How to Use Data to Create Healthier Communities


Author, Sheri Chaney Jones, President, Measurement Resources Company

Building a Society in which all People Live Long, Healthy Lives.

Isn’t this the long-term mission and vision of nearly every social sector organization? After working with hundreds of nonprofit and government organizations to create their vision, mission, logic models, and outcome measures, it seems the majority of those in the health and human services sector aspire to achieve some variation of this vision. With so many organizations aimed at achieving this, are we as a society getting healthier? Are your clients getting healthier?

I think so”, is the most common answer I get to these questions. Too few organizations have defined their outcomes and established a measurement system to determine if this is true. Most people don’t embark on a journey to lose weight without a scale. You don’t set a goal to reduce debt without tracking finances. Therefore, if an organization desires to improve the health and lives of the ones they serve, they must be managing to some set of outcomes. If you are looking to improve how your organization assesses whether it is truly contributing to healthier communities, here are four considerations to help you get started.

  1. Understand how your organization fits. How do you want to be a hero to your clients and stakeholders? Determine what problem your organization solves. New research demonstrates how almost every effective social service organization is contributing to the health of our communities. We know that social and physical environments are predictive of health outcomes. In order for health to be improved, people need the opportunity to make good health choices. According to the U.S. Department of Health and Human Services at, to ensure all people have the opportunity to improve, advances are not merely needed in the area of health. Areas of education, childcare, housing, business, law, media, community planning, transportation, and agriculture all need to be considered. The first step in achieving success is defining the ways your organization is helping improve the social and physical environments for your clients and communities.
  1. Define your results. Once you have narrowed in on how your organization helps increase opportunities for people in your community, you can start to develop the specific measures that will help you track your progress. A good place to start is to focus on your organization’s short- and medium-term goals. Short-term goals are the results that occur immediately after people engage in your services, such as increased knowledge, skill, and opportunity. Medium-term goals are the results people and communities experience once your clients implement the short-term goals, such as increases in positive behaviors, maintenance of new behaviors, and reduction of undesirable behaviors. Although there are several ways your organization may want to track this, here are some specific, measurable outcomes tied to Healthy People 2020.

a.  General Health Status

i.  Psychically and mentally unhealthy days

ii.  Self-assessed health status

iii.  Limitation of activity

b.  Health-Related Quality of Life and Well-Being

i.  Participation in education, employment, civic, social and leisure activities

c.  Determinates of Health

i.  Availability of resources to meet daily needs, such as education, job opportunities, living wages or healthy foods

ii.  Exposure to crime and violence

iii.  Increased access to transportation

  1. Track and Manage to Results. Without timely data, it is impossible to know if what you are doing works. Once you know what you believe your organization does to improve health, you need to develop your mechanism to track these outcomes for all your clients. The biggest obstacles to organizations measuring and managing to important outcomes are often time and technology systems. I’m a big advocate of starting with what is available to you. If all you have is paper-and-pencil surveys and Excel, start there. However, this process can be time consuming and require more staff hours than your organization wants to devote. Ideally, your organization will implement a technology system that will allow you to more easily and reliably measure and manage to your desired outcomes. Knowing what you want to measure and ideally how you want to report this data before seeking a software vendor will allow you to get the best product available.
  1. Advocate for Systems Change. A key to success will be selecting a software system that allows you to manage your clients as well as manage to your outcomes. A challenge faced by many organizations is the functionality of different data systems. Health organizations that bill insurance as part of their funding streams are often forced to create unwieldy workarounds due to the limitations of their electronic health record system that may not have been set up to track social outcomes. Social services organizations traditionally using case management systems are often not designed to collect aggregate results and track health outcomes. In recent months, there has been some promising realization of this dilemma. For example, Eccovia, a provider of cloud-based case management solutions recently signed a memorandum of understanding with MHIN, a not-for-profit health information exchange (HIE) to integrate health and human services data with clinical data to reduce costs and improve outcomes for population health. MHIN’s Director of Community & Population Health Development, Waldo Mikels-Carrasco, stated, “Combining data from health and human services with clinical data will allow our providers and partners to effectively address the social determinants of health in their care and evaluation process and positively impact the overall care for an individual and support they receive.” “This unique partnership is only the beginning of what healthcare in America needs in terms of collaboration with disparate types of care and services for everyday individuals.”  This partnership is promising for organizations desiring to track and manage how they are making themselves and others healthy. Your organization can encourage more of these partnerships by asking for this functionality in your discussions with your information technology solutions provider.

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Sheri Chaney Jones
Measurement Resources Company

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