2016
North Shore Community Health Network
(Community Health Network Area 13/14)
Health Assessment and Strategic Planning Project Elder Health and Youth Behavioral
SUMMARY REPORT
Produced by John Snow Inc.
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Table of Contents
A. Purpose and Background
Page 2
B. Project Approach and Methods
Page 3
C. Key Findings
Page 7
D. Recommendations
Page 12
Appendices
Appendix A: Massachusetts Community Health Information Profile
Epidemiological Data
Appendix B: Data Diagrams and Proposed Funding Streams
Appendix C: CHNA 13/14 Strategic Planning Approach / Process
List of Figures
TABLES
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Figure 1: CHNA 13/14 Service Area
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Figure 2: Healthy Communities Framework
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Figure 3: CHNA 13/14 Strategic Planning Approach and Methods
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Figure 4: CHNA 13/14 Community Forums and Planning
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Figure 5: Elder Health - Major Themes from Quantitative and Qualitative Data
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Figure 6: Youth Behavioral Health - Major Themes from Quantitative and Qualitative Data
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A. Purpose and Background
The North Shore Community Health Network (Community Health Network Area (CHNA) 13/14) is a
partnership between the Massachusetts Department of Public Health, hospitals, service agencies,
schools, businesses, boards of health, non-profit organizations and citizens working together to
improve the health of member communities. Over the past year, CHNA 13/14 has been working to
relaunch its role as a networking and cross-sector collaboration-fostering backbone organization
after a number of years of solely offering Community Health Initiative grant funding and is gearing
itself up to provide assessment planning support to inform, program and fund community-based
prevention and health promotion initiatives.
CHNA 13/14 is one of the 27 Community Health Network Areas across Massachusetts and works
with 18 partner communities including: Ipswich, Topsfield, Hamilton, Essex, Gloucester, Rockport,
Wenham, Manchester, Beverly, Danvers, Lynnfield, Peabody, Salem, Marblehead, Swampscott, Lynn,
Saugus, and Nahant to improve the
Figure 1: CHNA 13/14 Service Area
health of and well-being of those living
in these areas. (See Figure 1)
In May 2014, CHNA 13/14 was awarded
Determination of Need (DoN) funding by
Lahey Health totaling approximately
$1.7 Million, which was part of Lahey
Health’s mandate when they were
granted approval to expand their
emergency departments in the region.
After initial discussions with
representatives at Lahey Health it was
agreed that these funds would be used
to promote elder health as well as
address behavioral health issues
(mental health and substance abuse) in
youth. These funds will be distributed to
CHNA 13/14 for distribution over a 6year period beginning in Lahey Health’s fiscal year 2017.
This summary report, along with the associated recommendations, is the culmination of a six-month
process that was conducted so that CHNA 13/14 and its members could better understand the
health-related needs of elders (65+) and youth in the behavioral health sphere as well as target
Lahey Health’s funding to maximize impact. This project also fulfills Massachusetts Department of
Public Health and Lahey Health requirements meant to ensure that funds are distributed based on
community need with buy-in and support of the community, particularly the service providers,
program administrators, educators, local officials, and other stakeholders who are likely to be the
recipients of these funds.
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Historically, CHNAs have focused their efforts on supporting the development of “Healthy
Communities” through a continuous and collaborative process that aims to improve both its physical
and social environments. CHNA 13/14 will also take this approach and is eager to apply a multipronged strategy to build
capacity and support the
Figure 2: Healthy Communities Framework
development of a vibrant,
healthy, collaborative,
“Healthy” community. A
“Healthy” Community is a
community where people
come together to make
their community better for
themselves, their family,
their friends, their
neighbors, and others
through an open dialogue
that generates leadership
opportunities for all,
embraces diversity,
connects people and
resources, fosters a sense
of community, and shapes
its future. (See Figure 2). In a Healthy Communities context, health is not merely access to
healthcare and the absence of disease, but it also entails positive social, mental, physical, economic,
and environmental conditions.
B. Project Approach and Methods
This assessment and
planning project was
Figure 3: CHNA 13/14 Strategic Planning Approach and Methods
conducted by CHNA 13/14
with the support of John
Snow, Inc. (JSI), a recognized
expert in community health
assessment and planning
who has been working in
CHNA 13/14’s service area
for nearly a decade. The
project was conducted in
three phases, which allowed
CHNA 13/14 to: 1) compile
an extensive amount of
quantitative and qualitative data, 2) engage and involve key community stakeholders, and 3)
develop a strategic plan that had the buy-in and support of CHNA 13/14’s partners.
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The assessment portion of this project was conducted in collaboration with Lahey Health and drew
extensively on Lahey Health’s ongoing community health needs assessment efforts, which have
been occurring in parallel to this project. This allowed CHNA 13/14 to leverage a great deal of
existing, recent work and to incorporate an extensive amount of quantitative and qualitative data
that helped to characterize community need and inform the strategic planning process. This
information was then augmented by tailored community engagement, planning, and reporting
activities that captured additional information and input from CHNA 13/14’s membership and key
stakeholders, particularly CHNA 13/14’s Steering Committee. Quantitative and qualitative data
collection took place between August 2015 and January 2016. Community engagement and
planning activities took place between January and March 2016. Reporting activities took place in
March and April. (See Figure 3).
The assessment’s major objectives were to 1) characterize community need, particularly with respect
to older adults (65+) and youth, 2) capture community input, and 3) use quantitative and qualitative
data to inform the development of sound strategic plan supported by CHNA 13/14’s membership.
The following is a summary of the activities related to these three objectives.
Characterize Population and Community Need
Drawing from data captured from Lahey Health’s assessment and more targeted efforts done
specifically for CHNA 13/14, the assessment provided an understanding of the health-related
characteristics of the population living in the cities/town in CHNA 13/14’s service area, including
demographic, socio-economic, geographic, health status, care seeking, and access to care
characteristics. As mentioned above, this involved quantitative and qualitative data analysis,
including, to the extent possible, an analysis of changes over time using trend data and information
from previous assessments. First, JSI staff compiled data from the cities/towns in CHNA 13/14’s
service area that overlap with Lahey health’s service area. This allowed the JSI Team to identify
geographic gaps where data was still required. Then JSI staff compiled data on the remaining towns
to round out the quantitative data assessment.
Community-specific health data analysis. JSI characterized health status and need at the town, zipcode, or census tract level, depending on the data source. JSI collected data from a number of
sources to ensure a comprehensive understanding of the issues. The following is a listing of the
major sources of quantitative data that were brought to bear on the assessment.
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U.S. Census Bureau, American Community
Survey 5-Year Estimates (2009-2013)
Behavioral Risk Factor Surveillance System
(BRFSS), (2013-2014 aggregate)
CHIA inpatient discharges
MHDC ED Visits
MA Hospital IP Discharges (2008-2012)
MA Cancer Registry (2007-2011)
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Adolescent Substance Abuse Data from
National Institute on Drug Abuse (2014)
MA Communicable Disease Program (2011,
2012, 2013)
MA Hospital ED Discharges (2008-2012)
Massachusetts Vital Records (2008-2012)
Massachusetts Bureau of Substance Abuse
Services (BSAS) (2013)
All of the quantitative data that was compiled and brought to bear on this assessment can be viewed
in tabular and map form in the appendices to this Report.
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Key informant interviews with stakeholders. As part of Lahey Health’s community health needs
assessment, JSI conducted approximately 25 interviews with service providers, community-based
service organizations, community leaders, and local health officials. This information was brought to
bear on this project’s assessment. Additional information was captured from key stakeholders during
community forums and CHNA 13/14 Steering Committee meetings. Most of these interviews were
conducted using a standard interview guide, and information was gathered related to major health
issues, mortality/morbidity, barriers to care, underlying determinants of health, and service gaps that
could not be identified through quantitative data. Interviews varied depending on the interviewees
experience and interests but nearly all of the interviews involved a discussion of elder health and
child/adolescent health, which are at the heart of the CHNA 13/14 assessment. The goals of these
interviews were to 1) understand which health issues, barriers to care, and access issues perceived
by service providers and policymakers were to be most critical, and 2) to gather insight on what the
community should do to address these issues.
Capture Community Input
As part of JSI’s work with Lahey Health, they conducted a series of community and provider forums in
CHNA 13/14’s service area to gather community input. During the community forums, JSI discussed
findings of the data and posed a range of questions that solicited input on community ideas,
perceptions and attitudes, including: 1) Does the data reflect what you see as the major needs and
health issues in your community? Are the identified gaps the right ones? What segments of the
populations are most at-risk? What are the underlying social determinants of health status? 2) What
strategies would be most effective to improving health status and outcomes in these areas? The
provider forums captured similar information but more time was dedicated to discussing service
gaps and strategies for improving health status and health outcomes.
Figure 4: CHNA 13/14 Community Forums and Planning Meeting
Date
Event
December 16th, 2015 CHNA 13/14 General Meeting
January 27th, 2016
CHNA 13/14 Steering Committee Meeting
March 10th, 2016
CHNA 13/14 Core Planning Team Strategic Planning Meeting
February 25th, 2016
CHNA 13/14 Core Planning Team Strategic Planning Meeting
March 23rd, 2016
CHNA 13/14 Larger Planning Team Strategic Planning Meeting
In addition to these community/provider forums, JSI captured information from a series of 5
community meetings with CHNA 13/14 membership between October 2015 and March 2016, listed
in Figure 4.
Use Data to Inform the Development of Sound Strategic Plan
The goal of the final phase of the assessment was to first assess the results, identify priorities with
respect to demographic, geographic, or disease-specific sub-populations (e.g., middle school
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students, frail older adults, residents of Burlington, Opioid abusers, etc.) and then determine a range
of proven, feasible, evidenced-based approaches, practices or interventions that CHNA 13/14 could
promote to address the issues that were prioritized for elders and youth in the area of behavioral
health. To fulfill this objective, JSI staff facilitated a series of strategic planning sessions with the
CHNA 13/14 Steering Committee and its members. At these meetings, JSI presented and discussed
in varying degrees of specificity the community-specific health data from the secondary data, the
interview findings, and the input from the community forums and CHNA 13/14 membership
meetings. Next JSI staff gathered input on the extent to which CHNA 13/14 stakeholders and
partners felt the strategic plan should be targeted on specific sub-populations, geographies, types of
providers, or health conditions. JSI also facilitated discussions regarding proven best practices as a
way of determining if the group wanted to support the adoption of specific, proven interventions.
Finally, JSI staff facilitated discussions on the structures, systems, and mechanisms that CHNA
13/14 would apply to distribute the funds and promote achievements towards health status
improvements in the targeted areas.
With respect to the development of an actual strategic plan, JSI is still in the process of supporting
CHNA 13/14 to develop a formal strategic plan. This assessment and planning report will summarize
the approach and methods that were applied, indicate findings, and list recommendations. A
detailed strategic plan will evolve from this report and will be developed by the CHNA 13/14 Steering
Committee and staff.
Data Limitations
Assessment activities of this nature nearly always face data limitations with respect to both
quantitative and qualitative data collection. With respect to the quantitative data compiled for this
project, the most significant limitation is the availability of timely data. Relative to most states and
commonwealths throughout the United States, Massachusetts does an exemplary job at making
comprehensive data available at the commonwealth-, county- and municipal-level. This data is made
available through the Massachusetts Community Health Information Profile (MassCHIP) data system,
an on-line, internet-based resource provided by the Massachusetts Department of Public Health
(MDPH).1
MassCHIP makes a broad range of health-related data available to health and social service
providers and the public at-large. The data compiled for this assessment represented nearly all of
the health-related data that was made available through MassCHIP. The breadth of demographic,
socio-economic, and epidemiologic data that was made available was more than adequate to
facilitate an assessment of community health need but often fell short with respect to supporting
CHNA 13/14 to assess the magnitude of the need for specific population segments and to isolate
specific, targeted initiatives. These types of targeted analyses and specific planning initiatives
required detailed data that is not often readily available. Much of the epidemiologic data that is
Massachusetts Community Health Information Profile (MassCHIP) system.
http://www.mass.gov/eohhs/researcher/community-health/masschip/. The MassCHIP portal was down due to
technical difficulties at the Massachusetts Department of Public Health but JSI Staff made a formal,
comprehensive request in writing, which was met by staff at MDPH. This process limited our ability to do
multiple, iterative data draws but the JSI staff still was able to capture ample data through the MassCHIP
system.
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available, particularly at the sub-county or municipal-level, is four to five years old and is not provided
by specific age, income, or race/ethnicity cohorts.
With respect to qualitative data, information gathered through interviews, community forums, and
planning sessions provided invaluable insights on major health-related issues, barriers to care,
service gaps, and at-risk target populations. However, given the relatively small sample size and the
nature of the questioning, the results are often not generalizable to the larger population. While
every effort was made to advertise the community forums and to select a broadly representative
group of stakeholders to interview, the selection or inclusion process was not random.
C. Key Health-Related Findings
Health-Related Issues that Impact All Populations, Including Elders and Youth
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Limited Access, Barriers to Care, and Disparities in Health Outcomes Exist for Many Residents of
CHNA 13/14’s Service Area. Essex County is a healthy, vibrant community with a strong health
care and social service system. Relative to Massachusetts, the County overall fares better with
respect to many of the leading health conditions, but not all. Particularly in the areas of physical
chronic disease and cancer, there are geographic regions in the service area that fare worse off
than the Commonwealth overall. It is also important to note that there are segments of the
population, particularly low income, racial/ethnic minority, geographically isolated, and older
adult populations, that face significant barriers to care and struggle to access services due to
lack of insurance, cost, transportation, cultural/linguistic barriers, lack of caregiver support, and
shortages of providers willing to serve Medicaid-insured or low income, uninsured patients. For
many, these barriers and access to care challenges lead to disparities in health outcomes that
need to be addressed. Efforts need to be made to collaborate with the health and social service
community to address existing disparities and barriers to care through enhanced case/care
management, more intensive patient navigation and social support services.
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High Rates of Obesity, Limited Physical Exercise, Poor Nutrition, Tobacco Use, Stress and Other
Health Risk Factors. More than half of adults (18+) in Essex County are either obese or
overweight. Rates for specific demographic, socio-economic and geographic population
segments are even higher. High proportions of residents in CHNA 13/14’s service area also do
not exercise, have poor nutrition, use tobacco, drink alcohol, are affected by too much
stress/anxiety, or are face other health risk factors. These risk factors are associated with the
leading chronic physical, emotional, and behavioral health conditions such as heart disease,
hypertension, diabetes, cancer, and depression. These issues have a particularly detrimental
impact on older adults who, due their age, are often less resilient or less able to cope with and
address these risk factors. With this in mind, there is a need for health education and preventive
services that raise awareness and educate residents and how they can take better care of their
physical, mental, and emotional health.
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High Physical Chronic Disease Rates. Essex County overall does not fare as well compared to the
State against most health indicators. Furthermore, as mentioned above, there are many
cities/towns in CHNA 13/14’s that have higher rates of physical chronic disease prevalence,
hospitalization or emergency department service utilization, and/or mortality than the
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Commonwealth overall. The assessment looked at data reported by the Massachusetts
Department of Public Health related to respiratory disease (most notably asthma and chronic
lower respiratory disease - COPD), cardiovascular disease, cerebrovascular disease (stroke),
diabetes, heart failure, and hypertension. Illness and death rates vary by condition and are
available by looking at the data in the appendices to this report. We do not always have data on
specific population cohorts but we also know that rates of illness and death vary substantially by
demographic, socio-economic, and geographic population variables. Efforts need to be made to
screen for and identify those with these conditions or who are at-risk of having these conditions
with the ultimate goal of ensuring that they are engaged in care and have the ability to manage
their chronic health conditions.
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High Cancer Rates. Cancer is the second leading cause of death in the United States and the
first leading cause of death in the Commonwealth. Just like in the case of the physical chronic
disease conditions mentioned above, there are many cities/towns in CHNA 13/14’s service area
that have higher rates of cancer incidence, hospitalization, and/or mortality than the
Commonwealth overall. The assessment looked at rates of Cancer-All Types as well as in a more
in-depth way at the four cancer types that make up the majority of all cancers (i.e., lung cancer,
colorectal cancer, breast cancer in women, and prostate cancer in men). As with the physical
chronic health conditions mentioned above, rates of illness and death vary dramatically by type
of cancer and by city/town and are available by looking at the data in the appendices to this
report. As above, we do not always have data on specific population cohorts but we know that
rates of illness, utilization, and death, as well as screening, vary substantially by demographic
and socio-economic population variables. Once again, efforts need to be made to screen for and
identify those with cancer, with an emphasis on those facing barriers to care. Furthermore efforts
should be made to ensure that those who have cancer have access to the highest quality care
and the supportive services they need to manage and cope with their illness.
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High Mental Health and Substance Abuse Rates. Mental illness and substance abuse have a
profound impact on the health of people living throughout CHNA 13/14’s service area. Data from
the Centers for Disease Control and Prevention suggests that approximately one in four (25%)
adults in the United States has a mental health disorder and approximately 1 in 10 (10%)
Americans struggle with drug or alcohol problems. Similar data specifically for Essex County is
not available but quantitative and qualitative findings from Lahey Health’s assessment clearly
support the idea that behavioral health issues are a leading priority for the region, particularly for
older adults and youth.
o
Substance Abuse. Many of the cities/towns in CHNA 13/14’s service area had higher
rates per 100,000 population of alcohol/substance abuse related hospital emergency
department (ED) discharges than the Commonwealth. Many of the cities/towns in CHNA
13/14’s service area also had higher rates per 100,000 population of opioid-related
hospital ED discharges than the Commonwealth. Overall, Essex County experienced a
164% increase in opioid abuse overdose deaths between 2002 and 2013 and a 64%
increase between 2013 and 2014, the year that the most recent data is available.
o
Mental Health, Many of the cities/towns in CHNA 13/14’s service area had higher rates
per 100,000 population of hospital emergency department discharges when a mental
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health condition was the primary reason for the visit. Quantitative data specifically
related to mental health morbidity or mortality for Essex County residents is very limited
but the burden of mental health on residents is well understood and mental health was
one of the leading themes in the assessment’s stakeholder interviews,
community/provider forums, and planning sessions.
Elder Health
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High Proportions of Elders. In the United States, in the Commonwealth, in Essex County, and all
the cities/towns in CHNA 13/14’s service area, older adults are among the fastest growing age
groups. The first “baby boomers” (adults born between 1946 and 1964) turned 65 years old in
2011 and over the next 20 years these “baby boomers” will gradually enter the older adult
cohort. In 2014, Essex County had a median age of 40.6. Many of the cities/towns in CHNA
13/14’s service area had higher percentages of 65+ year old residents and higher percentages
of households with one or more people 65+ years old compared to the Commonwealth.
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High Rates of Obesity, Limited Physical Exercise, Poor Nutrition, Stress and Other Health Risk
Factors. As mentioned above, many older adults grapple with health risk factors that have a
major impact on their physical, emotional, and mental well-being. These issues comprised a
major theme from our interviews, community forums, and planning sessions and were
referenced specifically for older adults.
Figure 5: Elder Health
(Major Themes and Overlap from Quantitative Data and Forum Discussions)
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Major Barriers to Care, Lack of Service Coordination, and Fragmentation of Services. According
to the assessment’s interviews, community forums, and planning sessions, older adults
comprised one of the most at-risk population groups and participants cited a broad range of
health conditions and underlying risk factors that had a major impact on this segment of the
population including social isolation, food insecurity, cost barriers, lack of care
coordination/fragmentation of services, lack of caregiver support, and lack of adequate
transportation.
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High Numbers of Physical Chronic Conditions and Cancer. While specific data at the
Commonwealth-level and municipality-level is not available for older adults, as a cohort we know
that older adults age 65 years or older are more likely to have chronic illnesses such as heart
disease, hypertension, diabetes, congestive heart failure, and cancer than adults in the
population overall.
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High Rates of Mental health and substance abuse. Once again, while specific data at the
Commonwealth-level and municipality-level is not available for older adults, as a cohort we know
that older adults age 65 years or older suffer from mental health and substance abuse issues
that have a major impact on their ability to lead healthy, productive, social, and fulfilling lives.
Major mental health and substance abuse issues referenced from our assessment include
depression, anxiety/stress, alcohol abuse, and prescription drug abuse. These issues often coexist with other physical health conditions or other risk factors that collectively exacerbate overall
well-being and an individuals or caregivers ability to provide support.
Youth Behavioral Health
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High Rates of Substance Abuse. The impact of substance abuse on youth (middle- and high
school-aged children/adolescents) is widely understood and was a major, if not the most
significant, finding from many of our interviews, community forums and planning sessions. It
dominated the discussions in many of qualitative discussions. In youth these issues are broad
and affect all demographic and socio-economic cohorts. Opioid abuse, alcohol, and marijuana
were the most often cited concerns during our qualitative data collection activities.
There is startling data related to the prevalence of substance abuse in middle-aged and high
school-aged children and youth. Data captured from the National Institute of Drug Abuse on the
proportion of children and youth who have ever used drugs or are occasional or even frequent
users of alcohol, marijuana, prescribed medications, and other illicit drugs are provided in
Appendix A and provide dramatic evidence of the impact of substance abuse on children/youth.
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Major Concerns in the Area of Mental Health (e.g., depression, anxiety, and suicide). Like
substance abuse, the burden of mental health on children and adolescents as well as on the
health and social service system overall is widely understood. Youth experience tremendous
stress from family, school, and peer-settings that can lead to depression, anxiety/stress, social
isolation, and low self-esteem. These conditions and their emotional consequences can lead to
very poor decision-making and risk behavior that can exacerbate underlying mental health
problems, add other mental and emotional issues, or lead to co-morbid substance abuse or
physical health conditions.
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Need for Programs that Educate/Raise Awareness on Health Risk Factors, Foster Greater Selfesteem and Resilience in Adolescents, Create Community Cohesion among Youth, and Promote
Engagement in Productive After-school Activities. There has been a wealth of research and
experience over the past decade that have strongly supported the development of school-based
and other types of community-based initiatives that promote adolescent health (physical,
emotional, and behavioral), community cohesion, and healthier environments. These programs
Figure 6: Youth Behavioral Health
(Major Themes and Overlap from Quantitative Data and Forum Discussions)
have typically focused on changing or improving the contexts in which adolescents live (family,
school, peer, and community environments) or changing individual behavior(s) and encouraging
better health-related decision-making. Most participants in the CHNA 13/14 planning process
were aware, at least to some extent, of this body or research and experience and advocated
strongly for support for youth programming.
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D. Recommendations
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CHNA 13/14 Mission
The mission of the North Shore Community Health
CHNA 13/14 in a short-time has
Network
is to improve health outcomes in the North
re-invigorated its community
Shore area. We do this by supporting organizations that
health network and is quickly
provide health and social services through funding,
becoming an effective, well-led
professional development, and networking.
community organization with a
strong future. The following
● ● ●
recommendations have been
developed based on the quantitative and qualitative data collected as part of this assessment and
are meant to augment and support its mission, vision, and its existing organizational structures.
CHNA 13/14’s Steering Committee and members were integrally involved in this project’s
assessment and planning processes, including the development of these recommendations. They
are not JSI’s recommendations; rather they reflect the collective interest of CHNA 13/14.
The following recommendations fall into four categories – Target Population, Health Priorities,
Evidence-Based Practices, and Funding Distribution Strategy – and are meant to provide a
framework to guide how Lahey Health’s DoN funding will be targeted and distributed.
Specific Target Populations and Priorities
CHNA 13/14 focuses its activities to meet the needs of all segments of the population with respect
to age, race/ethnicity, income, sexual orientation, and the myriad of other factors that characterize a
population. However, its activities are guided by on-going needs assessment efforts and care has
been taken to ensure that efforts are focused on those most at-risk. CHNA 13/14 and Lahey
Health’s leadership reviewed recent needs assessments and the existing community context and
together selected Elder Health and Youth Behavioral Health as the focal areas for Lahey Health’s
DoN funding. However, leadership left it up to the strategic process to dictate how the funds would
be distributed with respect to specific sub-priorities within these focal areas or with respect to
specific geographic or demographic targets.
Ultimately, the CHNA 13/14 Steering Committee, based on clear guidance from its membership
decided that there should not be any absolute targets with respect to age, race/ethnicity, income,
geographic or other population factors. The over-riding sentiment in this regard seemed to be a
desire to support community health improvement for the population overall and to fund programs
that were likely to have the greatest impact on the greatest number of people in need. When funding
was distributed in a competitive context, planning participants agreed that applicants who could
show that they were targeting those particularly at-risk or populations facing disparities in health
outcomes would be provided some level of preference in the review process. There was a desire that
funds be distributed broadly across the region with an understanding that given the nature of
adolescent and elder health, all communities faced a considerable level of need. However, there is
also a clear appreciation that some communities had greater needs than others and that these
communities should be prioritized to some extent.
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Areas of Need and Highlighted, Evidence-based Practices/Interventions
The following is a summary description outlining the major focal areas and evidence-based
interventions that were cited during discussions in the areas of elder heath and youth behavioral
health. At each group meeting there were lengthy discussions highlighting areas of need and the
challenges that elders and youth faced along with their families and caregivers, as well as possible
responses or ideas on key interventions required to address the needs identified. The following is a
very brief review of these discussions. It is not meant to be an exhaustive list but rather a review of
some of the key themes from the discussions.
Elder Health
Areas of Need
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Depression and Stress/Anxiety
Dementia and Other Cognitive Impairments
Hoarding
Falls Prevention
Chronic Disease Management and Self-management Support
Alcohol and Opioid/Prescription Drug Abuse
Social Isolation
Elder Abuse
Lack of Transportation
Lack of Care Coordination/Service Integration
Need for Programs to Support Medication Management
Need for Family/Caregiver Support Programs
Need for Efforts to Identify and Engage Isolated Elders in Care and Services
Highlighted Responses/Interventions
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Activities Focused on Identifying and Engaging Isolated Elders
Initiatives Enhancing the Care Transitions Process from Hospital and Other Service Settings
(Particularly with the Integration of Behavioral Health)
Initiatives Focusing on Navigation of Community-Based Services
Programs to Support Independent Living and Caregiver Support
Programs Supporting “Options” Planning for Frail Elders
Interventions to Address Hoarding
Programs Enhancing Geriatric Care Management
Programs Enhancing Screening and Identification of Elders with Mental Health and
Substance Abuse Issues
Programs Addressing Transportation Barriers and Isolation
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Youth Behavioral Health
Areas of Need
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Depression and Stress/Anxiety
Alcohol, Opioid/Prescription Drugs, Marijuana, and Other Illicit Drug Abuse
Suicide
Risky Sexual Behavior
Safe Internet Use
Peer Pressure
Family Stress
Stress Related to Transition from High School
Highlighted Responses/Interventions
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Peer to Peer Programs in Schools
Programs to Support “Mindfulness” and Promote Resilience/Stress Reduction
Drug Abuse Prevention
Suicide Prevention
Collaborations with Schools, Community Organizations, and Law Enforcement
Employment and Training Interventions with Business and Stakeholders
Promotion of Diverse After-school Opportunities
Safe and Responsible Internet use
Family Case Management and Support Programs
Sexual Health Education and Gender Identify Interventions
Funding/Distribution Strategies and Mechanisms
There was considerable discussion and vigorous debate regarding how funds should be distributed.
Key discussion points revolved around: 1) the size of the awards, 2) the number of awards that
should be granted, 3) whether the awards should be single-year or multi-year awards, 4) how
targeted the funding initiatives should be (e.g., focused on specific population segments, types of
evidence-based interventions, or on types of providers or community settings), and 5) the very
mission of CHNA 13/14. Some participants advocated strongly for focusing efforts on a more narrow
set of programmatic objectives, applying a smaller number of funding mechanisms, and funding a
smaller number of larger grant awards. Others strongly advocated for the opposite; for focusing
efforts on a broader range of objectives that allowed flexibility, greater participation, and for greater
opportunities to leverage existing, already funded efforts.
Ultimately, participants decided that CHNA 13/14 should promote flexibility in how funds were
distributed and the types of programs and target populations that would be supported. Generally,
there was a belief that promoting flexibility would maximize partner engagement and allow CHNA
13/14 to fully leverage and support investments by other stakeholders and funding sources. There
was also an appreciation that CHNA 13/14 support should be provided with the unique contexts that
existed within its service area communities in mind. If CHNA 13/14’s funding strategy was too
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narrowly focused than it would limit engagement and investment and therefore potentially limit
overall impact by squelching promising community-based activities. Finally, there seemed to be clear
agreement that CHNA 13/14’s goal was to promote collaboration and information sharing, to build
capacity, and to promote the development of systems and structures in the context of a “healthy
community.” While CHNA 13/14’s funding from Lahey Health and other sources provided
considerable opportunity, it was not nearly enough to solve the region’s issues in these priority areas.
Therefore, greater impact would come from fostering a more inclusive funding strategy that
encouraged stakeholder engagement, leveraged existing opportunities, and maximized funds
invested from other sources. The following distribution strategies were developed by the Steering
Committee and were broadly endorsed by the membership and planning committee participants.
1. Multi-year Grants for Program Planning, Implementation, and Sustainability Targeted to Support
Youth Behavioral Health or Elder Health Programming
 Allocated through RFP Process
 Multi-year funding for planning and implementation
 Flexible funding based on grantee proposals. Not fixed to a particular model
 Limited number of larger awards (2-3 awards Totaling $60-100,000 over 3-years)
 Preference will be given to applicants: 1) showing potential for high impact , 2) implementing
evidence-based programs, 2) showing broad community support/collaboration, 3) ability to leverage
other funds, 4) ability to track/measure impact, 5) targeting high need demographic sub-groups or
geographic “hotspots,” 6) other factors
2. Non-competitive, One-time Grants to Support Special Projects
 Rolling RFP process, targeting communities that were not awarded multi-year grants
 Flexible funding based on grantee proposals. Not fixed to a particular model
 Larger number of smaller awards ($300-$1,000) (8-10 awards per year)
 Preference will be given to applicants: 1) showing potential for high impact , 2) implementing
evidence-based programs, 2) showing broad community support/collaboration, 3) ability to leverage
other funds, 4) ability to track/measure impact, 5) targeting high need demographic sub-groups or
geographic “hotspots,” 6) other factors
3. Competitive, One-time Grants, Including Mini-grants, Capacity Building Grants, and Training Grants
(Existing Programming)
 Collaborative Grants - directed towards meaningful, “healthy communities” based collaborations
 Professional Development Grants - generally for staff or community training
 Capacity Building Grants - available to build capacity and may include development of small
projects, marketing, fund raising, web or print based resources
 Mini-Grants - awarded for projects serving one or more communities incorporating proven,
innovative practices to improve health services for vulnerable populations
4. Non-competitive, Multi-year Scholarships to Support Participation in “Learning Communities” or
“Collaboratives” in the Areas of Youth Behavioral Health and Elder Health
 Open to all key stakeholders
 Periodic “learning community” events geared to promoting targeted general education, capacity
building, adoption of best practice, networking, and sharing of ideas in the areas of Youth
Behavioral Health and Elder Health. Meetings quarterly or bi-annually).
 Targeted workshops and technical assistance from subject matter experts
 Scholarships “awarded” to organizations or individuals willing to commit to participating in a
consistent and meaningful manner based on set parameters defined by MOU
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