobacco coalition was provided by the RCHN
Community Health Foundation. Open access publication fee
provided by NYU Langone Health.


The authors gratefully acknowledge the contributions and
work of the members of the Community Service Plan
Coordinating Council.


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Conflict of Interest: The authors declare that the research was conducted in the

absence of any commercial or financial relationships that could be construed as a

potential conflict of interest.

Copyright © 2020 Kaplan and Gourevitch. This is an open-access article distributed

under the terms of the Creative Commons Attribution License (CC BY). The use,

distribution or reproduction in other forums is permitted, provided the original

author(s) and the copyright owner(s) are credited and that the original publication

in this journal is cited, in accordance with accepted academic practice. No use,

distribution or reproduction is permitted which does not comply with these terms.

Frontiers in Public Health | www.frontiersin.org 7 March 2020 | Volume 8 | Article 88

  • Leveraging Population Health Expertise to Enhance Community Benefit
    • Introduction
    • Defining and Engaging Community and Setting Priorities
    • Leveraging Population Health Expertise in Evidence-Based Programs
      • ParentCorps
      • Tobacco Free Community
    • Planning for Sustainable Impact
      • Building Capacity
      • Integrating Programs Into Operational Flow
      • Promoting Policy Change and Program Diffusion
      • Leveraging Resources
    • Challenges and Lessons Learned
    • Conclusion
    • Data Availability Statement
    • Author Contributions
    • Funding
    • Acknowledgments
    • References

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