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LoginTri-County Health Department / Community Health Promotion Divison
Public health partnering with local business communities on an initiative for workplace health and well-being
Jennifer Tellis
Workplace Policy Specialist
jtellis@tchd.org
303 720 8867
Westminster
Colorado
80031
Your summary must address all the questions below:
Description
Tri-County Health Department (TCHD) is the largest local public health agency in Colorado, serving over 1.5 million people in Adams, Arapahoe and Douglas Counties. Our mission is to promote, protect and improve the lifelong health of individuals and communities through the effective use of data, evidence-based prevention strategies, leadership, advocacy, partnerships, and the promotion of health equity.
TCHD provides over 60 programs and services from our 11 sites. In addition to providing core public health services, TCHD partners within our communities to address important health issues. Since achieving Public Health Accreditation in 2017, TCHD has undergone restructuring, resulting in more opportunities to integrate our work and collaborate more effectively across sectors with both internal and external stakeholders.
Public Health Issue
Recent data show that over 45% of Americans have at least one chronic disease. Five chronic diseases or risk factors (high blood pressure, diabetes, smoking, physical inactivity, and obesity) cost U.S. employers $36.4 billion a year due to missed work days. In Colorado, it is projected that chronic diseases cost $34.2 billion in medical costs and an extra $13.1 billion annually in lost employee productivity.
According to the Centers for Disease Control and Prevention , adults spend the majority of their waking hours at work (approximately 1/3 of their life), making the workplace an ideal setting for chronic disease prevention.
References:
Partnership to Fight Chronic Disease, Colorado, 2019: https://www.fightchronicdisease.org/sites/default/files/download/PFCD_CO_FactSheet_FINAL1.pdf
The 7 Best Reasons to have a Wellness Program: Benefits of Wellness, Dr. Steve Aldana, 2018: https://www.wellsteps.com/blog/2018/07/04/reasons-to-have-a-wellness-program-benefits-of-wellness/
Centers for Disease Control and Prevention Total Worker Health Model https://www.cdc.gov/niosh/twh/default.html
Goals & Objectives
The goal of TCHD’s Initiative for Workplace Health and Well-being (the project) is to reduce risk factors for chronic disease for all employees through organizational policies, systems, and environmental change implemented in the workplace.
Main objectives include:
1) Partner with local and state business leaders to form employer coalitions
2) Work with employers to complete organizational assessments
3) Support employers with technical assistance to develop policy, systems and environmental changes to create healthier workplaces
4) Promote healthy employer and breastfeeding friendly certification programs and recognition
5) Increase capacity through mini-grants to eligible employers
Implementation
A key component of the project was the formation of employer coalitions and the provision of technical assistance to develop leaders within these organizations to implement systems changes that improve, rather than undermine, the health of their employee population. Emphasis was given to recruiting employers with low-income workers who are more likely to experience health inequities. TCHD created five employer coalitions and formed a multi-sector Advisory Council to steer the project. Employers receive training to complete Coalition Milestones and become a Certified Healthy Employer and/or a Breastfeeding Friendly Employer as well as sharing resources, challenges and successes with each other.
“Meeting/sharing with other employers is the best component of the coalitions.” – Employer Feedback from Coalition Effectiveness Survey Results
Outcomes
During the first funding period, five employer coalitions were formed with over 75 employers, representing over 100,000 employees. More than 50 employers completed an organizational assessment and over 60 policies were adopted. Based on these outcomes, TCHD was funded for an additional three years. In its fourth year alone, 35 breastfeeding friendly employer assessments and 79 organizational assessments were completed. Nine employers achieved the Breastfeeding Friendly Employer designation and 42 employers became Certified Healthy Employers. Thirty-five employers received funding to support sustainable healthy food and beverage and breastfeeding-friendly changes. TCHD has met or exceeded all objectives to date, and now is using lessons learned to train other LPHAs.
Factors that led to the success included the following:
Public Health Impact
TCHD is integrating awareness of public health programs, such as the National Diabetes Prevention Program, and tobacco/substance abuse resources into the daily lives of employees and, in so doing, has transformed workplaces and inspired businesses to become committed allies in the fight against chronic disease. The project addresses social or structural determinants of health through reducing health disparities in selected communities with the highest chronic disease burden and lowest opportunities for health (determined by TCHD’s health mapping).
Program Website:
Initiative for Workplace Health and Well-being: https://www.tchd.org/289/Worksite-Health-Well-Being
A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be -
Public Health Issue
Chronic diseases and related lifestyle risk factors are the leading drivers of health care costs for employers. Nationally, each risk factor or disease is associated with annual absenteeism costs greater than $2 billion. Absenteeism costs ranged from $16 to $81 (small employer) and $17 to $286 (large employer) per employee per year. Chronic conditions and unhealthy behaviors also reduce worker productivity. Five chronic diseases or risk factors (high blood pressure, diabetes, smoking, physical inactivity, and obesity) cost US employers $36.4 billion per year due to employees missing days of work.
In Colorado, 3.1 million people (55% of the population) have one chronic disease and about 1.1 million (20% of the population) have two or more chronic diseases. Over 18,400 lives could be saved annually in Colorado through better prevention and treatment of chronic disease. It is projected that chronic diseases could cost the state $34.2 billion in medical costs and an extra $13.1 billion annually in lost employee productivity. Colorado reports indicated the following variable risk factors for heart disease: obesity (21%), being physically inactive for the past 30 days (18%), high cholesterol (35%), high blood pressure (26%), current smoking (18%), diabetes (6.5%), eating fruit less than daily (36%), and eating vegetables less than daily (19%).
References:
Center of Disease and Control, Workplace Health Promotion, 2019: https://www.cdc.gov/chronicdisease/resources/publications/factsheets/workplace-health.htm
Partnership to Fight Chronic Disease, Colorado, 2019: https://www.fightchronicdisease.org/sites/default/files/download/PFCD_CO_FactSheet_FINAL1.pdf
Healthy People 2020, Colorado Heart Healthy Solutions Program Reduces Risk Factors for Cardiovascular Disease, 2016: https://www.healthypeople.gov/2020/healthy-people-in-action/story/colorado-heart-healthy-solutions-program-reduces-risk-factors
Response to Issue
The priorities of public health and the business sector may, at first glance, seem to be unaligned. With the advent of Public Health 3.0, however, LPHAs are increasing efforts to work with their local business communities, with the understanding that local economies and community health are linked and require a multi-sector approach. The Tri County area business community has been receptive to collaborate with local public health and this is especially true with small businesses (less than 500 employees). Small businesses comprise about 98% of all companies in Colorado, many of which lack adequate expertise and/or resources to develop effective workplace wellness practices and policies without external support.
Beginning with a pilot project in 2012, TCHD has forged close relationships with the local business communities located within the three counties it serves. These relationships were enhanced by the growing tide of chronic diseases and the realization by employers that they were taking a direct hit in the form of increased healthcare expenditures and costs associated with lost productivity and absenteeism. With this partnership, TCHD expanded the scope of its community-based prevention model to include workplace settings. Since that original pilot, TCHD has applied sustainable strategies by working with businesses to implement organizational policy, environment, and systems changes. Both Healthy People 2020 and the Community Guide identify workplaces as settings where organizational policy, environment and systems changes can influence employee risk factors for chronic disease. With working adults spending approximately one third of their waking hours at work, the workplace represents an ideal setting for implementing healthy policy and systems changes.
New to public health and/or an Innovative use of existing tools
Smart adoption and adaptation of existing tools has increased efficiency and effectiveness: TCHD partnered with multiple national organizations to apply their tools to the employer coalition framework.
References:
Center of Disease Control, Worksite Health Scorecard, Exp. Date: 3/31/2022: https://nccd.cdc.gov/DPH_WHSC/HealthScorecard/Home.aspx
The Guide to Community Preventive Services, Physical Activity Interventions, 2017 https://www.thecommunityguide.org/findings/physical-activity-interventions-including-activity-monitors-adults-overweight-obesity
World Health Organization, Preventing Chronic Disease, a Vital Investment, 2015: https://www.who.int/chp/chronic_disease_report/en/
Target Population
The target population for this project is workplaces with low-income and hourly employees and government settings that are public facing. Industries include manufacturing, health care, social assistance, hospitality, construction and school districts. Many of these employers’ efforts will reach not only their employees, but the larger public as well. Recruitment for the project is focused in TCHD communities with the highest chronic disease burden and lowest opportunities as determined by TCHD’s mapping of educational attainment, median household income, race, unemployment, and lack of health insurance. By county, poverty ranges from 4% in Douglas County, to 12% in Arapahoe County, and 14% in Adams County, compared to 11.5% in all of Colorado.
According to data from 2013-2015, 9% of adults in Adams County and 6.6% of adults in Arapahoe County had been diagnosed with diabetes, compared to the Colorado average of 6.8%. Additionally, it is estimated that about 25% of those who have diabetes are undiagnosed and more than 30% of American adults have prediabetes. Cancer and heart disease remain the two leading causes of death for all races/ethnicities in TCHD’s jurisdiction, and diabetes is also in the top ten causes of death for all three counties.
Two of the project’s main strategies, 1) increase access to healthy foods and beverages and 2) increase access to breastfeeding friendly environments, address chronic disease risk factors of those who reside and work in the selected communities. Less than 20% of adults living in Adams and Arapahoe counties consume fruits and vegetables five or more times per day. Furthermore, 31% of adults in Adams County and 34% of those in Arapahoe County drink one or more sugar-sweetened beverages per day. Thirty percent of adults in Adams County and 21% of those in Arapahoe County experience food insecurity. In addition, increased breastfeeding duration lowers risk for obesity and chronic diseases. While the Healthy People 2020 targets for 6 and 12-month breastfeeding duration rates are 60.6% and 34.1% respectively, the rates for participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in the target communities are much lower, further underscoring the need for widespread adoption of wellness policies that reduce nutrition-related health inequities.
The current coalitions include 75 employers with a total of over 100,000 employees. Employer sizes range from 7 to well over 3,000 employees representing a diverse group of industries.
Examples of existing coalition members:
Percentage Reached
In consultation with the project’s Advisory Council, a goal was set to achieve a minimum of ten employers participating in each targeted region, for a total of 50 employers. The goal has been surpassed with a total of 75 participating employers in the coalitions. As part of continual performance improvement efforts, the Advisory Council has now shifted focus from employer recruitment to digging deeper on policy adoption and implementation with current employer coalition members. Despite reduced recruitment efforts, an average of two to three new employers join each quarter. Participating employers also include those from counties outside of TCHD’s jurisdiction, due to word of mouth and referrals from partners, and represent many parts of Colorado.
References:
American Communities Survey, 2010-2014, 2015 data
Behavioral Risk Factor Surveillance System (2011-2015), Colorado Department of Public Health and Environment
Colorado Department of Public Health and Environment, (2014), Colorado chronic disease state plan: A coordinated approach to chronic disease prevention & control. Available at: https://www.colorado.gov/pacific/sites/default/files/DC_Colorado-Chronic-Disease-Plan-2013-17.pdf
Colorado Department of Public Health and Environment, Vital Statistics Branch, CDPHE (2015 data)
State Demography Office, Colorado Department of Local Affairs, 2012, 2015
U.S. Census Bureau, 2010-2014 American Community Survey 5-year estimates
What has been done in the past to address the problem?
Historical efforts to connect with the business community have generally been in the form of isolated presentations at local chambers of commerce or at a local conference. These examples are based on traditional outreach models involving local employers being invited to attend an event on the topic of employee wellness. While the presentations may be informative, there are no efforts to keep the employers engaged and supported for the long-term outcomes. Without accountability, the resources and ideas gleaned from a presentation are often put in a pile once the employer returns to their desk. Another major issue is the lack of local expertise and resources to support an employer in their efforts to implement an employee wellness project.
Why is the current/proposed practice better?
The model of the project is new to the field of public health in that it is a sustainable network and pipeline for public health to engage the business community with relevant and up-to-date technical assistance and a peer network of ongoing, mutual reinforcement. This is in addition to the core elements of the project, which keep employers engaged for the long term, as they work through evidence-based milestones (Coalition Milestones), including:
Creative Use of Existing Tools
TCHD utilizes several tools to support the activities of the project, which are briefly explained below. Each tool and a description of how TCHD e collaborates with the tool’s creators is described further in the collaboration section. Most important of these tools is Health links™ Organizational Assessment Tool, which is a major component of the Coalition Milestones; employers must complete the Assessment in order to be eligible for mini-grant funds. Health Links™ Organizational Assessment Tool: https://www.healthlinkscertified.org/get-started. AAnother important tool, adapted for the Coalition Milestones, is the Community Health Assessment aNd Group Evaluation Tool; https://www.cdc.gov/nccdphp/dnpao/state-local-programs/change-tool/index.html. TCHD adapted the tool to create the Employer Policy Checklist, which supports employers to take a “policy inventory” of their current wellness guidelines, practices and policies along a continuum of development and implementation. To leverage additional support and recognition TCHD encourages employers with exceptional wellness practices and policies to complete the American Heart Association’s Workplace Health Achievement Index Tool: https://www.heart.org/en/professional/workplace-health/workplace-health-achievement-index/workplace-health-solutions-how-it-works. Another form of recognition comes from the Breastfeeding Assessment Tool designed by the Advancing Breastfeeding in Colorado Grant. TCHD uses this tool to help employers dive deeper into their breastfeeding friendly practices and policies and designate employers as a Breastfeeding Friendly Employer. Breastfeeding Assessment Tool: https://www.tchd.org/DocumentCenter/View/6091/BF-Self-Assessment-Fillable-Form.
Evidence-based Project
Evidence suggests that the total reach and impact of workplace wellness initiatives is more impactful than other efforts to improve the health of adults. The project employs best practices for workplace wellness as recommended by Wellness Councils of America, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, the Center for Public Health Systems Science, U.S. Chamber of Commerce, The Guide to Community Preventive Services, the Center for Health, Work and Environment at the Colorado School of Public Health and Healthy People 2020.
Healthy People 2020 stresses the importance of community-based programs in schools, health care facilities, communities and the workplace. These settings provide opportunities to reach people using existing social structures. Using nontraditional settings for public health efforts can also help encourage informal information sharing through peer social interaction. Making changes within existing systems, such as improving workplace wellness policies, can effectively improve the health of many in the community through changes in attitudes, beliefs, and social norms.
The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broadbased involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.
Goals & Objectives
The overarching goal of the project is to build a sustainable partnership between local public health and the business community and work together to reduce risk factors for chronic illnesses through workplaces within their shared community. The primary objective is to train local employers and community organizations to implement internal policies, systems, and environmental changes that support employees’ efforts to lead a healthy lifestyle. Emphasis is given to recruiting organizations with low-income workers who are vulnerable to socio-economic and/or racial disparities in health. Additionally, TCHD is providing training to develop organizational leaders that will reach beyond the workplace to become champions for health initiatives in the communities in which they do business and mentors to other employers on workplace wellness. The following are the objectives involved with the project.
Steps taken to implement the project
TCHD formed five employer coalitions, as listed below:
The Coalitions Milestones hold employers accountable and motivate them in a variety of ways to make workplace wellness policy, system and environmental changes.
Finally, they feel accountable to each other, coalition members follow-up, encourage, and challenge each other to continue their efforts.
TCHD formed an Advisory Council comprised of representatives from healthcare, insurance, business, community and education sectors. This group was charged with overseeing the project’s activities, assisting with employer recruitment, participating in strategic planning sessions, and developing and implementing the sustainability plan.
The key components that are provided to employers through the coalitions include access to the evidence-based assessment tool, advising from a workplace wellness specialist, networking with other employers, mini-grant funding opportunities and a multitude of training opportunities. On average, TCHD facilitates 40 trainings and meetings per year, eight for each of the five coalitions. Training topics are based on requests from participating employers and have included: health equity, breastfeeding friendly worksites, healthy food and beverages, mental health, opioid addiction, substance abuse, ageism, Family Medical Leave Act (FMLA) practices, diabetes prevention, employee volunteer programs and the best practices in wellness policy implementation. Participating employers are provided with support to attend local wellness conferences such as the American Heart Association Symposium and the Colorado Culture of Health Conference.
In a coalition effectiveness survey, employers were asked to rate each of the key components stated above using the following scale: 1 (not important) - 5 (very important). Employers rated all of the coalition’s key components as either important or very important. It is noteworthy that the meetings and trainings received a higher score across all five (5) coalitions, indicating that employers place a high value on both the content of meetings/trainings and on the networking and sharing opportunities these events afford. Over the period of 2015 - 2018, more than 112 employers participated in coalition activities and 59 employers completed an organizational assessment.
During the past year (2018-2019), momentum continued to meet established objectives. A total of 79 employers completed organizational assessments, with 42 achieving national recognition as a healthy employer. Thirty-five employers completed breastfeeding-friendly assessments with nine employers achieving the Breastfeeding Friendly Employer designation. Thirty-five employers received funding to support workplace access to healthy food and beverages and breastfeeding-friendly changes at their worksites, for a total of $29,920.00 awarded.
In the current program year of 2019-2020, TCHD is on track to complete annual goals and objectives. During the first quarter, 12 employers completed an organizational assessment (30% of the annual goal), and 5 employers are in the process of taking the assessment. Additionally, the annual goal of four breastfeeding-friendly assessments has already been surpassed with six employers having completed an assessment. Employers are steadily completing the criteria to qualify for mini-grant funding and over $5,000 has been awarded to support policy and environmental changes so far this year.
Criteria for Coalition Members
A focus is placed on recruiting employers in industries with low-wage employees from target geographical areas with higher chronic disease burden and lower opportunity scores (based on social determinants of health data as described above). The Advisory Council and community partners have become the primary referral sources, relieving TCHD staff of this task. Participating employers represent a diverse list of industries including healthcare, manufacturing, education, and hospitality. City and county employers are actively recruited in order to reach both their employee population and the community members that visit their buildings to access services. Although the project has been intentional about engaging employers from TCHD’s jurisdiction, about 8% of the participating employers are from other counties within Colorado. TCHD attributes this to the fact that similar industries communicate with each other and many of the participating employers heard of the project from a peer. Employer participation outside of the TCHD jurisdiction also points to the fact that the project is unique and filling a need for employer support and networking on workplace wellness.
Timeframe
Pilot Project - May 2011 – December 2012
TCHD partnered with local stakeholders in the City of Aurora to conduct a 19-month pilot project. Partners included the Aurora Chamber of Commerce, the City of Aurora and the YMCA. The project involved recruiting 8 local employers to form a coalition which convened quarterly. TCHD provided technical assistance to the group to lead them through the process of policy adoption and implementation. The employers reported that the most valuable component was the networking with the other employers participating and the mini-grant funding. The pilot project was recognized as a NACCHO Model Practice in 2014. TCHD wanted to duplicate the model to expand to a larger scale in order to reach more employers and employees in the communities served. TCHD incorporated lessons learned, such as employers needing more time to make sustainable changes and focusing on policy adoption for sustainability. Added a national organizational assessment, Health Links™ as a benchmark and updated the best practices based on many CDC and NIOSH guidelines for workplace health promotion.
First Funding Round: July 2015 – June 2018
TCHD applied for the Colorado Department of Public Health and Environment’s Cancer, Cardiovascular and Pulmonary Disease (CCPD) Grants Program and was awarded a 3-year grant to expand and improve upon the original pilot project. Major differences from original pilot included the following: expanded reach into all three counties, the addition of an evidence-based online organizational assessment tool, focused recruitment on employers with low-income employees and government employers, and the development of a sustainability plan using an evidence-based tool. TCHD continued the networking opportunities, mini-grant funding and focus on HEAL policy strategies. During the 3-year period, five employer coalitions were formed with a total of 75 public and private employers, representing more than 100,000 employees. In addition, more than 50 employers completed an organizational assessment and over 60 supportive policies and guidelines were adopted. Finally, an Advisory Council was created to assist in the development of the sustainability plans and to oversee the materials and activities of the coalitions.
Second Funding Round: July 2018 – June 2021
After the success from the first 3 years, TCHD was funded an additional 3 years through the Colorado Department of Public Health and Environment’s Cancer, Cardiovascular and Pulmonary Disease (CCPD) Grants Program. TCHD revised the employer requirements by creating milestones which are based on best practices. Health equity training was added to the curriculum for both the employer coalitions and the Advisory Council. A dietician was added to the team to provide one-on-one technical assistance to employers who wish to focus work on one or both of the project’s primary strategies: 1) healthy food and beverages and 2) breastfeeding supportive practices and policies. During the first year of this funding round, 35 employers received funding to support healthy food and beverages and breastfeeding friendly changes at their workplace, for a total of $29,920.00 awarded. A total of 35 breastfeeding friendly employer assessments were completed and 79 organizational assessments were completed. Nine employers achieved a Breastfeeding Friendly Employer designation and 42 employers were recognized as Certified Healthy Employers. Now in the second year of the current funding round, TCHD is on track to complete the project’s goals and objectives. During the first quarter, 12 employers completed an organizational assessment, and an additional five employers are in the process of completing the assessment. Additionally, the project has already surpassed the annual goal of four completed breastfeeding friendly assessments with six employers having already completed an assessment. A new funding opportunity process was also created for members to apply for mini-grant funding. Employers are steadily completing the criteria to qualify for funding and approximately $6,000 has been awarded to 15 employers to date.
Role of Stakeholders
TCHD’s project includes a wide range of partners representing academia, business, healthcare, insurance, social services, government, and community entities. The following paragraphs provide details and context about four partner collaborations that have been central to the success of the project.
Funding
This project was funded by two 3-year grants from the Colorado Department of Public Health and Environment Cancer Cardiovascular and Chronic Pulmonary Disease Grants Program. The following table reflects the average annual budget for the project.
Description | In-kind | Amount |
Personnel: Grant-funded wage and benefits (1.9 FTE) | $174,385 | |
Personnel: County general funds | $90,000 | |
Supplies and Operating Expenses | $19,316 | |
Employer Mini-Grants (supporting policy efforts specific to healthy food and beverage and breastfeeding friendly policy) | $23,200 | |
Supplies and Operating Expenses | $19,316 | |
Travel | $5,254 | |
Contractual | $12,250 | |
Indirect | $65,894 | |
TOTAL | $319,615 |
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improve practice. Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
Achievement of Goals & Objectives:
The project employs a mixed methods approach, using both quantitative and qualitative data to manage performance, identify quality improvements, and evaluate efficacy. The overarching goal of the project is to build a sustainable partnership between local public health and the business community and work together to reduce risk factors for chronic diseases through workplaces. The primary objective is to train local employers to implement internal policies, systems, and environmental changes that support employees’ efforts to lead a healthy lifestyle. Additionally, TCHD provides training to develop organizational leaders that will reach beyond the workplace to become champions for health projects in the communities in which they do business and mentors to other employers on workplace wellness. Performance is assessed in key areas such as:
While it is not in TCHD’s scope to evaluate the individual health outcomes of the employees impacted by the project, one of the main strategies is to provide employers with the technical skills to evaluate their workplace wellness initiatives and employee health data. Multiple trainings and resources are provided to employers on how they can evaluate their employees’ health and see long-term results, such as understanding insurance company data, sick day usage, utilizing health risk assessments and how to apply the data and present results. Inviting additional staff to trainings, especially upper-level management and human resources representatives, is encouraged and sometimes incentivized.
Five different tools are utilized that include all stakeholders providing input to the evaluation process. The project will provide short-term results, with increases to; the number of employers engaged, number of employees reached, number of assessments completed, improved employer knowledge and awareness of workplace wellness best practices, and improvement in their policies and workplace environments. The project includes one process evaluation, which was developed by TCHD’s epidemiology team and three existing outcome evaluation tools. Additionally, TCHD utilizes a performance management dashboard, which serves as both an outcome and process evaluation. All of the tools are described below.
1) Coalition Effectiveness Survey, this is an anonymous online survey created by TCHD epidemiology team and completed annually by all coalition members (employers). This is the process evaluation for employers to evaluate the value and effectiveness of the coalitions and to provide feedback about activities, materials and other components of the project. This is also a space for employers to leave comments and request workplace wellness topics. The results provide both qualitative and quantitative results, such as “the opportunity to network and learn from other employers participating is considered more important than all other components in the coalition” and 100% believe they have the basic understanding of the project’s goals. TCHD collects the data and provides a final report of findings and results to the Advisory Council, CDPHE, Kaiser Permanente’s evaluation team, internal TCHD teams and all coalition members.
Metrics include but are not limited to:
How effective are the coalitions?
“The coalition has been instrumental in providing resources and innovative strategies that enhance the wellness initiatives we've started. Without the coalition we certainly would not be as far along the path as we are at today!” – Employer Feedback in Coalition Effectiveness Survey Results
2) SustainTool.org, this is a Program Sustainability Assessment Tool developed at the Center for Public Health Systems Science (CPHSS) and completed anonymously online by TCHD and Advisory Council members. This is an outcome evaluation and is a key component of the strategic planning sessions with the Advisory Council and improving the project’s sustainability plan. Users rate eight different domains of sustainability, and a final report with aggregate scores are sent to TCHD and reviewed with Advisory Council members. The report results are used to establish a roadmap for the coming year with project areas to address. Report findings are also shared with CDPHE, Kaiser Permanente’s evaluation team, and internal TCHD teams. Score across all Domains have increased each year thus far (see Sustainability section below for more details).
Domain Example:
Program Adaptation: Taking actions that adapt your program to ensure its ongoing effectiveness. Examples of indicators include:
3) Internal Dashboard (TCHD Performance Management): This evaluation tool was developed by program staff in collaboration with TCHD’s Quality Improvement Team and is used to track the work and outcomes of the project, primarily for internal use across the agency. The format is an Excel dashboard template. TCHD collects the metrics and reports them to stakeholders, including agency leadership and the Board of Health. A select group of metrics were mined from the other evaluation tools used by the project, providing a quarterly snapshot of program progress.
Metrics include but not limited to:
4) The PiER DoCK System, this evaluation was developed exclusively by Kaiser Permanente to be a third party evaluator for the CCPD grants program. This evaluation includes cross all grantees metrics and grantee-led only metrics. This evaluation provides the grant funders with qualitative and quantitative results and summarizes the results of the project’s efforts. The outcome evaluation is completed annually online by TCHD and reviewed by Kaiser Permanente staff, results are presented to CDPHE and TCHD. TCHD then share the results with the Advisory Council, TCHD Quality Improvement Team, TCHD Board of Health, TCHD Community Health Promotion Team and coalition members.
Metrics include but not limited to:
What policies or environmental changes targeting healthy food and beverage consumption have been adopted or implemented?
Among those reached, how did the policy and/or environmental change impact healthy food and beverage purchase/consumption?
Change in target healthy eating/drinking behavior before and after exposed to the new policy/practice/environmental change.
What stage is each participating worksite in along the policy development process?
5) Health Links™ semi-annual reports, this outcome evaluation is completed by employers interested in workplace wellness projects, it should be noted that this is a national assessment and TCHD’s coalition members make up 25% of all completed assessments. TCHD partners with Health Links™ to receive specific reports designed by TCHD and finalized by Health Links™. Employers are encouraged to complete the assessment annually and reports are reviewed and presented semi-annually by Health Links™ to TCHD staff. The reports provides data on all employers completing the assessment in TCHD’s jurisdiction, breakdown of data per coalition and individual coalition member data. The reports are shared to the Advisory Council, TCHD Quality Improvement Team, TCHD Board of Health, TCHD Community Health Promotion Team and coalition members
Sample of Health Links™ results:
In addition, Health Links™ posts employer success stories on their website and of their reported stories more than 45% of them are from the project’s coalitions. This demonstrates that the employers in the coalitions are getting the proper technical assistance and motivation to implement best practices and create sustainable workplace wellness policies and changes. The link below shares success stories from Health Link’s book of business. A few of TCHD’s coalition members are: City of Aspen, Metro Wastewater Reclamation District, Colorado Rural Health Center, Fitzsimons Credit Union, Visiting Angels of Denver and many more.
Modifications Made
TCHD makes modifications as needed based on the results of the evaluations above. Needed modifications that are identified through performance management and evaluation are collectively discussed with Advisory Council and coalition members. An example of a minor modification occurred in response to employers expressing that they are not able to attend all trainings in person, due to time and conflicting priorities, and travel expenses (as noted, some participants are located in far and remote areas). TCHD made accommodations by offering some trainings online via Zoom. TCHD also records trainings so if an employer can’t attend they can still receive the training and share it with their wellness committee as a way to extend reach and impact. Informed by data, the city and county coalition shifted from a one-hour monthly meeting to a half-day quarterly training session to improve access to cities and counties located outside of the Denver Metro area. A major modification was implemented in response to employers indicating that the $180 Health Links™ assessment fee was a major barrier to them completing the assessment. After reviewing this, TCHD made budget changes to allocate grant funds to cover the employer fees. Now, coalition members receive a discount code, which provides them free access to the assessment. Coalition Effectiveness Survey results show that the employers now highly value the assessment and are more motivated to renew their certification. Employers expressed that after completing the assessment and seeing its value, their organizations were more willing to invest in future assessments and implement related changes.
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that the stakeholders are invested in its maintenance and to ensure it is sustained after initial development (NACCHO acknowledges that fiscal challenges may limit the feasibility of a practice's continuation.)
Sustainability Plans
The project defines sustainability as 1) the ability to maintain programming and benefits over time and 2) the ability to maintain a strong, mutually beneficial partnership with the business community. The goal for sustainability is to strengthen structures and processes that exist within the project to ensure resources and strategies to battle future changes and challenges related to workplace wellness. An underlying additional goal is to sustain the systems changes within the health department concerning relationships with the business community so that TCHD can continue to use and adapt the established network as a pipeline for future change.
The project’s Sustainability Plan is based on the SustainTool results, which is completed by the Advisory Council, and recommended best practices from CPHSS. TCHD selected the SustainTool based on its eight organizational and contextual domains: Environmental Support, Funding Stability, Partnerships, Organizational Capacity, Program Evaluation, Program Adaptation, Communications and Strategic Planning. When an Advisory Council member takes the online assessment, they receive a summary report of their individual responses and their responses are added to an aggregate final report. TCHD encourages all Advisory Council members to participate to ensure that a diverse cross-section of perspectives are included in sustainability planning. TCHD also conducts strategic planning sessions to fully engage Advisory Council members in the Sustainability planning process. During these sessions, TCHD combines the aggregate SustainTool report with the other evaluation results and assesses outcomes. The strategic planning sessions include all Advisory Council members (19 individuals representing coalition leadership, employers, employees, community partners, and benefit providers - health insurance, workers compensation and employee assistance). Next steps include:
An example of strategic planning session findings included the identification of strengths such as strong leadership and expertise from TCHD; stable financial support for three additional years; and an engaged Advisory Council offering knowledge, connections and commitment to the success of the project. Identified areas for growth included communication with stakeholders and the public, cultural resistance to changing workplace practices, and tools to assess economic return on investment at the employer level. Identified potential threats include an economic downturn, competition for time and priorities, and instability that can accompany political and ideological changes. The sessions also revealed several elements to be sustained, including employer training and funding opportunities, convening of employers for sharing and networking, community partnerships, technical advising for employers, healthy business assessment tools, employer leadership training, and an engaged Advisory Council. The sustainability plan is updated regularly and considered a long-term, working document.
Sustainability Plan Example
Strategy: Communications
Objective: By June, 2021, partners, stakeholders, coalition leadership and members of the Advisory Council will have the tools and confidence necessary to effectively promote the project and recruit employers to join the coalitions, and the project will have an established presence and recognition in the community at-large as well as well as a strong social media presence.
Steps:
Sustainability of Project
According to the SustainTool results, TCHD has increased scores across all domains (see table below). The scores below indicate that some of the lowest scores in the first year increased the most in the second year, demonstrating TCHD’s intentional use of the tool to make the necessary updates and corrections, such as within the Communications domain. Communications was rated 2.2 in 2018. In response, TCHD increased efforts in branding, media, and marketing through the development of a logo, social media presence, recruitment materials, and consistent messaging including promotion of outcomes. Now the Advisory Council feels more confident in using the materials to promote the project through their many media channels. In 2019, they rated communications 4.9; a 2.7 increase from the previous year. TCHD’s overall score has increased from 3 to 5.1; the goal is by 2021 to achieve a sustainability score of 6.5 or higher.
2018 | 2019 | Points Increased | |
Organizational Capacity | 3 | 5.4 | 2.4 |
Communications | 2.2 | 4.9 | 2.7 |
Strategic Planning | 2.4 | 5.1 | 2.7 |
Partnerships | 2.4 | 4.9 | 2.5 |
Environmental Support | 3 | 5.4 | 2.4 |
Funding Stability | 2.6 | 4.1 | 1.5 |
Program Evaluation | 4 | 5.6 | 1.6 |
Program Adaptation | 4.4 | 5.5 | 1.1 |
Total Score | 3 | 5.1 | 2.1 |
Not only is TCHD improving the sustainability of the project, the coalition members (employers) are making their efforts into sustainable policies and changes at their sites as well. Through the Employer Policy Checklist, adapted from the CHANGE tool, TCHD can see employers moving through the process of policy adoption. This Checklist indicates where an employer is in the policy process of multiple healthier policies, such as healthy meeting policies, paid leave and nursing mother accommodations. TCHD is able to see and track the employers’ progress towards implementation of sustainable policy, system and environmental change.
Lessons Learned
With a five year track record, the project has documented many lessons learned, overcome challenges, and developed strategies to prevent them in the future. One of the major ongoing challenges is language framing. TCHD recognized early on that traditional public health terminology and messaging would need to be modified in order to more effectively communicate with the business community, however, challenges remained in explaining the project to employers and the public. It is difficult to develop effective marketing materials to convey all the elements and benefits of the project. TCHD continue to work with the Advisory Council to improve the communication strategies. As mentioned, SustainTool results indicated a measurable improvement in communications, and it will remain a consistent focus. Another lesson learned was that the Health Links™ assessment fee posed a significant barrier to employer completion, and therefore served as a barrier to successful implementation. Based on employer and leadership feedback, TCHD leveraged funding to remove this barrier for participating employers.
TCHD also underestimated the length and complexity of the policy adoption process for the employers. Although it differs by organization, it typically involves many preliminary steps before a policy reaches the point of implementation. Depending on the organization, these can include 1) identifying the issue, 2) obtaining management buy-in to address the issue, 3) drafting/modifying policy language, 4) getting the policy approved and, 5) rolling out the policy and gaining employee buy-in. Throughout this process, employers greatly benefit from continuous assistance to turn an idea into a final policy. Conveying value is a challenging and important step. Ultimately, participating employers have businesses to run, with traditional emphasis on rapid returns. The Initiative for Workplace Health and Well-being will continue to innovate and bridge the gap between today’s actions and tomorrow’s accrued benefits, serving as a strong model across public health issues.
“Please keep this group going! It has evolved since the start of the group and it has become very valuable.” – Employer Feedback in Coalition Effectiveness Survey Results
2014 / NACCHO Model Practice
