Chapter 6: Implementing Strategies, Managing and Sustaining the Process and Measuring Progress

After you have developed your HP 2010 plan, published and made it available to the public, it is time to regroup and implement the strategies for meeting your objectives. This part of the process may actually be easier than the planning process because all of the "doers" that were bored with the planning process are now ready to spring into action. The key to successfully implementing activities and tracking progress, however, is effective management of the process. This involves delegation of responsibilities, creation of timelines, an effective and efficient communication system, and periodic rekindling of people's enthusiasm. Strategies for accomplishing these challenging tasks are presented throughout this chapter.

Strategies for Implementing Objectives

While some states and communities still are in their HP 2010 planning stages, others already have published their HP 2010 plans and are in the process of implementing strategies to meet their objectives. At this point, systems to track progress on the objectives and the leading health indicators should be in place.

The national HP 2010 Oral Health Chapter (Chapter 21) and numerous other references and Web sites listed in this toolkit provide examples of effective strategies to prevent or reduce oral diseases and conditions and address other HP 2010 issues. It is beyond the scope of this toolkit to present all of these strategies. A few resources that highlight "best practices," however, may be helpful.

• Partners in Information Access to Public Health Professionals makes information and evidence-based strategies related to HP 2010 easier to find. Oral health is not yet one of the focus areas included, but some of the information from other related areas might be useful. Eventually the Partners hope to expand the range of searches to cover all Healthy People 2010 focus areas.
• HRSA's Bureau of Primary Health Care maintains a "Models that Work" database where communities describe dental and other health programs that appear to be successful in addressing access to care issues (www.bphc.hrsa.gov, search on "dental"). Contact and Web site information are provided for each program.
• The Association of State and Territorial Dental Directors is in the process of finalizing a Best Practices for State Oral Health Programs database, which can be accessed via www.astdd.org. The Web site will be searchable by topic and state, and will summarize best practices that meet established criteria in various categories.
• The DHHS Assistant Secretary for Health is showcasing best practices in public health from around the country to foster an environment of peer learning and collaboration. View the current listings or sign up for their email listserv at http://www.hhs.gov/ophs/.

When selecting, implementing and evaluating strategies, the following factors should be considered:

• evidence of effectiveness in community-based programs
• appropriateness for each target audience (e.g., age, culture)
• cost-effectiveness
• sufficient human resources to implement them
• sufficient financial resources to implement them
• political will to make them happen
• criteria for documenting "progress"
• mechanisms available for tracking progress.

Moving the HP 2010 Agenda Forward

There are many ways to make sure your implementation plan keeps moving. A national conference, "Steps to a Healthier US: Putting Prevention First" was held on April 15-16, 2003 in Baltimore, MD. Portions of the conference highlighted exemplary programs in communities.

The Governor's Task Force for Healthy Carolinians held a series of four forums around North Carolina after presenting their draft HP 2010 objectives. Through public input the Governor's Task Force arrived at numerous ways to move their objectives and health agenda forward. Uses for the objectives fell into eight categories:

• Partnerships (Coordination and Collaboration)
• Funding
• Policy
• Planning
• Evaluation
• Education
• Media
• Organizational use.

The Governors Task Force also identified barriers to implementation, which fell into five categories:

• Resources
• Community
• Logistics
• 2010 Health Objectives
• Politics-Politics-Politics.

View these online at www.healthycarolinians.org/2010objs/movingforward.htm.

The Healthy Iowans HP 2010 plan was completed in the summer of 2000. Chapter teams that developed the plan evolved into monitoring teams to track progress. These teams developed strategies to assist communities in developing local plans. Chapter teams meet on a quarterly basis. Midcourse review is set for 2005-06.

One way to integrate HP 2010 activities into ongoing annual activities is through national health observances such as Children's Dental Health Month, Give Kids a Smile Day, National Nutrition Month, World Health Day, etc. View a list of national observances by month at www.healthfinder.gov/library/nho.

Assessing and Reporting Progress

"The ability to quantify and assess progress on health objectives is at the heart of the Healthy People Initiative" (Source: Edward Sondik, Tracking Healthy People 2010). One of the deficiencies noted in the Surgeon General's Report on Oral Health and ASTDD's Infrastructure report (see reference on page 23 of the Resources section for Chapter 2) is the lack of state-based oral health surveillance systems and the need for enhanced systems at the national level. As noted in Chapter 3, some of the HP 2010 oral health objectives and other oral health data are being tracked through various databases at federal agencies such as CDC and NIH. DATA 2000 is the Healthy People database that can be accessed online at www.cdc.gov/nchs/about/otheract/hpdata2010/aboutdata2010.htm. Users can create tables that contain baseline and tracking data for each HP 2010 national objective.

States continue to experience difficulty collecting and submitting data in a usable and comparable format for a variety of reasons. The July 27, 2001 issue of Mortality and Morbidity Weekly Report provides an excellent overview of guidelines for evaluating public health surveillance systems.

Most national objectives are tracked by a single measure (e.g., percentage reduction in dental caries in primary teeth.) For these objectives, progress will be assessed by the change from the baseline measure toward the target. Some objectives seek to increase positive behaviors or outcomes (e.g., percentage of adults who report having had an oral cancer exam), while others are stated in terms of decreasing negative behaviors or outcomes (e.g., percentage of adults whose activity is limited due to chronic lung and breathing problems.) A number of your objectives may contain multiple measures. Progress will need to be assessed separately for each measure. For these objectives, therefore, the progress may be mixed if some measures are progressing toward the target and others are regressing. Whenever possible, assessment of progress should consider the standard errors associated with the data (see a statistician or epidemiologist for help with this.) For some objectives, precise measures that match the objective are not available. In these cases, similar proxy measures may be used to track progress.

For specific details on the national oral health objectives, see Tracking Healthy People 2010 at www.cdc.gov/nchs/hphome.htm. For each objective (or subobjective), the following are included:

• national data source
• state data source
• HP 2000 objective
• measure (e.g., percentage)
• baseline (including year)
• numerator
• denominator
• population target
• questions used to obtain national data
• expected periodicity
• comments

Part C of the document discusses major surveys for HP 2010 data, some of which are also described in Chapter 3 of this toolkit.

A progress review for the oral health objectives is scheduled for March 2004. The tracking data and methods for assessing progress will be reviewed at that time and again during the midcourse review in 2005, and a determination will be made at that time whether any changes will be made. Reports of midcourse reviews from other years were included in Chapter 1 of the toolkit. States should establish similar timelines for review of their objectives prior to 2010. For semi-annual updates on HP 2010 activities, see www.health.gov/healthypeople.

Progress reports can be written and disseminated in a variety of formats, using the techniques described in Chapter 5. Vermont chose to display its HP 2000 progress in a simple report card format (see page 2 in the Resources section of this chapter) by categorizing progress as 1) goal met; 2) progress made; 3) baseline data collected; 4) data not available; and 5) no progress made. These categories help facilitate discussion about celebrating successes, conducting follow-up surveys for those objectives with baseline data, considering new strategies where inadequate or no progress was made, developing tracking systems, or finding resources to collect data where no data are currently available.

Case studies also are an innovative way to report on progress toward a specific objective or cluster objectives on a particular topic. This approach also translates well to articles for newspapers or newsletters and to human interest stories for radio, TV or community presentations.

Assessing and Creating Sustainability

Periodically reassess the membership of your coalition to see if the stakeholders have changed and if the current participants are still committed and active. Washington's Community Roots for Oral Health lists reasons why people stay or leave coalitions and how to celebrate the working relationships. The following list is an adaptation of the list.

• People change, as do their interests, job descriptions and priorities. They need to be thanked for their contributions and feel that it's OK to move on to another project.
• Relationships change. Celebrating new opportunities for working together on new or different projects is one way to support on-going success. Find new ways for people to contribute to the HP 2010 effort.
• Organizations that have assigned or allowed their employees to contribute their time and effort should be recognized for this contribution. If they need to reduce their employees' time because of workloads or budget cuts, this needs to be respected.
• Coalitions build on friendships and create new ones. Maintaining a friendly, fun, supportive environment is crucial to sustain initiatives.
• Sustained momentum needs consistent leadership. Make sure you have a coordinator or coordinating group that is committed to a long-term process.

Another list of tips for successful community or tribal program sustainability, from the Seven Circles Coalition, part of the Southeast Alaska Regional Health Consortium, can be viewed at http://www.searhc.org/.

It might be helpful to review your Plan for Securing Resources (see worksheet on Page 4 of the Resources section for Chapter 4) to determine what additional resources are needed for implementation and how they will be acquired. Be sure to include who is responsible for each activity. This plan can then be translated into a sustainability plan, which should be reviewed and revised, if needed, every 2-3 years.

A good worksheet that you can use to create sustainability goals and identify new funding resources is available through the Ohio Community Service Council at http://www.serveohio.org/. You can also go to the Afterschool Alliance Web site at http://www.afterschoolalliance.org/prog_sustain.cfm to print worksheets on 1) vision; 2) building collaboration; 3) advocating for support; 4) finding funding; and 5) template for a sustainability plan.

Another resource is the Sustainability Toolkit: 10 Steps to Maintaining Your Community Improvements (see references). The Sustainability Toolkit contains 1) Examples and stories from communities throughout the nation; 2) a CD ROM with activities to complete; 3) sample plans, timelines, and completed activities; and 4) tips and resources.

Two examples are presented here to exemplify ways that states or organizations have developed a series of strategies to sustain interest and funding for oral health activities and coalitions. Other state coalition activities can be reviewed via dental summit reports at http://www.mchoralhealth.org.

Acknowledging Successes and Contributions

Successful coalitions and projects usually are maintained through appropriate incentives and acknowledgment of efforts by individuals and agencies. These can range from a simple "thank you" to public acknowledgments and awards. The Sierra Health Foundation's We Did it Ourselves series on coalition building and evaluation lists six important R's to keep in mind to keep collaboratives and community members engaged (see box on the rightà).

Examples from HP 2010 or oral health projects include:

• Healthy Delaware's Heroes Nomination, a way to feature individuals, businesses or organizations in each of their 13 focus areas.
• Newspaper recognition of sponsors for clinical services at Dientes Community Dental Clinic in Santa Cruz, CA (see Resources section, page 1)
• Community Campus Partnerships in Health Award to recognize exemplary partnerships between communities and higher education institutions
• HHS Secretary's Award to students in health professions schools who submit an innovative health promotion or disease prevention project; awards range from $1,500 to $7,500

Be creative! Think of innovative ways to reward efforts and maintain high levels of motivation for accomplishing or exceeding established goals and objectives.

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