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Harvard T.H. Chan School of Public Health Case-Based Teaching & Learning Initiative

Teaching cases & active learning resources for public health education, case library.

The Harvard Chan Case Library is a collection of teaching cases with a public health focus, written by Harvard Chan faculty, case writers, and students, or in collaboration with other institutions and initiatives.

Use the filters at right to search the case library by subject, geography, health condition, and representation of diversity and identity to find cases to fit your teaching needs. Or browse the case collections below for our newest cases, cases available for free download, or cases with a focus on diversity. 

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Many of our cases are available for sale through Harvard Business Publishing in the  Harvard T.H. Chan case collection . Others are free to download through this website .

Cases in this collection may be used free of charge by Harvard Chan course instructors in their teaching. Contact  Allison Bodznick , Harvard Chan Case Library administrator, for access.

Access to teaching notes

Teaching notes are available as supporting material to many of the cases in the Harvard Chan Case Library. Teaching notes provide an overview of the case and suggested discussion questions, as well as a roadmap for using the case in the classroom.

Access to teaching notes is limited to course instructors only.

  • Teaching notes for cases available through  Harvard Business Publishing may be downloaded after registering for an Educator account .
  • To request teaching notes for cases that are available for free through this website, look for the "Teaching note  available for faculty/instructors " link accompanying the abstract for the case you are interested in; you'll be asked to complete a brief survey verifying your affiliation as an instructor.

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Faculty and instructors with university affiliations can register for Educator access on the Harvard Business Publishing website,  where many of our cases are available . An Educator account provides access to teaching notes, full-text review copies of cases, articles, simulations, course planning tools, and discounted pricing for your students.

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Atkinson, M.K. , 2023. Organizational Resilience and Change at UMass Memorial , Harvard Business Publishing: Harvard T.H. Chan School of Public Health. Available from Harvard Business Publishing Abstract The UMass Memorial Health Care (UMMHC or UMass) case is an examination of the impact of crisis or high uncertainty events on organizations. As a global pandemic unfolds, the case examines the ways in which UMMHC manages crisis and poses questions around organizational change and opportunity for growth after such major events. The case begins with a background of UMMHC, including problems the organization was up against before the pandemic, then transitions to the impact of crisis on UMMHC operations and its subsequent response, and concludes with challenges that the organization must grapple with in the months and years ahead. A crisis event can occur at any time for any organization. Organizational leaders must learn to manage stakeholders both inside and outside the organization throughout the duration of crisis and beyond. Additionally, organizational decision-makers must learn how to deal with existing weaknesses and problems the organization had before crisis took center stage, balancing those challenges with the need to respond to an emergency all the while not neglecting major existing problem points. This case is well-suited for courses on strategy determination and implementation, organizational behavior, and leadership.

The case describes the challenges facing Shlomit Schaal, MD, PhD, the newly appointed Chair of UMass Memorial Health Care’s Department of Ophthalmology. Dr. Schaal had come to UMass in Worcester, Massachusetts, in the summer of 2016 from the University of Louisville (KY) where she had a thriving clinical practice and active research lab, and was Director of the Retina Service. Before applying for the Chair position at UMass she had some initial concerns about the position but became fascinated by the opportunities it offered to grow a service that had historically been among the smallest and weakest programs in the UMass system and had experienced a rapid turnover in Chairs over the past few years. She also was excited to become one of a very small number of female Chairs of ophthalmology programs in the country. 

Dr. Schaal began her new position with ambitious plans and her usual high level of energy, but immediately ran into resistance from the faculty and staff of the department.  The case explores the steps she took, including implementing a LEAN approach in the department, and the leadership approaches she used to overcome that resistance and build support for the changes needed to grow and improve ophthalmology services at the medical center. 

This case describes efforts to promote racial equity in healthcare financing from the perspective of one public health organization, Community Care Cooperative (C3). C3 is a Medicaid Accountable Care Organization–i.e., an organization set up to manage payment from Medicaid, a public health insurance option for low-income people. The case describes C3’s approach to addressing racial equity from two vantage points: first, its programmatic efforts to channel financing into community health centers that serve large proportions of Black, Indigenous, People of Color (BIPOC), and second, its efforts to address racial equity within its own internal operations (e.g., through altering hiring and promotion processes). The case can be used to help students understand structural issues pertaining to race in healthcare delivery and financing, to introduce students to the basics of payment systems in healthcare, and/or to highlight how organizations can work internally to address racial equity.

Kerrissey, M.J. & Kuznetsova, M. , 2022. Killing the Pager at ZSFG , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract This case is about organizational change and technology. It follows the efforts of one physician as they try to move their department past using the pager, a device that persisted in American medicine despite having long been outdated by superior communication technology. The case reveals the complex organizational factors that have made this persistence possible, such as differing interdepartmental priorities, the perceived benefits of simple technology, and the potential drawbacks of applying typical continuous improvement approaches to technology change. Ultimately the physician in the case is not able to rid their department of the pager, despite pursuing a thorough continuous improvement effort and piloting a viable alternative; the case ends with the physician having an opportunity to try again and asks students to assess whether doing so is wise. The case can be used in class to help students apply the general concepts of organizational change to the particular context of technology, discuss the forces of stasis and change in medicine, and to familiarize students with the uses and limits of continuous improvement methods. 

Yatsko, P. & Koh, H. , 2021. Dr. Joan Reede and the Embedding of Diversity, Equity, and Inclusion at Harvard Medical School , Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract For more than 30 years, Dr. Joan Reede worked to increase the diversity of voices and viewpoints heard at Harvard Medical School (HMS) and at its affiliate teaching hospitals and institutes. Reede, HMS’s inaugural dean for Diversity and Community Partnership, as well as a professor and physician, conceived and launched more than 20 programs to improve the recruitment, retention, and promotion of individuals from racial and ethnic groups historically underrepresented in medicine (UiMs). These efforts have substantially diversified physician faculty at HMS and built pipelines for UiM talent into academic medicine and biosciences. Reede helped embed the promotion of diversity, equity, and inclusion (DEI) not only into Harvard Medical School’s mission and community values, but also into the DEI agenda in academic medicine nationally. To do so, she found allies and formed enduring coalitions based on shared ownership. She bootstrapped and hustled for resources when few readily existed. And she persuaded skeptics by building programs using data-driven approaches. She also overcame discriminatory behaviors and other obstacles synonymous with being Black and female in American society. Strong core values and sense of purpose were keys to her resilience, as well as to her leadership in the ongoing effort to give historically marginalized groups greater voice in medicine and science.

Cases Available for Free Download

Weinberger, E. , 2015. Weighing the Evidence: One University Takes a Hard Look at Disordered Eating Among Athletes , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract Colburn University is the largest private university in the fictitious state of Columbia and is often recognized by people from distant parts of the country for its award-winning Division I athletic teams. That’s why when athletic director Harry Ritchie makes an offhanded comment about Colburn student-athletes with eating disorders, the press pounces. This incident coupled with a complaint from a parent draws the attention of Dean Francis Reilly, who finds himself needing to peel back some of the layers embedding college athletics on the issue of eating disorders among athletes. Throughout the narrative, different perspectives on sports and eating disorders are revealed from top-level administrators, like Dean Reilly, to the student-athletes themselves. As the story concludes, the conversation about eating disorders has begun, but questions still remain on how to make Colburn University a healthy environment for its student-athletes. Intermediate and advanced level teaching notes  available for faculty/instructors .

In August of 2020, after a day treating patients, John McAdams, MD, gets ready to meet with a young couple from the community. He is excited to share the latest progress on his institution’s Cancer Treatment and Control Center, which is set to open in 3 years. The $230+ million project is something that Dr. McAdams has been building in his mind for years. Its brick and mortar location will strive to be a truly different cancer center that emphasizes population health alongside acute treatment. Cutting edge technologies and innovative public health initiatives working in tandem will close the gap between rural and urban cancer patient outcomes.

After decades of diligence, vision, and advocacy from John, Midwest Regional Health (MRH) has purchased the physical location of what will be a state-of-the-art cancer treatment and control center—a rarity for rural America. The site is on the main campus and will be connected to the inpatient and pediatric hospitals by tunnels to have the cancer center be better integrated into the continuum of cancer care than an outpatient center at a separate location. According to John, “The architects have worked very hard to make the center what we wanted…very welcoming and reassuring but intertwining all the workings of the various departments.”

However, with just three years before the grand opening, questions remain about how to structure the management of the cancer center relative to the medical center and the oncology service line, how to expand the research base in oncology, and how to drum up excitement and support in the community.

Rossano, P. & Johnson, P. , 2015. Adrienne Germain: A Leader in Women's Health Rights , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case explores strategies for changing policy and attitudes at national and international levels through the lens of women’s health. Adrienne Germain: A Leader in Women’s Health Rights charts the career of Adrienne Germain, a leader in the field of women’s sexual and reproductive health and rights (SRHR). Germain successfully broadened and shifted the area of reproductive health to encompass SRHR. While the context of this case is women’s health, Germain’s strategies and choices would also interest those focused on generating lasting social change. The lessons students could learn from the use of this case in classroom discussion easily extend beyond women’s health to areas of social change, political advocacy, and the importance of judicious negotiation in health policy efforts. 

Gordon, R. , 2014. Who Owns Your Story? , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case uses a role play simulation to illustrate ethical implications when research practices violate cultural taboos and norms. In Who Owns Your Story? the Trilanyi - a fictional Native American tribe based on a real community that is not identified or located in the case – is adversely affected by a high prevalence of diabetes. They ask a university professor with whom they have a close relationship to study their tribe, and they agree to give samples of their blood – which they consider sacred – for the study. Tribe members signed a consent form to participate but it was unclear whether they realized that the consent covered the university potentially using their blood for other possible research topics beyond diabetes. Ultimately, the study does not discover that the tribe has a genetic predisposition to diabetes. Years later, however, tribe members learn that their samples had also been used to study topics they considered objectionable. The case is based on true events between the Havasupai tribe and the University of Arizona which ultimately led to a legal suit that was settled out of court. In the case, students are asked to develop and simulate role play negotiations toward an acceptable resolution for all the parties involved. 

Weinberger, E. , 2014. Beauty and the Breast: Mobilizing Community Action to Take on the Beauty Industry , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract How does one learn to become an effective advocate? “Beauty and the Breast: Mobilizing Community Action to Take on the Beauty Industry” tells the story of protagonist Joe Wendell, known as Wendell, an emergency room nurse and widower raising a teenage daughter in Franklin, a largely working class town in the fictional US state of Columbia. One day his daughter announces she would like to have breast implants. The distressing news prompts Wendell into new, unforeseen directions as he learns all he can about implants and surgery, the “beauty culture” permeating society especially in his community, and the psychological development of teenagers. Though relieved to find out that as long as she is a minor she cannot legally obtain the surgery without his consent (and, no doubt, without his cash), Wendell starts to believe that greater protections for teen girls in Columbia are needed. In this effort he is guided by the confident figure of Anna Pinto, director of a community center in an East Franklin neighborhood with a vibrant Brazilian-American community where cosmetic surgery, especially for girls and young women, is something she perceives to be a particular problem and has some ideas about how to address. Teaching note available for faculty/instructors .

Focus on Diversity, Equity, and Inclusion

This case describes and explores the development of the first medical transitions clinic in Louisiana by a group of community members, health professionals, and students at Tulane Medical School in 2015.  The context surrounding health in metro New Orleans, the social and structural determinants of health, and mass incarceration and correctional health care are described in detail. The case elucidates why and how the Formerly Incarcerated Transitions (FIT) clinic was established, including the operationalization of the clinic and the challenges to providing healthcare to this population. The case describes the central role of medical students as case managers at the FIT clinic, and how community organizations were engaged in care provision and the development of the model.  The case concludes with a discussion of the importance of advocacy amongst health care professionals.

Al Kasir, A., Coles, E. & Siegrist, R. , 2019. Anchoring Health beyond Clinical Care: UMass Memorial Health Care’s Anchor Mission Project , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract As the Chief Administrative Officer of UMass Memorial Health Care (UMMHC) and president of UMass Memorial (UMM) Community Hospitals, Douglas Brown had just received unanimous and enthusiastic approval to pursue his "Anchor Mission" project at UMMHC in Worcester, Massachusetts. He was extremely excited by the board's support, but also quite apprehensive about how to make the Anchor Mission a reality. Doug had spearheaded the Anchor Mission from its earliest exploratory efforts. The goal of the health system's Anchor Mission-an idea developed by the Democracy Collaborative, an economic think tank-was to address the social determinants of health in its community beyond the traditional approach of providing excellent clinical care. He had argued that UMMHC had an obligation as the largest employer and economic force in Central Massachusetts to consider the broader development of the community and to address non-clinical factors, like homelessness and social inequality that made people unhealthy. To achieve this goal, UMMHC's Anchor Mission would undertake three types of interventions: local hiring, local sourcing/purchasing, and place-based community investment projects. While the board's enthusiasm was palpable and inspiring, Doug knew that sustaining it would require concrete accomplishments and a positive return on any investments the health system made in the project. The approval was just the first step. Innovation and new ways of thinking would be necessary. The bureaucracy behind a multi-billion-dollar healthcare organization would need to change. Even the doctors and nurses would need to change! He knew that the project had enormous potential but would become even more daunting from here.

This module will present two unfolding case studies based on real-world, actual events. The cases will require participants to review videos embedded into three modules and a summary module: Introduction to Concepts of Social Determinant of Health and Seeking Racial Equity  Case Study on Health and Healthcare Context - Greensboro Health Disparities Collaborative (GHDC)​    Case Study on Social and Community Context - Renaissance Community Cooperative (RCC) Summary (Optional)

The learning objectives for the modules are related to achieving the Healthy People 2020 Social Determinants of Health Objectives – specifically the (1) Health and Healthcare Context, and (2) Social and Community Context.   

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Browse our case library

Quelch, J.A. & Weber, J. , 2014. Pfizer Astrazeneca: Marketing an Acquisition (Parts A & B) , Harvard Business Publishing. Available from Harvard Business Publishing Abstract In 2014, Pfizer proposed a friendly acquisition of AstraZeneca, but the AstraZeneca board resisted over price and strategy concerns. Was this good for pharmaceutical consumers? Pfizer, like pharmaceutical companies in general, faced difficulties in growing sales due to the challenges of developing new drugs. Over the previous decade or more, Pfizer had pursued acquisitions as a way to acquire new drugs, increase sales, and to reduce costs by combining operations and cutting staff. Pfizer, a U.S. company, was also interested in AstraZeneca, a U.K. company, as a way to reduce its corporate taxes. In recent years, AstraZeneca had significantly strengthened its pipeline of potential new drugs and its board felt it was in a strong position to go it alone. The company's CEO also indicated that an acquisition would be disruptive to its drug development efforts and delay new drugs coming to market. U.K. politicians expressed concerns over downsizing and job losses in the economically important pharmaceutical sector. The case allows readers to explore who benefits from a potential acquisition (shareholders, employees, drug consumers) and which of these stakeholders should be considered when deciding on an acquisition.

Siegrist, R. , 2014. Eastern Cape Clinic (Parts A, B, & C) , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract Thandeka Sisulu had just been hired as the new administrative director for the Eastern Cape Clinic, located in the outskirts of the South African city of East London. The Clinic had opened about 18 months ago with support from the government and from two anonymous donor groups. Those funds would soon run out and Thandeka faced the dual challenge of helping the Clinic become self-sufficient and dealing with the long wait times for patients to be seen.  She knew that the budget for this year projected a loss, so she decided to better understand the financial problem first.

“Alameda Health System” (AHS) describes a county-owned safety net health system adapting to the implementation of the Affordable Care Act and an increasingly competitive health delivery environment. It takes the perspective of senior management, specifically the Chief Medical Officer for the system, who has been in his job for just over one year. The case begins in late 2014, when the CEO of 9 years announced that he was leaving AHS to become CEO of a Detroit health system. He was leaving behind a senior management team that had been in place for 1–2 years, and had turned over several times throughout his tenure. At the same time, the system was experiencing a financial downturn, brought on in part by the loss of many low-income, formerly county indigent patients who selected subsidized private health insurance plans on the new state health exchange that contracted primarily with AHS’s two largest competitors. AHS also had yet to integrate clinically or administratively with two community hospitals, both of which were in poor financial health, recently acquired as part of a strategy to diversify the AHS payer mix.

The system faced operating challenges common to many publicly-owned safety net hospitals, including: a unionized workforce; an independent, mission-driven medical staff that had grown weary of administrative turnover; a poorly functioning revenue collection system; unprofitable contracts with managed care plans; relatively few commercially insured patients or contracts; long wait times for care; lack of telephone and transportation access to providers; and a low-income population with multiple poorly managed chronic diseases, including mental illness and substance abuse, as well as a high rate of violent crime.  

The case requires that students understand key aspects of the ACA and can synthesize other relevant environmental and organizational trends in order to recommend and evaluate the actions that senior management should take.

2019. The Case Centre . Visit website A non-profit clearing house for materials on the case method, the Case Centre holds a large and diverse collection of cases, articles, book chapters and teaching materials, including the collections of leading business schools across the globe.

Quelch, J.A. & Rodriguez, M. , 2014. Cancer Screening in Japan: Market Research and Segmentation , Harvard Business Publishing. Available from Harvard Business Publishing Abstract Since founding CancerScan in 2008, Jun Fukuyoshi and Yoshiki Ishikawa had helped to improve cancer screening rates in Japan. Between 2005 and 2007, awareness of breast cancer in Japan rose from 55% to 70%, but the incidence of breast cancer screenings remained constant. Jun and Yoshiki applied marketing research techniques to increase the screening rate for breast cancer, a disease which killed over 12,000 Japanese women in 2011. Cancer screening initiatives accounted for 60% of the company's 2013 sales of $2.5 million.

Siegrist, R. , 2013. Children's Hospital in Transition , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract John Leader, president of Simsbury Children’s Hospital, was reviewing the recommendations put together by his senior management team to resolve the growing problems his hospital was facing. The recommendations, totaling some $10 million, could put the hospital back on a sound financial footing. But John was unsure which of the recommendations made sense and should be implemented. He was particularly interested in understanding the financial, operational and political impact of each one. He was due to meet with the senior management team that afternoon to develop an action plan.

In February 2015, technical staff reviewed the results from a jointly conducted study on malaria control. This study had major implications for malaria in Zambia—and elsewhere. The preliminary analysis strongly suggested that the study’s Mass Drug Administration (MDA) strategy was reducing the incidence of malaria disease. In addition, MDA seemed to be driving down the infection reservoir among asymptomatic people in the study area of the Southern Province of Zambia. Further analysis with mathematical models indicated that if the intervention was sustained so current trends continued, then the MDA strategy would make it possible to eliminate malaria in the Southern Province. 

If malaria could be eliminated in one region of Zambia, that would provide new evidence and motivation to work towards elimination throughout the country, an ambitious goal. But it would not be easy to move from conducting one technical study in a single region to creating a national strategy for malaria elimination. The scientists realized that their new data and analyses—of malaria infections, mosquito populations, and community health worker activities—were not enough. A national malaria elimination effort would require mobilizing many partners, national and local leaders, and community members, and convincing them to get on board with this new approach. 

Teaching note available for faculty/instructors .

Beginning in 2013, Humana Inc., headquartered in Louisville, Kentucky, pursued a major organizational transformation, from being an insurance company focused on paying claims to becoming a health and well-being company focused on improving the health of its beneficiaries. The company set a “Bold Goal” of improving the health of the communities it served by 20% by 2020. To achieve this new goal, Humana undertook a multiyear redesign and investment of people, processes, and products in order to gain the trust of consumers and providers, and to partner with communities to improve health. The case focuses on community initiatives, where Humana was developing its new role as “convener of conversations,” providing leadership infrastructure and partial funding to spark community planning with a wide range of stakeholders and to design and monitor interventions that were tailored to local health improvement. At the same time, Humana remained a publicly-held corporation accountable to its shareholders for revenue growth and financial return. The case protagonist, Andrew Renda, MD, MPH, Director, Bold Goal Measurement, must design and implement a business plan, including leading and lagging performance metrics, that would measure Humana’s progress toward its Bold Goal in ways that supported continued investment in community health improvement in Humana’s local markets, while satisfying its traditional business constituents.

This case can be used in courses on strategy, community health improvement, the corporate role in public health, and other courses exploring the intersection of business and society. It also offers a rich opportunity to explore the research design and measurement challenges associated with evaluating the impact of public health interventions on local communities.

National Academies Press: OpenBook

Health and Wellness Programs for Commercial Drivers (2007)

Chapter: chapter 4 - health and wellness program case studies.

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

40 In addition to the surveys and literature review presented, this synthesis includes four trucking case studies and one bus company case study describing implementation of innovative company-sponsored employee health and wellness practices and programs. The four trucking industry case studies presented here include both large and small carriers from TL, LTL, short- haul carriers, and one very large nationwide (short-haul) waste management company. Case study data were obtained from a single intercity, interstate bus company: Greyhound Lines, Inc. Some of the key points identified from the four trucking and one bus company case studies include • Significant value is placed on drivers as the cornerstone of companies because they are crucial to continued company success. • Recognition of the challenges to driver health and wellness related to the unique nature of the truck driving lifestyle. • Recognition of the connection between driver health and driver safety. • The value of health and wellness initiatives on the compa- nies’ bottom lines through the reduction of health claims, early identification of treatable health issues, and improved driver retention. • The value of an integrated human capital management strategy for controlling overall health care and workers’ compensation costs. The case studies identified some key initiatives being con- ducted by carriers. These initiatives include more extensive pre-employment and annual physical testing, establishment of onsite clinics, health coaches, and training programs such as Gettin’ in Gear, additional efforts to address sleep apnea for all drivers by means of early testing and diagnosis, and implementing more ergonomic cab settings (such as seat adjustments). The carriers emphasized the importance of educating drivers about the availability of the health and wellness programs and working together toward reducing any additional health-related costs for drivers. The carriers described methods for advocating and imple- menting the programs. Some of the carriers conducted claims studies to examine the cost savings of particular programs. All the carriers discussed the importance of identifying the ben- efits to the corporate bottom line and overall reduced health care costs, and conveying those to management. The carriers emphasized the importance of educating all levels of the organization about the importance of health and wellness programs. Some of the benefits discussed by carriers included • Holding rises in claims cost to single digit increases over 1 year compared with an industry norm of expecting dou- ble digit annual increases, • Reduction of claims involving serious musculoskeletal injuries and workers’ compensation claims, • Decreased accident rates, • Decreased personnel turnover rates, and • Early identification and the costs savings associated with identifying potential health problems of individual employees (drivers) early. 4.1 Case Study: Schneider National, Inc. Headquartered in Green Bay, Wisconsin, Schneider National, Inc., is the nation’s largest truckload carrier, employing more than 15,000 drivers and independent con- tractors. Schneider National’s approach to driver health and wellness is based on recognition that drivers are the corner- stone of the operation. Without drivers, the company would not be successful. Schneider National believes that focusing on driver health and wellness results in improvements across the safety continuum from individual drivers, to their fami- lies, to the motoring public who share the highway with Schneider National drivers. C H A P T E R 4 Health and Wellness Program Case Studies

Acknowledging that the lifestyle of a truck driver makes meeting health and wellness goals challenging, Schneider National has instituted a number of initiatives designed to mitigate the impact of the various wellness challenges (long periods sitting, truck stop diet, shift work, being away from home for extended periods of time, etc). Schneider National reports that its health and wellness initiatives have had a pos- itive impact on the company’s bottom line. Sleep Apnea Initiative. In an effort to reduce the risks associated with sleep apnea, Schneider National initiated a program to identify and treat drivers suffering from sleep apnea. An initial cohort of 339 drivers deemed positive for sleep apnea were tested. The one-night study in a sleep malady clinic, conducted with a third-party vendor and paid for by Schneider National, resulted in the diagnosis of drivers with sleep apnea who were sent home with a Continuous Positive Airway Pressure (CPAP) machine. After treatment with a CPAP for 1 year, Schneider National experienced a $538 per driver per month health care savings among the cohort and a 55% greater retention rate among participating drivers than the fleet as a whole. Based on the success of this initial test, Schneider National now pays for all sleep malady testing and CPAP costs for drivers at risk for and diagnosed with sleep apnea. The driver is followed for 30 days post-CPAP intervention to trou- bleshoot any specific issues to assist the driver in getting used to the CPAP treatment. Quarterly follow-up with the driver is done to ensure long-term compliance with the sleep apnea intervention. Ergonomic Improvements in Seating. Truck drivers spend a significant portion of their time in the cab of the truck, specifically in the seat, while driving. Therefore, seat comfort is an issue for commercial drivers who may experi- ence back, head, or shoulder pain as a result of poor seat design or use, combined with the constant vibration from the road. Schneider National wanted to find a way to promote more in-cab comfort for their drivers, believing that it would promote driver satisfaction as well as safety. Schneider National’s solution to the driver seat comfort issue was to invest in a system that works with existing cab and seat ergonomics to provide drivers with the ability to adjust seats and steering wheel for maximum comfort and safety. With the seat and steering wheel customized to each driver’s build and specific needs, Schneider National believes that drivers feel better, perform better, and are less fatigued. In the first year of its implementation at Schneider National, performance metrics calculated included lost time injuries, driver discomfort, and workers’ compensation claims. Schneider National’s results with the ergonomic seating showed a significant decrease in lost time injuries, workers’ compensation injuries, and improved driver dis- comfort complaints by 47%. Schneider National officials comment that while driver sat- isfaction and comfort were the primary drivers of the seat sys- tem, there has been a demonstrated return-on-investment (ROI) as a result of system implementation. Disease Management and Health Coaches. Under the direction of and in conjunction with a full-time Occupational Health medical team and Benefit Administration, Schneider National has several disease management and health coaches who work with the drivers on a regular basis. Areas of focus include cardiac health, diabetes, asthma, chronic obstructive pulmonary disease and congestive heart failure. Schneider National’s focus is on education and prevention, believing that educated drivers will be safer, more productive, and more invested in their overall health and wellness. Overall Program Effectiveness. In an attempt to meas- ure the impact of its various health and wellness initiatives, Schneider National undertook a study to review health care claims costs pre- and post-wellness program interventions. Through July 2005, Schneider National was able to hold claims costs to a single-digit percentage increase from the previous year, which is relatively low compared with indus- try norms. Schneider National cites as a key to the success of its various health and wellness initiatives the education and inte- gration of the programs across the organization from drivers to management. Additionally, with its corporate focus on the health and wellness of drivers as a cornerstone of the com- pany’s success, Schneider National believes that its programs must address a reduction in accidents and the risk of injury to the driver. All these efforts, when used in an integrative model approach, have led to health and safety benefits for the organization. 4.2 Case Study: Trucks, Inc. Based in Jackson, Georgia, Trucks, Inc., is a regional truck- load carrier with hundreds of drivers, operating 300 tractors, primarily in Georgia, Florida, Alabama, and South Carolina. Personal Approach to Health and Wellness. Trucks, Inc., officials believe their personal approach with their driv- ers is a key to the company’s success and this approach includes a health and wellness program. With a self-funded health insurance program, the safety department has done considerable research to correlate their drivers’ physical and emotional well-being to safety performance. Believing firmly in the connection between driver health and wellness and driving safety, the company provides drivers with health and 41

wellness education and with the tools necessary to change drivers’ mindset toward adopting a health and wellness lifestyle. Company Officials Train in Health and Wellness. Company safety officials have completed the Gettin’ in Gear training course and they use materials from the course, along with workers’ compensation materials from their insurance provider, to educate drivers on health, wellness, and safety issues. Trucks, Inc., relies on driver testimonials to encour- age other drivers to participate in the health and wellness activities. Healthier lifestyle choices are often the focus of the education provided and specific topics covered have included instruction on nutrition, exercise, and smoking cessation. Annual Physical Examinations. Included in the health and wellness program at Trucks, Inc., is an annual DOT phys- ical exam, for which the company employs a medical doctor and a physician’s assistant to conduct the exams onsite. The physical form used by Trucks, Inc., exceeds the minimum DOT physical requirements in a number of areas. Physical results from all Trucks, Inc., drivers are tracked to identify driver training needs based on resulting diagnoses. Any drivers with borderline physical exam results are rechecked on a more frequent basis. Trucks, Inc., annually checks drivers’ blood work to identify risk factors such as high cholesterol and to check prostate-specific antigen (PSA) levels. The company also provides exercise equipment for drivers, available 24 hr/day at company facilities. Health and Wellness Program Pays Off. Company offi- cials report that the health and wellness program has had a significant ROI. Early diagnosis of health issues has saved Trucks, Inc., more than $250,000 in medical insurance costs. The company reports that thus far the program has led to early identification of two cancer cases, five pre-heart attack conditions, and numerous pre-diabetic conditions. Trucks, Inc., believes that its personal approach with drivers and the care shown in drivers’ health and wellness have paid dividends in terms of driver retention as well. The personnel turnover rate at Trucks, Inc., is under 30%, com- pared with industry averages in the truckload sector of more than 100%. The company has also been recognized by the Georgia Motor Trucking Association for its safety perform- ance (which Trucks, Inc., believes is closely related to driver health and wellness) for the last 11 years. 4.3 Case Study: JB Hunt, Inc. JB Hunt, Inc., one of the nation’s largest truckload carri- ers, is headquartered in Lowell, Arkansas. Driver Medical Examinations. JB Hunt uses a third- party provider for comprehensive DOT medical examina- tions and early health risk identification of its drivers. The medical exam includes cardiovascular testing, a thorough musculoskeletal evaluation performed by a physical therapist, and job-specific testing to determine abilities to perform job tasks. Once complete, the DOT medical examination is entered into a web-based application so that all data are maintained electronically. Statistical analyses can be performed on all data fields of the DOT exam and trend analyses are conducted regularly. These analyses allow JB Hunt to focus wellness initiatives on specific health risks and allow for health and wellness programs to be more effective. Health Coaching. JB Hunt provides health coaches to individual drivers. Drivers who are determined to have health risks such as hypertension and diabetes are given information that will assist them in initiating a relationship with a health coach who can assist in making lifestyle changes and create accountability. Health Program Results Favorable. JB Hunt has seen many significant results due to the use of health coaches and the electronic tracking of DOT medical examination findings. There has been a reduction in the number of workers’ com- pensation claims and costs, a reduction of claims due to serious musculoskeletal injuries, a reduction in workers’ compensation claims within 90 days of hire, a reduction in accident rates, and a decrease in driver turnover. 4.4 Case Study: Waste Management, Inc. Waste Management, Inc., (WM) is one of the nation’s largest short-haul trucking companies, employing more than 30,000 drivers, about half of whom hold CDLs and drive trash and garbage hauler trucks. Assessing Company Health-Related Costs. In 2002, WM’s health-related costs were high and increasing rapidly. After successes with a Mission to Zero (M2Z) safety program, WM embarked on an effort to address excessive health care costs. Guided by management information produced out of an integrated human capital management data warehouse, WM established a human capital management (HCM) approach to addressing its health and disability challenges and achieving cost savings through focused programs and policy changes. WM’s approach yielded a management infra- structure that supports more comprehensive efforts to man- age human capital in the future. WM admits it takes patience and leadership to follow the road map they identified for itself in controlling health, safety, and job performance risks and 42

costs. However, WM reports outstanding success in the rela- tively new program and currently experiences some success in terms of cost control results. WM’s decreased cost inflation trend dropped from 22+% to a negative 1.3%, and WM reports having saved well over $100 million in just the few years since implementing new HCM programs (Hoffman and Kasper 2006). WM’s new HCM program has numerous facets to it, but only a few that, in particular, pertain directly to employee health and wellness are described. Integrated HCM Data and Information System. WM began to examine total human capital data across all aspects of the company. It incorporated those sources of data into an HCM information system that permitted an examination of the integrated nature of human capital cost situations. This permitted management to “see across” benefit programs and to lead WM to make a critical transition from benefit-centric administration, to people-centered management of the com- pany’s benefit investments that examines costs more precisely and searchers for person-centric solutions. WM’s HCM analysis pointed out how individual employ- ees use portions of the full range of health and absence- related benefits offered. The analysis showed that just over 10% of all WM employees use 80% of the dollars spent on health care, workers’ compensation, absence, and disability benefits. On average, those employees in this high risk group cost WM over $17,000 annually versus an average cost of less than $500 per year for the balance of WM’s lower risk employees. For WM drivers, the average cost of this high risk group was even higher at over $212,000 and a very slim minority (about 1.4%) in the high risk group consumed a broad array of benefits and accounted for 40% of the total benefits spent, whereas a significant majority (over 90%) of employees (the low risk group) consumed only 20% of the benefit dollars. Occupational Health Counselors (OHCs). Among the several HCM initiatives on health, WM partnered with a team of occupational health counselors to establish 19 field-based occupational health specialists as the primary points-of- contact for supervisors to engage immediately on hearing of an injury accident. The OHCs guided employees to the best medical care resources and worked with employees, supervi- sors, safety, and human resource personnel to coordinate a safe and timely return to work when injuries resulted in lost duty time. OHCs were equipped with information that enabled them to address employees as people rather than as injury cases. They treated employees on a broad range of issues related to job satisfaction, safety, return to health, and return to pro- ductive work. Specific Employee Health-Related Programs. Based on analyses of employee health care data, priority health conditions for WM employees include musculoskeletal/back problems, cardiovascular/circulatory problems, obesity, and asthma. WM conducts health and wellness programs including diagnosing and treating sleep apnea, driver safety, managing obesity and blood pressure, lunch-and-learn educational programs, and first aid training. WM treats the CDL physical exam as an opportunity to track and link employees needing follow-up assistance to the appropriate resources to obtain medical help. Overall Strategy. WM actively steps into the breach between what employees need and what the health care sys- tem is geared to provide, especially in support of employees for their chronic medical conditions. WM’s strategy is to get employees and their dependents to change their attitudes and behaviors with respect to their health and health care costs and, as needed, to take advantage of the programs and benefits available to help them improve their health, safety, and job performance. WM is launching a comprehensive communication and education program that will provide all employees and their dependents with a steady stream of reliable information to help them better understand and improve their health. The program will include a wellness newsletter and monthly edu- cation program modules, offering flu shots, health fairs, health screenings, health coaching and counseling, and other health-related activities. 4.5 Case Study: Greyhound Lines, Inc. (Amalgamated Transit Union National Local 1700 Health and Welfare Plan) This plan covers the ATU-represented employees of Grey- hound Lines, Inc. The company is based in Dallas, Texas, but the employees and participants are located throughout the United States. Some of the programs available to the drivers, spouses, and dependents enrolled in the medical plan include: Disease Management. These programs are available for chronic conditions, such as asthma, diabetes, heart disease, low back pain, chronic obstructive pulmonary disease, and weight complications. Each program allows one to design a personalized action plan under the employee’s doctor’s guid- ance. Participants are provided with access to a personal, experienced registered nurse to call for guidance and support who provides educational material about an individual’s medical condition, self-care information, reminders of important tests and exams, and informational newsletters. The goal is to help the person anticipate his/her own symp- toms and manage them better. 43

Various Wellness Options. Participants are able to obtain discounts on fitness club memberships, weight man- agement programs, massage therapy, chiropractic care, and two different smoking cessation options. In addition, there is a program to show members the benefits of consistent shorter sessions of physical activity throughout the day. This pro- gram features a pedometer to measure walking distance and an online tool to log daily steps, track progress, and receive coaching tips. 24-Hour Health Information Line. Helpful health infor- mation is available by phone from a trained registered nurse or from an audiotape library of more than 1,000 health- related topics. Online Tools. Participants can complete a health risk assessment that helps them assess and monitor their health status, obtain a personal analysis of many preventable and common conditions, review details of their contributing risk factors, access recommended steps for improvement, inter- active tools, and wellness information. A hospital informa- tion tool allows them to compare hospitals for over 50 surgical and medical procedures. A prescription drug tool allows the member to research individual drugs or compare several drugs used to treat a specific condition. An interactive library provides information on health conditions, everyday health and wellness, first aid, and medical exams. Miscellaneous. If employees have purchased certain voluntary insurance, they could be eligible to receive cash back for obtaining certain preventive testing or routine examinations. All employees and their dependents are eligible for an employee assistance program free of charge that cov- ers counseling for issues that could relate to health and wellness issues. 44

TRB's Commercial Truck and Bus Safety Synthesis Program (CTBSSP) Synthesis 15: Health and Wellness Programs for Commercial Drivers explores health risks facing commercial truck and motorcoach drivers. The report examines the association between crash causation and functional impairments, elements of employee health and wellness programs that could be applied to commercial drivers, and existing trucking and motor coach employee health and wellness programs. In addition, the report includes several case studies on employee health and wellness programs in the truck and motorbus industries, focusing on the elements that appear to work effectively.

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Case Studies in Community Health

Case Studies in Community Health

  • Jo Fairbanks - University of New Mexico, School of Public Administration, Centennial Group, Latin America
  • Judith Candelaria - New Mexico Department of Health
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Case Studies in Community Health presents 14 classroom-tested case study scenarios, including background information and discussion questions. Written for students in public health and community health courses, these cases help integrate the basic concepts of public health into an applied setting. The case studies provide an opportunity for students to apply those basic concepts to a "real-life" situation. The overall purpose of the book is to help students understand that public health practice occurs in a social context and therefore is subject to all the complexities of a social environment. The cases explore a broad range of topics in three critical areas of public health: epidemiology, health administration, and health program planning.

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Challenges to evidence-based health promotion: a case study of a Food Security Coalition in Ontario, Canada

Samantha b meyer.

1 School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, Canada

Sara S Edge

2 Ryerson University, 350 Victoria St, Toronto, Ontario, Canada

Jocelyn Beatty

Scott leatherdale, chris perlman, jennifer dean, paul r ward.

3 Flinders University, Sturt Road, Bedford Park, South Australia, Australia

Sharon I Kirkpatrick

Developing the evidence base for health promotion can be challenging because interventions often have to target competing determinants of health, including social, structural, environmental and political determinants; all of which are difficult to measure and thus evaluate. Drawing on a case study of food insecurity, which refers to inadequate access to food due to financial constraints, we illustrate the challenges faced by community-based organizations in collecting data to form an evidence base for the development and evaluation of collective programmes aimed at addressing food insecurity. Interviews were conducted with members of a multi-stakeholder coalition ( n  = 22 interviewees; n  = 10 organizations) who collectively work to address food insecurity in their community through a range of community-based programmes and services. Member organizations also provided a list of measures currently used to inform programme and service development and evaluation. Data were collected in a city in Southern Ontario, Canada between May and September 2015. Participants identified four barriers to collecting data: Organizational needs and philosophies; concerns surrounding clientele wellbeing and dignity; issues of feasibility; and restrictive requirements imposed by funding bodies. Participants also discussed their previous successes in collecting meaningful data for identifying impact. Our results point to the challenge of generating data suitable for developing and evaluating programmes aimed at broader determinants of health, while maintaining the primary goal of meeting clients’ needs. Documenting change at intermediate- and macro-levels would provide evidence for the collective effectiveness of current programmes and services offered. However, appropriate resources need to be invested to allow for scientific evaluation.

There is a growing recognition of the importance of evidence-based practice in health promotion. It has been shown to lead to more effective interventions, and provides organizations with the information necessary to evaluate impact ( Green, 2000 , 2002 ; Rychetnik and Wise, 2004 ). However, producing the evidence to inform evidence-based health promotion can present challenges given that interventions include activities to address determinants of health (social, structural, environmental and political) that are difficult to measure ( Green and Kreuter, 2005 ) and are beyond the day-to-day mandate of many community organizations. Community interventions often target a variety of drivers (social, environmental, political), and thus there are a multitude of considerations that need to be accounted for in their development and evaluation ( Green, 2006 ).

Ideally the provision of health promotion interventions requires acknowledgment of how social contexts shape individual and community circumstances ( Kickbusch, 1989 ). Interventions thus require coordination across a range of organizations and various levels and targets for intervention. It is this coordination that leads to challenges in the development and evaluation of health promotion interventions. Consequently, health promotion continues to struggle with its evidence base ( Van den Broucke, 2012 ) due to what Koelen et al. (2001) refer to as dilemmas in: Interventions and outcomes (difficulty identifying independent and dependent variables related to social, cultural and organizational factors within complex organizations); numbers (difficulty in measuring outcomes at social, political and environmental levels); and the absence of control groups. Tilford (2000 ) argues that while the importance of disseminating evidence in health promotion is well-recognized, ‘appropriate methods to enhance uptake and use of evidence have not always been applied’ (p. 661). The current paper presents a case study identifying challenges faced by community-based organizations in collecting and disseminating data to determine if their existing programmes and services are working to address the underlying determinants of food insecurity.

The case explored in this study focuses on responses to household food insecurity within one community. Food insecurity exists ‘when people do not have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life’ ( Dietitians of Canada, 2005 ). In 2012, the last year for which a nationally representative estimate is available, almost 13% of Canadian households were characterized as food insecure, representing over 4 million affected Canadians. The correlates of household food insecurity have been well-documented through analyses of national survey data and include reliance on government assistance as the main source of income, being in a household led by a lone mother, Aboriginal status, and lack of home ownership ( Che and Chen, 2001 ; Ledrou and Gervais, 2005 ; Kirkpatrick and Tarasuk, 2009 , 2011 ; Tarasuk et al. , 2012 ). Food insecurity has been recognized as a serious public health problem given the links with compromised nutrition and poor physical, mental and social health ( Vozoris and Tarasuk, 2003 ; Health Canada, 2007 ; Kirkpatrick and Tarasuk, 2008 ; Mikkonen and Raphael, 2010 ; Dietitians of Canada, 2016 ; World Health Organization, 2016 ). Responses to food insecurity have been dominated by food banks and other food relief programmes, as well as capacity building initiatives such as community kitchens ( Dietitians of Canada, 2016 ). However, there have been repeated calls for responses that address the underlying determinants. For example, a 2016 position statement from Dietitians of Canada calls for responses to address the root causes of the problem ( Dietitians of Canada, 2016 ). Within this context, local communities are attempting to craft strategies that go beyond providing food relief as a means of ameliorating vulnerability to food insecurity. However, generating evidence of the effectiveness of interventions targeting underlying determinants (e.g. housing, employment) is challenging, and requires appropriate targets and methods for data collection and analysis.

Our research was conducted in a Southern Ontario, Canada community where 12 local organizations have self-organized to develop a multi-sectorial Food Security Coalition (FSC) to address this growing issue within their community. Collectively, they offer a wide range of health promotion services that aim to address the determinants of food insecurity by focusing their services at drivers of food insecurity, such as employment and lack of housing. Local food banks also participate in the FSC, although their role is more an immediate response to food insecurity rather than addressing the broader determinants. Through engagement with our participating community as part of a larger research initiative, it was identified that the community faces significant challenges in collecting data to form an evidence base for both developing and evaluating the impact of the FSC in ameliorating vulnerability to food insecurity. Whilst data exist in other jurisdictions, this community (along with others) has unique characteristics that make it difficult to determine if what ‘works’ in other jurisdictions will have a similar (if not negative) impact in the context of this community. Working alongside the FSC, we designed a research project to interrogate these challenges and develop a means by which the community might work to collect meaningful evidence within the given constraints. The project aim was to map out key actors and the infrastructure necessary for building a more comprehensive evidence base for developing and evaluating interventions targeting food insecurity in this community.

Our research was designed using a case study methodology. Case studies are research strategies in which the distinguishing characteristic is an attempt to examine a contemporary phenomenon in a real-life context ( Yin, 1981 ). The methodology enabled us to uncover challenges faced when collecting the data required to develop evidence-based interventions and demonstrate programme effectiveness. We adopted a two-step approach that incorporated developing an inventory and semi-structured interviews ( Crabtree and Miller, 1999 ). The inventory allowed us to identify the types of data organizations are already collecting. The interviews allowed us to understand, from the participating organization’s perspective, the difficulties faced in collecting data. Collectively, our data provide an understanding of the additional actors, and infrastructure necessary for building a more comprehensive evidence base for developing and evaluating interventions targeting food insecurity.

Recruitment

Individual organizations were recruited through the Chair of the FSC, with whom the authors met through a larger research initiative in the case city. Representatives from the FSC organizations were contacted by the Chair through e-mail, sent a letter of consent and an interview time was scheduled based on the participants’ schedule and preference. The research team interviewed 22 individuals (representing 10 organizations). Two FSC member organizations did not participate; a charitable organization and an organization offering mental health services. Interviews were conducted in person or by telephone by J.B., S.E. and S.M. between May and September 2015.

Data collection

Data inventory.

Participating organizations were asked to provide the team with surveys or other instruments they use to collect information from their clients, or to list the type(s) of data they track regarding service use. An inventory spreadsheet was created to organize this information. The aim was to understand if and how organizations on the ground were collecting data that permitted them to measure their impact on community food insecurity.

Semi-structured interviews sought to uncover the range of approaches taken, and challenges faced, by FSC member organizations when collecting data to develop an evidence base. Participants were asked to discuss the factors that influence what data they collect from their clients, and any related barriers or challenges they may face when collecting or disseminating this data to member organizations. We wanted to understand what the organizations identified as necessary to developing a comprehensive evidence base for developing and evaluating interventions targeting food insecurity in their community.

Interviews were transcribed verbatim. Steps used for analysis followed those outlined by Miles and Huberman (1994) : (i) coding of the transcribed data to identify the words or sections of text regarding challenges faced in collecting data from clients; (ii) sorting through the coding to identify themes with regard to challenges faced and (iii) confronting these themes with a formalized body of knowledge (researcher’s expertise and academic/grey literature). Data analysis was carried out by three independent researchers (J.B., S.E. and S.M.). Discrepancies were settled during two full days of discussion regarding emerging themes and structure of the current paper. Data analysis was also informed by ongoing consultation with the FSC with whom the researchers have been engaging with since June 2014. Data were discussed with the FSC on two separate occasions (April and November 2015) through oral presentations, whereby themes emerging from the data were confirmed as being representative of the voices of committee members. All interviewees reviewed the data presented for accuracy.

For the purpose of anonymity, we have assigned a label to each participant based on their organizational mandate. If there were multiple organizations that represented a category, the organizations were further denoted with a number. Several of the participating organizations were represented by numerous workers/volunteers, and each of these participants is denoted with a letter.

This research was approved by the University of Waterloo Office of Research Ethics (project number 20748). All participants provided written consent.

The data currently collected by members of the FSC provide member organizations with information about the socio-demographics of their clientele, frequency of service use, physical and mental health, finances and use of social services ( Table 1 ). While this information may be used to tailor programmes to suit specific client needs, and to observe changes in these variables over time, it does not necessarily provide a sufficient evidence base for developing interventions or evaluating existing services’ impact on food insecurity. The limitations of these data, as prescribed and restricted by a number of different factors, were discussed during our interviews.

Examples of data collected by FSC member organizations

The main themes identified in the interviews relate to: organizational needs and philosophies; concerns surrounding clientele wellbeing and dignity; issues of feasibility; and restrictive requirements imposed by funding bodies. Interviews also highlight some of the successes and potential opportunities related to enhancing programme and service delivery that may also inform future debates around: What data is most meaningful to collect; what data might best inform an evidence base; and what data might accurately reflect the impact of interventions.

Organizational needs and philosophies

While the organizations’ emphasis is direct service rather than evaluation, they do seek information from clients for the purpose of improving service delivery. Participants noted that demographic and/or anecdotal information allows them to better understand the needs of different population groups and adapt services to meet those needs. For example, in recent years, Food Bank 2 has seen an influx of single men using their services, with families being more likely to frequent Food Bank 1. Two of the food banks emphasized that having the flexibility and autonomy to make judgment calls over the kind of data, if any, they collect is imperative to ensuring they are sensitive to the unique circumstances of their clients and can subsequently tailor services in an individualized fashion. As noted by Family/Financial Assistance 1-C, certain segments of the food insecure population ‘only go to the one food bank because they [the organisation] don’t ask questions and that’s one way of [the clients] keeping control of their own information’. Food Bank 3-A discussed that organizations took diverse approaches to serving the community, reflecting that although other organizations require more invasive information, their mandate is to first ask clients ‘what can we do to help?’ rather than asking for their personal information. This is of particular interest, given that numerous organizations discussed the fact that access to healthy food is a fundamental human right, and should be treated as such.

Informal conversations and interactions with clients were valued as an effective approach for informing food bank staff about the needs of clients, in comparison to more rigid processes of data collection and intake. Two volunteers at Food Bank 2, a faith-based organization, summarized this position:

Our role is that if somebody comes to the door and says they are hungry, we provide food because that is what we’re called to do by our faith. It is as simple as that (Food Bank 2-A). It is as simple as that. (Food Bank 2-C)

Because the drivers of food insecurity are complex and many factors influence the financial resources available to a household for food and other basic needs, many FSC organizations collect data consistent with their specific mandate; data that may be used to inform interventions aimed at the broader determinants of food insecurity (e.g. financial counselling), among other social issues. For example, family services requests information regarding income versus monthly living expenses to tailor programmes to their clients, while the women’s shelter tracks information-like client engagement with counselling services (Women’s Shelter-A; Women’s Shelter-B). However, currently there is no infrastructure for identifying what impact these services are having on rates of food insecurity.

For other organizations, an intentional choice was made not to collect data as part of their service provision. For example, eligibility and access to the school food programme is not tied to, or dependent on, demonstrated indicators of poverty or food insecurity. The school board places importance on minimizing the stigmatization of students who are ‘in need’. Collecting data conflict with philosophical values of preserving client confidentiality and dignity. This concern was echoed by other participants, for example, Food Bank 1 who identified the intrusive nature of collecting and tracking client information:

[if we were going to collect more data from clients] I’d have to know more of what and who was going to be involved and who is going to see this information. I mean it’s just like I said, if I was John or Fred, or whoever I was, I don’t think I would like to have people knowing everything about me.

Concerns surrounding clientele wellbeing and dignity

Participants expressed widespread concern over requiring clients to provide information that could give the impression that their service use was being monitored, as this could be both a stigmatizing action and a perceived infringement on privacy rights. NGO-C noted that they observe a common hesitance across the food banks to collect data that might suggest ‘they gave [food] to someone who didn’t deserve it’. There was apprehension that the data could be used, or even be perceived as being used, to identify clients who are violating rules on how frequent one is allowed to access a food bank within a prescribed timeframe. This sentiment was asserted by food bank representatives. For example, Food Bank 3 explained that they register people without ‘going through their circumstances’, and simply ask for some personal information and photo ID, although this is not a prerequisite to access the food bank services. Ultimately, even if clients say “‘well, I don’t have any ID’, nobody ever goes away [hungry]…we never say no” (Food Bank 3-A).

Several participants alluded to the importance of maintaining the dignity of the clients they serve, and their concern that collecting data from clients in the form of intake tools and registration forms may detract from this objective. For example, Food Bank 1 said that they would not want to ask for more data from clients because they think that it ‘would be very intrusive’ (Food Bank 1-A):

They have probably gotten to a point where some of them may be awfully tired of having to keep telling their stories. You don’t ever want to give the impression that we are judging or evaluating them, because they are very sensitive to that. (Food Bank 2-A)

The fear of further victimizing already marginalized or isolated segments of the population was a large concern voiced by participants.

…most of the people who come to our food bank already feel that Big Brother is watching them all the time – they’re tired of having to justify their reasons for having to attend a food bank. That’s sort of what we try to stay away from. We want to build them up, not make them feel less secure than when they walked through the door. Food Bank 2-B

Food Bank 2 said that food banks should be a place where people can come freely without pressure or the obligation to disclose personal information—a ‘no questions asked’ place where they can simply access food (Food Bank 2-C). This theme emerged throughout the interviews with food provision service providers and is well summarized by Food Centre-A:

We (try and) track new participants in the meals, so we can have an idea of discrete users rather than just a number. That’s the only time when we’re really asking people to just sort of sign in and it’s really only to track, it’s not to qualify for what we do here. We would never be screening to make sure the people qualify, make sure they are ‘poor enough’. It’s voluntary – every time someone does give us information, other than when we track them as a number, it’s voluntary. We communicated to them that they’re helping us do the work that we’re doing here by participating in our surveys.

This reality is part of the reason that Food Bank 3 ‘switched [from having a conventional administrator] to having greeters that would take that moment to talk to [clients]’ in order to signal a welcoming environment. Adopting a more conversational tone in collecting information and greeting individuals represents a concerted effort to de-stigmatize the emergency food provision service. However, Food Bank 3-A stressed the reality that this ‘modest attempt’ in probing deeper into people’s lives is often unsuccessful due to the fact that clients are often hesitant to discuss their personal circumstances in public. Nevertheless, many did indicate that they saw value in having more information relating to demographics, such as more detailed employment data, to help illuminate root causes of food insecurity and other poverty related problems. While this information might not specifically inform the food bank services because they are already aware that the individuals they see are food insecure, this information might benefit other member organizations whose focus is to address the broader determinants of food insecurity.

Issues of feasibility

Reliance on an under-staffed office and poor infrastructure were also voiced as a significant challenge to collecting data for the purpose of evaluation. For example, Family/Financial Assistance Services 1-A voiced concern over the inability to evaluate the more intangible benefits of their services, such as broader community or economic benefits, due to feasibility concerns and their limited human capital:

We were talking about the evaluation of social value…[but] we have a very slim infrastructure. We have a beautiful building, but we don’t have an IT person, we don’t have an HR person, we don’t have a janitor!

Another key concern noted that relates to feasibility was the inherent information-gathering restrictions that come with a reliance on volunteerism to operate and deliver services. The inability to adequately train and retain volunteers is certainly a well-documented challenge in the not-for-profit sector. Food Bank 2-A expressed reservations that even if they wanted to collect more information, they are not in a position where they would have the capacity to do so. Food Bank 2-B said that ‘if it was a paid position, I would probably approach it with a more analytical [lens]…that’s a lot of work when you add it up…it’s staggering – we’re talking thousands of hours’. Organizations are clearly conscious of not over-burdening their volunteers with data collection. As Food Bank 2-A explains, ‘if we did it in a more elaborate and sophisticated way, we wouldn’t be able to have volunteers do what they do – we wouldn’t have as many volunteers.’ The lack of administration hinders the organization’s ability to collect data. Additionally, front-line service providers may not be the best individuals to elicit sensitive personal information, as they have to be ‘really economical about what [they] ask and how [they] ask it’ (Food Bank 2-A). This sentiment was well-supported by NGO-C, who stated that it is not the FSC’s intention to ‘add an administrative burden to people who are already often overwhelmed with administrative tasks. We don’t want to take people from dealing with clients beyond their expertise levels, or to filling [out more] forms.’

Restrictive requirements imposed by funding bodies

The type of funding that is acquired by the participating organizations ranges from local funding from wealthy philanthropists (e.g. food banks), to national not-for-profit funders (e.g. school food programme), to Federal or Provincial funding (e.g. Family/Financial Assistance-2). The majority of the organizations track data to justify their role in the community and need for funds to various funding bodies, or to simply provide evidence of the number of clients they are currently and/or prospectively serving. The data are collected by the organizations to demonstrate both ‘need’ and adherence to programme targets and/or organizational mandates. Many participants, particularly those who come from organizations that report to Provincial and National funding bodies, argued that much of the data they feel compelled to collect does not inform or benefit their day-to-day operations, with the exception of potentially assisting in their prospects for securing future funding. For example, Food Centre Program-A characterizes the information that their organization collects as ‘pretty much a funding funnel’, with little ‘real purpose to asking any of it’ in practice. Women`s Shelter-B similarly proclaimed that the information they track ‘doesn’t really influence the day-to-day work [and] most of the time is… very time consuming’. Community Food Centres Canada-A’s funders require them to track the number of educational materials and publications they produce, and how they have been distributed, which is ‘not something that we would ever care to track.’ School Food Program-A expressed similar sentiments:

I am working on my site visit reports today that I did all year and I look at them now, and I looked at my notes, and I think ‘Why am I keeping this? Is this of any use to me now?’

Given that the data many organizations are required to collect for funders is perceived as irrelevant to their frontline service to clients, there was some frustration that this takes away from the time and capacity available for carrying out other actions that may directly benefit their clients, particularly in the short term. Several organizations noted that they funnel data up to Provincial or National funding or reporting bodies and expressed hope that the data could be used to lobby the government for more funding or to influence policy change (e.g. Family/Financial Assistance 1-1, Family/Financial Assistance 2-A and Women’s Shelter-B). In a climate of limited resources and capacity, local organizations felt they could benefit from greater clarity around whether or how the information they are encouraged to collect is actually being used at higher levels to promote meaningful policy change. Community Food Centres Canada-A states:

Some of the information would really tell them [funders] nothing about our [actual] impact. To achieve more substantive change when it comes to poverty, we need to be looking more at the impact of the supports and services that exist, and maybe speaking more honestly with people that are trying to live on those, and trying to understand how they impact their lives. It’s just something we don’t have the resources to do at the time, but we’re certainly trying to get funding to look more carefully at [how] our advocacy office and social justice program impact people that come through our doors. I think it’s a matter of looking more carefully at the root causes of the poverty and how we could better address those.

This narrative also alludes to the necessity to embrace more qualitative approaches to data collection in order to adequately illustrate the true impact of the services provided. In this vein, the local development NGO is seeking to strengthen what they call the ‘new frontier’ of both qualitative and quantitative data collection, especially pertaining to programme outcomes (NGO-B). The type of information they want to collect would supplement existing datasets, while providing a deeper understanding of outcome-related findings. The NGO cites the desire to expand ‘evidence-based action’ through the elevated collection of ‘much more primary data that proves (an appropriate) use of funds’ (NGO-B). However, there is a lack of adequate funding and resources required to implement such initiatives.

Successes in collecting meaningful data for informing interventions

The interview data also revealed means through which FSC members are working to collect data that may inform evaluation of the collective efforts of individual organizations targeting broader determinants of food insecurity. Information that was perceived as most valuable for evaluation purposes was identified as going far beyond that which is typically collected for the purpose of securing funding. For example, the health unit collects higher level data such as average rents, whether their clients are receiving social assistance, etc., in order to assess the pertinence of the food baskets they distribute and to assess who could afford to live in the local community with all these factors considered. This approach appears to be embedded within an evolving trend to better understand the overall context of food security by asking about drivers of food insecurity (e.g. cost of living). For example, the NGO whose primary function is mobilizing and funding other local organizations to address identified community needs is ‘moving into a different model of measuring outcomes for the people they support’; yet is in early stages of the process of instituting this change (NGO-1). One characterization of this evolution is the FC’s approach, which includes the unique incorporation of pre-and-post client data that asks qualitative questions such as: ‘has the FC [food centre] increased your access to healthy foods?’ This information is combined with personal anecdotes on how the programme impacts a client’s life quality to collectively comprise the bulk of their annual report (Food Centre-A). Similarly, Family/Financial Assistance 1 aims to collect information that helps to reveal a deeper picture of the individual’s life and lifestyle:

For example, ‘do you smoke?’, do you, ‘yes, but I am going to quit, I am trying to quit’ and then there’s always a story. So, you do get a lot of personal information in, that comes with one question. So, the stats that we, all that information gets plucked into the system - every single thing - now not [emphasis added] that all the personal or the, the stories that may come… Which are very helpful because that gives me the information I needed if it’s something that I can offer than I can refer them to the programs or the services they need to help them do that.

Changes within the aforementioned organizations is reflected in, and supported by, Canadian Food Centres Canada (CFCC) who has been heralded by participants as helping to signal the trend towards more nuanced ways of gathering and reporting information related to food security, food access, and life quality. Within the organizations they govern, the CFCC encourages the introduction of programme-specific data collection that contain less demographic information, and more information relating to attitudinal and behavioural changes around food (Community Food Centres Canada-A). The Food Centre is one of the CFCC projects, therefore shaping the way they operate and the information they collect. Certain Food Centre programmes require unique sets of information—some examples include: food harvested, meals served, food sent home and recipes tried (Food Centre-A). Food Centre-A vocalized what working with the CFCC has allowed them to do:

If you can have the numbers to show for what you do, that it’s going to just benefit you […] The first thing that they have done is set up an online tracking system, and every programmer has the responsibility to track levels of participation and also their outcomes. We [track] the number of volunteers who helped out…for our social justice and activism it’s basically who participated and an intake form that summarize every case that’s come through.

In this model, staff can encourage the inclusion of quotes and stories; however, outcomes are still primarily based on quantitative data (Food Centre-A).

Health promotion interventions are often required to target a variety of underlying drivers (social, environmental, political), making it difficult to identify independent and dependent variables for measurement ( Koelen et al. , 2001 ). Determining the effectiveness of such interventions is challenging, and there are a multitude of considerations that need to be accounted for in their development and evaluation ( Green, 2006 ). Food insecurity is one such example that illustrates these challenges. As demonstrated in the interviews and by the development of the FSC, food insecurity is being embraced as a priority for a number of overlapping—yet incongruent—environmental, health promotion and social equity agendas, in recognition of the complex drivers that influence financial resources for food. Such an integrative approach to practice can foster collective action to address complex health issues, while taking into account the issues related to inequity and sustainability ( Lundy, 2010 ). This approach gets at a much broader definition of food insecurity than the focus on insufficient resources at the household level. Through our case study however, we illustrate a number of difficulties faced by front-line providers in collecting the data necessary to develop evidence-based interventions and more centrally, demonstrate the effectiveness of their programmes in addressing the broader determinants of food insecurity in their community. As the data illustrate, there are challenges to building an evidence base for community-based organizations that require coordination across multiple organizations and settings, who have unique priorities, constraints, and agendas.

Of greatest concern to participating organizations was ensuring that any data collected did not stigmatize or further victimize clients. Although it is widely supported that food security can be enhanced by having effective data collection, monitoring, and evaluation mechanisms ( McCullum et al. , 2005 ), Brug et al. (2010) caution that strict metrics often adversely impact organizations who require more individualized interventions for their clients. This may relate specifically to the food banks and community food centres, where the aim is not to address complex drivers of food insecurity, but rather to provide a service for those in immediate need. However, participating organizations beyond those related to food provision have also advocated for a qualitative approach to data collection, whereby client’s experiences could be used more extensively to evaluate programmes—this based on the idea that the success of the interventions can be determined by whether the needs of the clients are met. However, this does not tell us if the broader determinants, rather than immediate needs, are being addressed. Evaluation methods such as contribution analysis may be particularly useful for understanding how clients attribute their experiences, or outcomes, to the intervention ( Mayne, 2001 ). In this type of evaluation, a theory of change is established to outline how community-based programmes and services should lead to specific outputs or outcomes. Contextual data can then be collected to validate or modify this intended theory. Indeed, qualitative methods are important to this evaluation approach by contributing a rich picture of processes, achievements, and conditions for improvement ( Koelen et al. , 2001 ). Kemm’s (2005 ) discussion of ‘what constitutes evidence’ suggests that health promotors have long argued for a broader definition of ‘evidence’ that includes narrative descriptions and ‘lay knowledge’. Noting the limitations of narrative descriptions and views of practitioners and recipients (e.g. causation, validity), he argues that the question should drive the methods. It is evident from our data that questions around the impact of programmes on the lives of clientele may be better answered through narrative, though consideration needs to be given to how these data might be collected and the infrastructure required for tracking and analysis.

Our data also suggest that collective action creates challenges for implementing evidence-based practice and that individual level data cannot account for the variety of factors that shape socially determined health outcomes. Instead, our results point to the need for community-level longitudinal measures, including but not limited to robust quantitative measures of food insecurity, that can document the impact of FSC member organizations’ interventions. Documenting change at the macro-level, rather than exclusively at the level of specific clientele, would provide evidence for the collective effectiveness of current programmes and services being offered. However, appropriate resources would need to be invested in to allow for scientific evaluation, coupled with ethical clearance for data collection; a barrier not noted by participants. If the FSC were provided with the resources necessary for enhancing data collection and maintenance capacity (i.e. sustainable infrastructure and administrative support), their front-line efforts could remain focused on meeting the more immediate needs of their clients. This approach would alleviate the need for individual organizations to collect their own data, and perhaps if coordinated appropriately, higher-level data could document community-level change to demonstrate need to funding bodies. Furthermore, the development of community-level measures could incorporate input from both front-line providers and, when appropriate, clientele who may be the best source of input for identifying what data to collect, and through what practices. Although we present this as a ‘simple’ solution, we recognize complex health issues require time, realistic goals, and complex methods for measurement. Indeed, it is well established that interventions that require significant broader change require a far longer commitment than behavioural interventions and, additionally, are harder to demonstrate as ‘successful’ due to their inherently complex nature ( Brownson et al. , 1999 ; Golden and Earp, 2012 ). Consideration would also need to be given to the maintenance of client confidentiality and to ensure that programme evaluation does not hinder the intentions of the organizations. In presenting this approach we recognize that calls to expand the support for multi-level interventions have largely gone unheeded, increasing the challenges faced by health intervention practitioners ( Golden and Earp, 2012 ). However, decisions must still be made and actions taken even when our science or evidence is deemed imperfect ( Funtiwicz and Ravetz, 1993 ; Edge and Eyles, 2014 ).

It is critical to population health that we generate knowledge around the effectiveness of health promotion interventions, including documenting why they were, or were not, successful. Greater reliance on evidence has much to offer in terms of improving the effectiveness of interventions, the quality of health promotion practice, and achieving the most effective allocation of resources ( Green, 2002 ). However, determining the effectiveness of particular health promotion interventions may require other types of evidence ( Learmonth and Mackie, 2000 ; Dooris, 2005 ) and need to be informed by concepts of scientific evidence that are more suited to health promotion ( Rychetnik and Wise, 2004 ; Aro et al. , 2005 ; Armstrong et al. , 2007 ). The perverse consequence of the inability of health promotion to provide evidence of effectiveness using the established methodology of evidence-based medicine may well have weakened its position within health policy, as policymakers tend to take the incorrect but often-held view that a lack of evidence of effectiveness equals evidence of no effect ( Speller et al. , 2005 ). The desire to measure the evident ‘success’ of interventions continues to dominate much of the discourse on health promotion effectiveness. Rather than pose solutions, we hope that this case study has illustrated the challenges faced by the front-line providers whose primary intention is to serve their interests of their clients and their community, and points readers in the direction of how to make effective change.

ACKNOWLEDGEMENTS

We would like to thank the members of the Food Security Coalition for their invaluable insight. We would also like to thank Associate Professor Martin Cooke for his contribution to the conception of this project. Additionally, we thank the University of Waterloo CHEC initiative for supporting our collaboration. Finally, we would like to thank the anonymous reviews of this manuscript whose feedback helped to make for a more impactful paper.

This project was funded through the Propel Centre for Population Health Impact, Chronic Disease Prevention Initiative Seed Grant program. Dr. Leatherdale is a Chair in Applied Public Health Research funded by the Public Health Agency of Canada (PHAC) in partnership with Canadian Institutes of Health Research (CIHR). Sharon Kirkpatrick is supported by a Canadian Cancer Society Research Institute Capacity Development Award (702855).

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Improving Population Health: Three Case Studies

Two staff members help patient in wheelchair during discharge

The HIMSS Davies Awards program promotes HIMSS’s vision and mission by recognizing and sharing case studies, model practices and lessons learned on how to improve health and wellness through the power of information and technology. 2019 Davies Award winner St. Luke’s University Health Network was recognized for improving population health through infection control, reducing post-operative complications and more. Explore three case studies below to find out what led to their success.

Case Studies

1. reducing c. diff infection in the acute care setting.

St. Luke’s University Health Network recognized there was a high number of hospital-onset Clostridioides difficile (C. diff) cases. Their multidisciplinary performance improvement team addressed this through strategies focused on decreasing cases of C. diff through specimen collection, hand hygiene, antimicrobial stewardship and activating appropriate environmental controls.

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2. Taking Better Care of Sepsis Patients

Sepsis is one of the most common reasons for both admission and readmissions at St. Luke’s University Health Network. To ensure the best care was being provided while treating patients with the condition, the organization focused on compliance with the Centers for Medicare and Medicaid (CMS) Sepsis-1 Core Measure, using evidence-based best practices to improve outcomes.

3. Acute Kidney Injury and Hypotension in Total Elective Joints

Acute kidney injury and hypotension are common post-operative complications that were occurring frequently in St. Luke’s University Health Network’s elective total joint population. To address this population health priority , they implemented a series of best practice recommendations and clinical decision support tools in the EHR to improve communication between staff while caring for patients before, during and after surgical procedures.

Updated March 6, 2020

Medical doctor applying medicine inhalation treatment on senior woman by the mask of inhaler during coronavirus quarantine

The Collaborative Care model of integrated care developed at the University of Washington has been put in place at more than a thousand clinics across the country, including in the backyard of UW Medicine. The Behavioral Health Integration Program , or BHIP, has not only recently expanded to include all nine UW Neighborhood Clinics – a system of primary care clinics located throughout greater Seattle – but also received a Certificate of Significant Achievement from the American Psychiatric Association in October for the innovative way it integrates behavioral health care into primary care clinics. The program is also in place at five other clinics throughout the UW Medicine system.

“Both the expansion and the APA award signifies a growing recognition that Collaborative Care helps people get effective treatment for common mental health conditions like depression and anxiety,” said Jürgen Unützer , Chair of the University of Washington’s Department of Psychiatry and Behavioral Sciences. “We are proud to be able to offer quality, mental health care to our neighbors and we can use our experiences in BHIP to help improve how Collaborative Care is delivered locally, nationally and around the world.”

Formally launched in 2012, BHIP is an evidence-based and team-based model of Collaborative Care in which primary care providers are supported by clinic-based behavioral health care managers and psychiatric consultants, effectively bringing mental health treatment to where people feel comfortable receiving care. In this way, mental health care becomes an integral part of standard healthcare and mental health specialists are effectively ‘leveraged’ to reach more patients in need. The clinics vary in the populations served, which include patients who are commercially insured and employed as well as safety net patients who are medically complex, homeless, immigrants or remotely located. BHIP is funded by a combination of public and commercial billing, support from a managed Medicaid plan and Public Health – Seattle & King County, and support from the UW academic health care system.

BHIP Team Members and Staffing

The Collaborative Care team at each BHIP clinic is comprised of a PCP, 1 FTE care manager (nurse or clinical social worker), one 0.2 FTE psychiatric consultant, and the patient. The clinical team cares for a defined group of patients and closely tracks each patient’s progress using validated clinical rating scales (e.g., PHQ-9 for depression). Treatment is systematically adjusted if patients are not improving as expected, and patients who don’t respond to treatment are referred to more intensive mental health specialty care. Psychiatrists and care managers have dedicated time for caseload-based psychiatric case reviews for patients who are new to the program, not well-engaged, or are not improving. Psychiatric consultants work directly in the clinics, which is different from many Collaborative Care models where the psychiatric consultant speaks with the care manager via phone. The important principle is that all members of the team work together to care for the patient.

“Patients regularly tell me that they appreciate being seen as a whole person, where all aspects of their health are addressed in one place,” said Monica Miller , MSW, Care Coordinator/Social Worker at the UW Neighborhood Ravenna Clinic. “It has been a very rewarding experience for me to be a part of our Collaborative Care team.”

There is some variation of this basic model across sites. Some clinics have a separate social worker for traditional social work tasks, and some sites have one or more additional mental health providers such as a MA-level behavioral health counselor or a chemical dependency counselor. In 2013, two clinics split the 0.2 FTE psychiatry time.

BHIP Psychiatrist Role

A typical assignment for a psychiatric consultant includes 20% time (8 hours/week) structured around caseload-focused review (2-3 hours), direct patient consultation (4-5 hours), assisting with program coordination, quality improvement efforts, and training (1 hour), and at some locations, supervision of Psychiatry residents/fellows. Direct patient consultations focus on select patients who are presenting diagnostic or therapeutic challenges to the team.

“I work closely with a care coordinator and my primary care colleagues in helping identify patients who may need mental health services,” said Denise Chang, MD, BHIP psychiatric consultant. “This not only reduces stigma and increases access to mental health care, but it is also an effective, efficient and rewarding way of serving a large and diverse group of patients.”

Unützer notes that BHIP is not designed to provide care for patients who are more complex, such as a patient with difficult to manage bipolar disorder, and instead is meant to support patients who can be managed within primary care.

Program-Wide Goals and Effectiveness

BHIP utilizes a web-based Care Management Tracking System (CMTS) that supports population-based care, provides patient outcome measures, and assists in quality improvement efforts such as tracking on stated goals. In October 2012, several benchmarks were established for the BHIP program: increase patient access by care managers and across all BHIP clinics, improve patient outcomes on measures of depression and anxiety, increase provider satisfaction with care management, and improve provider satisfaction with psychiatric consultation.

When measured in August 2013 using numbers generated by CMTS, the BHIP program had exceeded initial targets for each of the seven indicators. The success of the BHIP program is consistent with other findings. More than 80 randomized controlled clinical trials have shown that Collaborative Care results in improved clinical outcomes, increased patient satisfaction and overall functioning, and lower total health care costs, achieving the Triple Aim of health care reform. But perhaps the biggest mark of success comes from the testimonials of patients and providers.

“You have no idea how helpful it is for a provider to have a resource like BHIP in the clinic,” said a primary care provider at one of the UW Neighborhood Clinics. “I practiced for 16 years without it and I will never go back!”

College of Nursing

Driving change: a case study of a dnp leader in residence program in a gerontological center of excellence.

View as pdf A later version of this article appeared in Nurse Leader , Volume 21, Issue 6 , December 2023 . 

The American Association of Colleges of Nursing (AACN) published the Essentials of Doctoral Education for Advanced Practice Nursing in 2004 identifying the essential curriculum needed for preparing advanced practice nurse leaders to effectively assess organizations, identify systemic issues, and facilitate organizational changes. 1 In 2021, AACN updated the curriculum by issuing The Essentials: Core Competencies for Professional Nursing Education to guide the development of competency-based education for nursing students. 1 In addition to AACN’s competency-based approach to curriculum, in 2015 the American Organization of Nurse Leaders (AONL) released Nurse Leader Core Competencies (updated in 2023) to help provide a competency based model to follow in developing nurse leaders. 2

Despite AACN and AONL competency-based curriculum and model, it is still common for nurse leaders to be promoted to management positions based solely on their work experience or exceptional clinical skills, rather than demonstration of management and leadership competencies. 3 The importance of identifying, training, and assessing executive leaders through formal leadership development programs, within supportive organizational cultures has been discussed by national leaders. As well as the need for nurturing emerging leaders through fostering interprofessional collaboration, mentorship, and continuous development of leadership skills has been identified. 4 As Doctor of Nursing Practice (DNP) nurse leaders assume executive roles within healthcare organizations, they play a vital role within complex systems. Demonstration of leadership competence and participation in formal leadership development programs has become imperative for their success. However, models of competency-based executive leadership development programs can be hard to find, particularly programs outside of health care systems.

The implementation of a DNP Leader in Residence program, such as the one designed for The Barbara and Richard Csomay Center for Gerontological Excellence, addresses many of the challenges facing new DNP leaders and ensures mastery of executive leadership competencies and readiness to practice through exposure to varied experiences and close mentoring. The Csomay Center , based at The University of Iowa, was established in 2000 as one of the five original Hartford Centers of Geriatric Nursing Excellence in the country. Later funding by the Csomay family established an endowment that supports the Center's ongoing work. The current Csomay Center strategic plan and mission aims to develop future healthcare leaders while promoting optimal aging and quality of life for older adults. The Csomay Center Director created the innovative DNP Leader in Residence program to foster the growth of future nurse leaders in non-healthcare systems. The purpose of this paper is to present a case study of the development and implementation of the Leader in Residence program, followed by suggested evaluation strategies, and discussion of future innovation of leadership opportunities in non-traditional health care settings.

Development of the DNP Leader in Residence Program

The Plan-Do-Study-Act (PDSA) cycle has garnered substantial recognition as a valuable tool for fostering development and driving improvement initiatives. 5 The PDSA cycle can function as an independent methodology and as an integral component of broader quality enhancement approaches with notable efficacy in its ability to facilitate the rapid creation, testing, and evaluation of transformative interventions within healthcare. 6 Consequently, the PDSA cycle model was deemed fitting to guide the development and implementation of the DNP Leader in Residence Program at the Csomay Center.

PDSA Cycle: Plan

Existing resources. The DNP Health Systems: Administration/Executive Leadership Program offered by the University of Iowa is comprised of comprehensive nursing administration and leadership curriculum, led by distinguished faculty composed of national leaders in the realms of innovation, health policy, leadership, clinical education, and evidence-based practice. The curriculum is designed to cultivate the next generation of nursing executive leaders, with emphasis on personalized career planning and tailored practicum placements. The DNP Health Systems: Administration/Executive Leadership curriculum includes a range of courses focused on leadership and management with diverse topics such as policy an law, infrastructure and informatics, finance and economics, marketing and communication, quality and safety, evidence-based practice, and social determinants of health. The curriculum is complemented by an extensive practicum component and culminates in a DNP project with additional hours of practicum.

New program. The DNP Leader in Residence program at the Csomay Center is designed to encompass communication and relationship building, systems thinking, change management, transformation and innovation, knowledge of clinical principles in the community, professionalism, and business skills including financial, strategic, and human resource management. The program fully immerses students in the objectives of the DNP Health Systems: Administration/Executive Leadership curriculum and enables them to progressively demonstrate competencies outlined by AONL. The Leader in Residence program also includes career development coaching, reflective practice, and personal and professional accountability. The program is integrated throughout the entire duration of the Leader in Residence’s coursework, fulfilling the required practicum hours for both the DNP coursework and DNP project.

The DNP Leader in Residence program begins with the first semester of practicum being focused on completing an onboarding process to the Center including understanding the center's strategic plan, mission, vision, and history. Onboarding for the Leader in Residence provides access to all relevant Center information and resources and integration into the leadership team, community partnerships, and other University of Iowa College of Nursing Centers associated with the Csomay Center. During this first semester, observation and identification of the Csomay Center Director's various roles including being a leader, manager, innovator, socializer, and mentor is facilitated. In collaboration with the Center Director (a faculty position) and Center Coordinator (a staff position), specific competencies to be measured and mastered along with learning opportunities desired throughout the program are established to ensure a well-planned and thorough immersion experience.

Following the initial semester of practicum, the Leader in Residence has weekly check-ins with the Center Director and Center Coordinator to continue to identify learning opportunities and progression through executive leadership competencies to enrich the experience. The Leader in Residence also undertakes an administrative project for the Center this semester, while concurrently continuing observations of the Center Director's activities in local, regional, and national executive leadership settings. The student has ongoing participation and advancement in executive leadership roles and activities throughout the practicum, creating a well-prepared future nurse executive leader.

After completing practicum hours related to the Health Systems: Administration/Executive Leadership coursework, the Leader in Residence engages in dedicated residency hours to continue to experience domains within nursing leadership competencies like communication, professionalism, and relationship building. During residency hours, time is spent with the completion of a small quality improvement project for the Csomay Center, along with any other administrative projects identified by the Center Director and Center Coordinator. The Leader in Residence is fully integrated into the Csomay Center's Leadership Team during this phase, assisting the Center Coordinator in creating agendas and leading meetings. Additional participation includes active involvement in community engagement activities and presenting at or attending a national conference as a representative of the Csomay Center. The Leader in Residence must mentor a master’s in nursing student during the final year of the DNP Residency.

Implementation of the DNP Leader in Residence Program

PDSA Cycle: Do

Immersive experience. In this case study, the DNP Leader in Residence was fully immersed in a wide range of center activities, providing valuable opportunities to engage in administrative projects and observe executive leadership roles and skills during practicum hours spent at the Csomay Center. Throughout the program, the Leader in Residence observed and learned from multidisciplinary leaders at the national, regional, and university levels who engaged with the Center. By shadowing the Csomay Center Director, the Leader in Residence had the opportunity to observe executive leadership objectives such as fostering innovation, facilitating multidisciplinary collaboration, and nurturing meaningful relationships. The immersive experience within the center’s activities also allowed the Leader in Residence to gain a deep understanding of crucial facets such as philanthropy and community engagement. Active involvement in administrative processes such as strategic planning, budgeting, human resources management, and the development of standard operating procedures provided valuable exposure to strategies that are needed to be an effective nurse leader in the future.

Active participation. The DNP Leader in Residence also played a key role in advancing specific actions outlined in the center's strategic plan during the program including: 1) the creation of a membership structure for the Csomay Center and 2) successfully completing a state Board of Regents application for official recognition as a distinguished center. The Csomay Center sponsored membership for the Leader in Residence in the Midwest Nurse Research Society (MNRS), which opened doors to attend the annual MNRS conference and engage with regional nursing leadership, while fostering socialization, promotion of the Csomay Center and Leader in Residence program, and observation of current nursing research. Furthermore, the Leader in Residence participated in the strategic planning committee and engagement subcommittee for MNRS, collaborating directly with the MNRS president. Additional active participation by the Leader in Residence included attendance in planning sessions and completion of the annual report for GeriatricPain.org , an initiative falling under the umbrella of the Csomay Center. Finally, the Leader in Residence was involved in archiving research and curriculum for distinguished nursing leader and researcher, Dr. Kitty Buckwalter, for the Benjamin Rose Institute on Aging, the University of Pennsylvania Barbara Bates Center for the Study of the History of Nursing, and the University of Iowa library archives.

Suggested Evaluation Strategies of the DNP Leader in Residence Program

PDSA Cycle: Study

Assessment and benchmarking. To effectively assess the outcomes and success of the DNP Leader in Residence Program, a comprehensive evaluation framework should be used throughout the program. Key measures should include the collection and review of executive leadership opportunities experienced, leadership roles observed, and competencies mastered. The Leader in Residence is responsible for maintaining detailed logs of their participation in center activities and initiatives on a semester basis. These logs serve to track the progression of mastery of AONL competencies by benchmarking activities and identifying areas for future growth for the Leader in Residence.

Evaluation. In addition to assessment and benchmarking, evaluations need to be completed by Csomay Center stakeholders (leadership, staff, and community partners involved) and the individual Leader in Residence both during and upon completion of the program. Feedback from stakeholders will identify the contributions made by the Leader in Residence and provide valuable insights into their growth. Self-reflection on experiences by the individual Leader in Residence throughout the program will serve as an important measure of personal successes and identify gaps in the program. Factors such as career advancement during the program, application of curriculum objectives in the workplace, and prospects for future career progression for the Leader in Residence should be considered as additional indicators of the success of the program.

The evaluation should also encompass a thorough review of the opportunities experienced during the residency, with the aim of identifying areas for potential expansion and enrichment of the DNP Leader in Residence program. By carefully examining the logs, reflecting on the acquired executive leadership competencies, and studying stakeholder evaluations, additional experiences and opportunities can be identified to further enhance the program's efficacy. The evaluation process should be utilized to identify specific executive leadership competencies that require further immersion and exploration throughout the program.

Future Innovation of DNP Leader in Residence Programs in Non-traditional Healthcare Settings

PDSA Cycle: Act

As subsequent residents complete the program and their experiences are thoroughly evaluated, it is essential to identify new opportunities for DNP Leader in Residence programs to be implemented in other non-health care system settings. When feasible, expansion into clinical healthcare settings, including long-term care and acute care environments, should be pursued. By leveraging the insights gained from previous Leaders in Residence and their respective experiences, the program can be refined to better align with desired outcomes and competencies. These expansions will broaden the scope and impact of the program and provide a wider array of experiences and challenges for future Leaders in Residency to navigate, enriching their development as dynamic nurse executive leaders within diverse healthcare landscapes.

This case study presented a comprehensive overview of the development and implementation of the DNP Leader in Residence program developed by the Barbara and Richard Csomay Center for Gerontological Excellence. The Leader in Residence program provided a transformative experience by integrating key curriculum objectives, competency-based learning, and mentorship by esteemed nursing leaders and researchers through successful integration into the Center. With ongoing innovation and application of the PDSA cycle, the DNP Leader in Residence program presented in this case study holds immense potential to help better prepare 21 st century nurse leaders capable of driving positive change within complex healthcare systems.

Acknowledgements

         The author would like to express gratitude to the Barbara and Richard Csomay Center for Gerontological Excellence for the fostering environment to provide an immersion experience and the ongoing support for development of the DNP Leader in Residence program. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

  • American Association of Colleges of Nursing. The essentials: core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdf . Accessed June 26, 2023.
  • American Organization for Nursing Leadership. Nurse leader core competencies. https://www.aonl.org/resources/nurse-leader-competencies . Accessed July 10, 2023.
  • Warshawsky, N, Cramer, E. Describing nurse manager role preparation and competency: findings from a national study. J Nurs Adm . 2019;49(5):249-255. DOI:  10.1097/NNA.0000000000000746
  • Van Diggel, C, Burgess, A, Roberts, C, Mellis, C. Leadership in healthcare education. BMC Med. Educ . 2020;20(465). doi: 10.1186/s12909-020-02288-x
  • Institute for Healthcare Improvement. Plan-do-study-act (PDSA) worksheet. https://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx . Accessed July 4, 2023.
  • Taylor, M, McNicolas, C, Nicolay, C, Darzi, A, Bell, D, Reed, J. Systemic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety. 2014:23:290-298. doi: 10.1136/bmjqs-2013-002703

Return to College of Nursing Winter 23/24 Newsletter

Australian Government Department of Health and Aged Care

About the Support at Home program

We are reforming in-home aged care to help older people live independently at home for longer. The Support at Home program will replace Home Care Packages and Short-Term Restorative Care Programme from 1 July 2025. The Commonwealth Home Support Programme will transition no earlier than 1 July 2027.

About the program

We are implementing the Support at Home program in response to the Royal Commission into Aged Care Quality and Safety . 

The program will bring together some of the current in-home care programs, ensuring a simpler and fairer system for older people.

Support at Home will ensure improved access to services, equipment and home modifications to help older people to remain healthy, active and socially connected to their community.

Read more about the  features of the Support at Home program . .

When Support at Home will start

From 1 July 2025, the Support at Home program will replace the existing  Home Care Packages (HCP) Program and Short-Term Restorative Care (STRC) Programme .

The Commonwealth Home Support Programme (CHSP) will transition to the new program no earlier than 1 July 2027.

We will continue to work with HCP and STRC providers to ensure they are prepared to transition to Support at Home well ahead of 1 July 2025.

The staged approach will give all CHSP providers time to change their business systems and adjust to new payment arrangements. This will ensure they can operate successfully under Support at Home and avoid disruptions for their clients.

We are also creating a Single Assessment System from 1 July 2024 . This will simplify and improve access to aged care services for older people.

Current in-home aged care programs will continue operating as normal until they transition into the new program.

Where we’re up to

The Australian Government has commissioned a range of work to develop the new Support at Home program including:

  • the Aged Care Taskforce , who will give independent advice on a range of design details, like the service list
  • conducting a pricing study by the Independent Health and Aged Care Pricing Authority (IHACPA) to determine fair and efficient prices for in-home aged care
  • a study to develop an inclusions list for assistive technology and home modifications and advise on the assistive technology needs of people with progressive conditions
  • a trial of an assistive technology loans program in partnership with states and territories
  • a study to provide higher levels of in-home aged care to support people to remain independent in their own homes for longer.

We held a webinar on 14 December 2023 to provide an update on the Support at Home program. The webinar slides and recording are available.

We will consult with the aged care sector and engage with older people to refine the program, addressing issues that matter most.

Learn more about past, current and future research, consultation and engagements .

How to get involved

You can register for one of our upcoming online Q&A sessions about Support at Home:

  • Q&A session for aged care providers  on Thursday 22 February 2024 from 1 pm to 2.30 pm AEDT
  • Q&A session for older people, their families and carers on Tuesday 27 February from 1pm to 2.30pm AEDT.

Stay up to date

To receive the latest information and learn about engagement opportunities:

  • visit the  Aged Care Engagement Hub
  • subscribe to the  aged care sector newsletter and alerts .

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  • Single Assessment System for aged care
  • Home Care Workforce Support Program
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May 5-8, 2024

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Target Trial Emulation in Practice: An Introduction and Exploration of Application Through Case Studies

Discussion Leader: Alind Gupta, PhD, University of Toronto, Toronto, ON, Canada Discussants: Eran Bendavid, MD, MS, AB, Stanford Univeristy, Stanford, CA, USA; Manuel Gomes, PhD, Department of Applied Health Research, University College London, London, UK

PURPOSE: Target Trial Emulation (TTE) represents an advancement in HEOR by offering a rigorous approach to establish treatment effectiveness from observational data, thus overcoming the limitations of traditional real-world evidence (RWE) studies. This workshop will delve into how TTE addresses the critical challenge of bridging the gap between randomized controlled trials and RWE, enhancing the accuracy and applicability of healthcare interventions in diverse patient populations, including case studies involving target trial emulation applications in practice. Topics include (1) how to benchmark studies, (2) per-protocol estimation and what adherence means, (3) external comparators from RWE, and (4) data limitations, including unmeasured confounders and missing data problems

Real World Data & Information Systems

UC Irvine co-led study that uses artificial intelligence to identify unwanted variations in blood samples by 95%

Findings are a significant step forward in precision medicine

  • Publication date February 21, 2024

min zhang & dabao

A new study led by co-corresponding authors, Min Zhang, MD, PhD , and Dabao Zhang, PhD , professors of epidemiology and biostatistics at the University of California, Irvine’s Program in Public Health, used artificial intelligence (AI) to analyze ‘big data’ sets of biological samples to reduce unwanted variations by more than 95%.  

The results, which are published in the journal PNAS , hold promise for the field of biostatistics and metabolomics – the study of small molecules – as it has shown that using AI can dramatically reduce variations in -omics data collected from different cohorts, such as metabolomics data or small biological molecules. 

Analyzing metabolite levels provides an immediate snapshot of an organism’s response to environmental changes, lifestyle factors, or disease states. Metabolite profiling of blood is a powerful tool to better detect, diagnose, and treat diseases. Blood is the one fluid most used in metabolomics as it provides a detailed picture of phenotypes (observable genetic traits) to be used in the field of precision medicine. 

Using the power of artificial intelligence and applying biostatistics to this study, we were able to essentially wipe out the variations that had previously challenged researchers like me.” – Min Zhang, MD, PhD

Yet, using metabolite profiles of blood samples for research has proved difficult due to its sensitivity to external factors. These factors can often be challenging to collect, leading to inconsistencies in research findings and complicating the use of metabolomics in precision medicine.  

The research team, also led by co-corresponding author Daniel Raftery, PhD, professor at the University of Washington School of Medicine, collected more than 400 healthy human plasma samples from three geographically dispersed sites along with demographic information. This method mirrors common challenges in preserving blood metabolite levels such as collection methods, geographical sites, and demographic, clinical, and genetic factors.  

“Using the power of artificial intelligence and applying biostatistics to this study, we were able to essentially wipe out the variations that had previously challenged researchers like me,” said Min Zhang. “Our findings are an important step forward in the field of precision medicine and AI’s potential in the research world.” 

Future studies will include an expansion of the number of samples processed and identifying abnormal biomarkers of disease. 

Additional authors include doctoral students Danni Liu and Zhongli Jiang, and postdoctoral researcher Kangni Alemdjrodo, all from Purdue University and G.A. Nagana Gowda from the University of Washington.  

This work was supported by U.S. National Institutes of Health grants R01GM131491, R01GM131491-02S2 and P30DK035816. 

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