From Assessment to Action: Building the Capacity to Do It Differently
By Angie Grover, Metopio | Hayley Alexander, Louisiana Public Health Institute (LPHI) | Laurie Call, Illinois Public Health Institute (IPHI)
At the recent NNPHI Annual Conference, one attendee captured what we were all feeling at this moment in time in public health:
"We get to do it differently. We get to innovate and create and build relationships and return to community. We get to care for each other in a way we haven't before, as a collective."
That sentiment shaped our session. Instead of delivering a slide deck to a passive audience, we built a live conversation about what it actually takes to turn community health data into real, measurable change. As promised, this blog is meant to carry that conversation forward.
The Gap Between Assessment and Action
Ask any public health practitioner where their work gets stuck, and the answer is almost always the same: the gap between assessment and action.
We collect data. We convene stakeholders. We identify priorities. And then, far too often, those priorities sit in a PDF that no one opens again until the next three-year or five-year cycle.
The question we brought to NNPHI was deceptively simple: What does it actually take to close that gap? The answer, it turns out, is sustained capacity, shared infrastructure, and the courage to do things differently.
Building Capacity That Lasts: The IPHI Model
When Laurie Call talks about capacity building at IPHI, she doesn't mean one-time training. She means infrastructure for sustained collective action.
"IPHI provides capacity building at the organization and collaborative levels through joint problem solving and decision-making, coaching, peer learning and learning collaboratives, and facilitating healthcare-community partnerships. We work on building individual and system capacity for co-design and community-driven strategies."
That progression, from doing-for to doing-with to doing-independently, is what powers IPHI's Alliance for Health Equity in Chicago and Cook County. Now 10 years old, the Alliance includes more than 20 hospitals and health systems, many of them direct competitors, now sharing data, aligning priorities, and collectively funding the work.
Early on, that required a real cultural shift. "When we started, we presented all this qualitative data, community voice, and asked what the priorities should be based on all the data being presented," Laurie recalls. "They came back with the same things they'd been choosing over and over. Community was not saying specific health conditions. They were saying housing, food insecurity, transportation, jobs."
It took one brave hospital leader to say it out loud: we have to address the social determinants of health. Today that's the focus that continues to be built upon for Alliance members with resources to address food insecurity and social connection for example.
Public health institutes and others that play a role as “backbone organizations” need sustained investment, not one-time grants. As Laurie puts it, partners "need to spend more time in planning and implementation than assessment", and the collaborative approach allows for local, regional, and system-wide strategies to move the needle on common priorities.
Tools like Metopio, used by IPHI and their members, to automate data-gathering and analysis phases aren't a shortcut; they're what creates the space and capacity for that deeper work.
Louisiana's Working Group Model: Shared Infrastructure from the Start
In Louisiana, Hayley Alexander and LPHI faced a different but related challenge: local governments, the state, and hospitals were each conducting their own assessments independently, with no shared infrastructure and no shared learning.
LPHI's response was the Louisiana Needs Assessment and Improvement Working Group, launched in 2024 to create the backbone infrastructure that collective impact requires. The group brings together not just government and hospital leadership, but academia and community-based organizations. It has already expanded into Mississippi, with survey tools and focus group guides that travel with it.
"I see all of these different assessments and improvement plans as building blocks to achieving greater health impact," Hayley explains. "Making sure that people have the opportunities to be a part of those building blocks, that's the work."
A standout example of that vision in practice: six hospitals on Louisiana's North Shore formed the Healthier North Shore group and, for the first time in the state, undertook a joint community health improvement plan. They aligned on shared priority areas, then divided complementary activities across facilities, each hospital contributing where it was strongest, all moving toward the same community goals.
The result isn't just efficiency. It's accountability. Pulling those metrics into a real-time dashboard on a platform like Metopio ensures that every institution can see what the others are doing, partners can make adjustments to address performance and everyone can effectively share the impact so no one can quietly deprioritize this important work.
LPHI has also addressed the equity dimension directly. Through a partnership with the Louisiana Rural Health Association, rural hospitals and critical access facilities receive discounted rates for the same quality of assessment and improvement planning support as larger systems.
"We're ensuring that they have the same access to the products and the same quality of work, but at a rate that's accessible to them," Hayley notes.
The Data Infrastructure That Connects It All
Neither the IPHI nor the LPHI model functions without shared data infrastructure. That's where Metopio enters the picture providing the connective tissue between assessment, planning, and impact measurement.
When health departments and hospitals across North Carolina, ranging from communities of 17,000 to large urban systems, all worked from the same Metopio platform, something unexpected happened: community members began hearing consistent health messaging across jurisdictions, reinforcing health literacy from multiple directions.
"Whether you went to one community or another, you were hearing the same language," notes Angie Grover. "That helps in the education of the communities as well."
Shared data is powerful, but we really need to shift to more timely data. The most persistent frustration in community health work is that the best available data is often two years old by the time it's in an assessment.
LPHI is pioneering a solution through its Louisiana Maternal and Infant Data Collaborative, which links electronic health record data for birthing people in the year before and after delivery and reports outcomes quarterly using a common data model replicable across hospital systems.
"You can see: are these programs having the outcomes you want to see?" Hayley explains. "If not, you can institute quality improvement practices to reach your greater goals."
Metopio does parallel work with hospital utilization and claims data, drawing on the 36 preventable hospitalizations identified by AHRQ and mapped to ICD-10 codes, so partners can see patterns emerging in real time. The results can then flow directly into Metopio's CHIP roll-up system, where clinical indicators sit alongside community activity metrics for a complete picture of what's driving health outcomes.
Think of it this way. If you want to address opioid mortality but you have limited staff, how do you demonstrate effectiveness and collective impact?
Try what one public health department did. As the public health department, you train community partners to deploy Naloxone. If appropriate, this might be your local law enforcement partners who are often first to arrive at an incident. Once they are trained, they can share their response data demonstrating the impact of that training. Add to it data from hospital opioid ED admissions and now you have three data streams from three sectors telling a story of impact that none could tell alone. That is the kind of real-time accountability is what turns a plan into a practice.
What We Heard in the Room
We asked attendees: What gets you excited about the future? Their answers reflected both the urgency of the moment and its possibility.
Several called for real-time data and feedback loops. Others pointed to projects that genuinely listen to communities and reflect their needs. One highlighted New York State's new five-year State Health Improvement Plan to address social determinants of health as proof that systems-level change is already underway.
The thread connecting nearly every response was the same one running through our session: the recognition that the current moment in public health, resource-constrained and structurally disrupted as it is, is also a genuine opening.
As one attendee put it: "It's breaking, and we get to rebuild something better. It hasn't worked the way we've been doing it. We need to do it differently."
Doing It Differently in Practice
There's a throughline beneath all of this: the shift from assessment as an event to assessment as an ongoing practice.
The most advanced partnerships we described aren't doing a community health assessment every three to five years and walking away. They're meeting regularly to look at shared data. They're tracking leading indicators alongside lagging ones. They're structured to ask, every quarter: is the work working?
The asthma families in Chicago who stopped returning to the ED after housing remediation. The North Shore hospitals tracking shared CHIP progress together. The Ohio county that brought the planning department to the table because housing data showed up in the hospital admissions data. These aren't flukes. They're what happens when shared data, shared language, sustained relationships, and a backbone organization keeping everyone accountable are actually in place.
We get to do it differently now! And this conversation was the spark to prioritize shared data infrastructure and a commitment to pairing action with measuring collaborative impact to tell the story of public health.
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