1 Co-Authors and PHN DNP 2010 Graduates:Quest for a Healthy City: Partnership with a Stakeholder Consortium to Build DNP PHN Core Competencies 3418.0, Public Health Nursing and Healthy Community Monday, November  8, at 4:30 PM University of Tennessee Health Science Center College of Nursing, Memphis, TN Patricia M. Speck, DNSc, APN, FNP-BC, DF-IAFN, FAAFS, FAAN Margaret T. Hartig, PhD, FNP-BC, FAANP Trimika Bowdre, MPH Renee' S. Frazier, FACHE, MHSA, Chief Executive Officer, Healthy Memphis Common Table Co-Authors and PHN DNP 2010 Graduates: Cynthia Suire, DNP, RN Marion L. Donohoe, DNP, APN, CPNP Bernadine Graham, DNP, APN, FNP-BC Cathy Hughes, DNP, RN

2 Presenter Disclosures Dr. Patricia M. SpeckThe following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months “This project is supported in part by funds from the Division of Nursing (DN), Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under grant number D09HP15005 and title Advanced Education Nursing Grants for $807,982. The information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the Division of Nursing, BHPr, DHHS or the U.S. Government.” There are no other conflicts of interest to report.

3 Presenter Disclosures Trimika BowdreThe following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months “This project is supported in part by funds from the Division of Nursing (DN), Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under grant number D09HP15005 and title Advanced Education Nursing Grants for $807,982. The information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the Division of Nursing, BHPr, DHHS or the U.S. Government.” There are no other conflicts of interest to report.

4 Presenter DisclosuresMargaret T. Hartig, PhD, FNP-BC, FAANP Renee' S. Frazier, FACHE, MHSA Cynthia Suire, DNP, RN Marion L. Donohoe, DNP, APN, CPNP Bernadine Graham, DNP, APN, FNP-BC Cathy Hughes, DNP, RN The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months There are no conflicts of interest to report.

5 Purpose The purpose is to explore community-based strategies for maintaining a healthy community UTHSC College of Nursing (CON) participates in community-academic partnerships to assess a community program and promote PHN core competencies in doctoral students. UTHSC CO facilitates community-based participatory action research involving community assessment leading to community health promotion. UTHSC CON disseminates the socio-drama product of the projects to guide planning and interventions to promote healthy communities.

6 Objectives The participant will be able to:Explain the educational value and benefits of community-academic partnerships in planning and implementing health promotion. Analyze community-based participatory action research results, socio-drama results, and community survey results to identify strategies for promoting healthy communities.

7 The Partnership Healthy Memphis Common Table (HMCT)New Executive Director (now CEO) Experienced and enthusiastic Expanded vision for organization University of Tennessee Health Science Center (UTHSC), College of Nursing Department Chair is HMCT Advisory Board member DNP PHN students need community projects HMCT stakeholders believe health is a key element of increasing mid-south jobs. Today, jobs are the number one concern for many American’s and Memphis is challenged to complete for new companies to locate to our Region and we are fortunate to have the headquarters for FedEx, Nike, AutoZone and International Paper. However, many others choose to locate elsewhere. HMCT believe that Memphis must become a city of choice!! And if they choose Memphis, it will bring jobs and build our economy. Business leaders look at various metrics when selecting a city for expansion. Health indicators and the cost of health care is very important because the sicker our City, the more it costs business!! In Shelby County the cost of health care is about $800 per person above the National average. So, if we use some simple math, our cost of health care is about $800 x 950,000= $760 million. In other words it will cost the average large employer (500 employees), about $400,000 more to do business in Memphis. This is a very important issue. In terms of health indicators, we rank number 2 in obesity and number 1 in violence. As a result, Memphis is in the bottom of other indicators: diabetes, heart diseases, hypertension and other chronic illness which are life style related. Our logic is that if Memphis is Healthy, Memphis will have more jobs because employers will be attracted to our city. Let’s set the stage for this collaboration – Dr. Peg Hartig, one of the authors of this project is my department chair of Primary Care and Public Health, and was an early adopter of the concepts that evolved into the Healthy Memphis Common Table. Her knowledge about the growth and purpose of the organization contributed to the foundation and to the initial partnership for the PHN DNP student activities. These included contact with the organization, assisting in meeting a need or goal of the member organization and then providing a report to the organization. With the addition of the new Executive Director, one with experience enthusiasm, who also brought a new and expanded vision for the organization.

8 HMCT Background Regional health and healthcare improvement collaborative for the greater Memphis area (Formerly “Just Health Foundation,” Est. 2000) HMCT assumes Not-for-Profit designation of Foundation (Est. 2003) Mission: “To mobilize Greater Memphis to achieve excellent health for all” “Take Charge for Better Health” Consumer Initiative (2010) HMCT was born from a strong desire to combine the focus of improving population health and improving our health care delivery system. We call this Big H (improving the health of the community) and Little h (improving the health care delivery system). We do this by building better quality and equity thru strong consumer engagement. The Big H work is evolving to address system, policy and environmental changes which impede the health of our region which I just spoke about. The work in little h translates itself toward more transparency of information to include: physician ratings, hospital ratings, payment reform for primary care providers and address health equity issues in the care delivery system. Mobilizing Memphis in both big H and little h is unique and requires quality in a multi stakeholder Regional Health Improvement Collaborative in the region. It provides us a tool to engage the entire community to address how to fix not only health of the community, but the system of care as well. Finally, the Take Charge for Better Health Initiative is a branding approach which puts health as a priority issue for everyone. It creates the sense of each person has to pay attention to the system of care and the overall health of our community. If we do not have a Take Charge approach, Mobilizing Greater Memphis will be very difficult. We, Memphis, has to own our future and Take Charge for Better Health is the HMCT message of ownership.

9 The Situation PHN Core Competency Web-enhanced programsDNP achievement of proficiency Web-enhanced programs Lack of graduate PHN preceptors 600 clinical hours over 3 terms Service hours by faculty Community agencies in need Community Partnerships can minimize challenges and meet needs for both students and agencies This is the situation... You heard about the goals and desires for the collaborative that calls itself the Healthy Memphis Common Table. The DNP PHN Option at UTHSC CON is based on development of PHN Core Competencies domains and performance measures for graduate public health nurses (PHN). We are a distance learning program which developed a web-enhanced educational curriculum. However, a lack of graduate PHN preceptors presented challenges to locating quality complex clinical student experiences. Those who have watched my efforts over the years know that I create these complex activities for the DNP PHN students and it is hard. The DNP PHN students are expected to complete 600 clinical hours which, at the UTHSC CON, must address the PHN Core Competencies. On top of that, faculties are expected to perform service hours at UTHSC CON. Given that today most community agencies lack finances, expertise, time and staff to investigate, evaluate and implement evidence based outcomes, partnerships between academic institutions and community agencies can minimize the challenges that each face and help meet each other's needs – we call it “community based participatory research”

10 The Solution HMCT and UTHSC CON DNP Primary Care and Public Health Department faculty collaborated to survey stakeholders’ perceptions about health of the community (City of Memphis) Most of us know that the best programs are borne over a cup of tea or coffee in the local bistro... And this collaborative was no different. The executive director and an advisory board member proposed a PHN DNP student project to assess the larger group of stakeholders and their current perception of health in their community. So, sure enough, a meeting between the department chair, the new executive director and myself occurred at a bistro in the grocery store where we queried the new ED about what direction and necessary steps might be needed. The ED wanted and we thought a repeat of the existing survey of the Board of Directors was needed but this time, it the expanded survey would not only include all the former persons who were surveyed, it would also include the greater number of stakeholders on their supporter list which numbered several hundred. The hope was that gaps would be identified so that targeted activities would occur. This was a project made in heaven... It had all the elements of a major project!

11 Project Purpose Primary Purpose Secondary PurposeTo identify gaps between perceptions of stakeholders and the community at large To develop Public Health Nurse (PHN) competencies Secondary Purpose Introduce and use standardized language to define Healthy Cities Determine stakeholder perceptions about health of Memphis So the primary purpose was to identify gaps between perceptions of stakeholders and the community at large, but more importantly, the project had to develop specific PHN core competencies. A secondary process was to begin to introduce and standardize language to define healthy cities with the stakeholders and then survey their perceptions about our community. So the question was: what are the perceptions about the health of our community in the stakeholders of HMCT?

12 PHN DNP Student ProjectThe literature review Informed “Healthy Cities” criteria Existing survey expanded to reflect the evidence and case studies Executive Director review of new survey and her suggestions incorporated The electronic survey Students built Received and analyzed the raw data The project included a review of the literature for “healthy cities,” and a review of the pilot survey review (previously completed); it would also include development and implementation of a larger evidenced-based survey of the organization's stakeholders. DNP PHN students met with the organization's director and board member where a strategy to expand the survey to identify perceptions about the health of the community was developed. The literature review informed “healthy cities” criteria and students expanded the survey to reflect the evidence and case studies. The survey was reviewed by the director who suggested an additional question, which was incorporated. The students then built the electronic survey, received and analyzed the raw data, and created a 52-page report, a presentation and an expanded evidence-based survey for use by the HMCT should they want to survey the community at large.

13 Methods Review of the literature Survey Sample of StakeholdersInternational and National Healthy Cities initiatives guided topic selection and question formation Survey Demographic questions (9) Likert-type questions (18) Sample of Stakeholders From the HMCT Website Analysis Descriptive statistics The review of the literature required use of the University’s online library resources since the 4 students were located in different states. In addition, there was considerable information online about what “Healthy Cities” were doing to create great environments for their citizens. The search informed the students about international and national initiatives and the detail of these initiatives guided the selection of the question topics. There were 9 demographic questions and 18 Likert type questions about healthy city initiatives. The sample was the HMCT stakeholders from the website and the analysis used descriptive statistics.

14 Results Expanded survey identified criteria for healthy citiesProvided perceptions of stakeholders Gap identification (stakeholders v community) Gap identification resulted in sample expansion recommendation PHN DNP students implement, analyze, and reported results of the survey Helped HMCT administration plan future goals It provided complex PHN DNP clinical hours Laid foundation for additional collaboration The expanded survey identified criteria for healthy cities, provided specific information about perceptions of stakeholders, and identified a gap between stakeholders and the community that resulted in a sample expansion recommendation. The collaboration provided additional workers to implement, analyze, and report the results of the survey and helped the agency's administration plan future goals. For me, one of the most important things was that the project provided complex clinical hours and laid foundation for additional activities and interventions by future PHN DNP students.

15 Gaps Respondents vs. Community 2000 CensusRace – Memphis population is predominately African American (61%), though represented only 30% of the survey respondents while 64% of the survey respondents were white Gender – More females (81% v 53%) and fewer males (19% v 47%) Age – More older persons years of age responded (39%) than are reflected in the Memphis population (7.2%) for that age group (average age = 34.4 years) Education –12+ years of school (91% v 39%) The students used the 2000 Census to create a profile for the Memphis community. This became the benchmark for the survey results. Let’s look and see what they found. First, Memphis is a predominantly African American community, around 60%, and the respondents were 30% African American, with 64% being Caucasian. In Memphis, the male to female ratio is 47 to 53% and the respondents were 19 to 81%. Also the Memphis area has 7% older persons years of age and the older person represented 39% of the respondents. Last, the community of Memphis has 39% high school education and the 91% of the respondents had more than 12 years of education. So, as you can see, there are some major differences between the Memphis community and the stakeholder respondents to the student survey.

16 Gaps Just in case you are a visual learner, here is a graphic representation of some of the data.

17 Recommendations Disseminate the results to the HMCT Board of DirectorsImplement community based participatory research (CBPR) principles Develop measurable outcomes Survey community member’s perception using the Healthy Cities criteria in the expanded survey The next step was to disseminate the results to the HMCT Board of Directors. To do this, the students implemented community based participatory research (CBPR) principles, by developing measurable outcomes that reflected the wishes of the board of directors. The students brought the concept and language of healthy cities to the board and then used these criteria for development of the expanded survey.

18 Recommendations Survey populations without internet access, e.g., seniors, youth, homeless & unemployed, pregnant women, and Neighborhood Associations Engage the community voice through focus groups Guide the discussions using the evidence base on diverse topics e.g., maternal and child health, adult and older person health Include identified topics of concern in survey e.g., employment, education, and violence Let’s talk about the survey. It became clear that if the HMCT looked at all the work necessary to improve health, the task would soon become insurmountable. So the students believed that after they presented their results, the HMCT should survey populations without internet access, e.g., seniors, youth, homeless & unemployed, pregnant women, and Neighborhood Associations to include the voices from the people who live and work in the community. The students also suggested that HMCT engage the community voice through focus groups to identify the community needs for health and that the focus groups should be guided by evidence based topics such as the health of the child, adult and older person, and pregnant women and the survey should include topics of concern (employment, education, and violence) that were identified by the initial HMCT stakeholders. In response to these recommendations, Renee tells me that HMCT has now hired a Project Manager for Health Equity and Neighborhood Transformation. This person has the role of connecting with neighborhoods to create a ongoing conversation about the health and health care gaps in the community. This works also will include opportunity for focus groups and other means of getting more input. She said, “This work with UT helped us determine what we needed to do to support the need for more engagement with the sector of people not polled in our survey.“

19 Results Strengths ChallengesHealthy Cities criteria guided the survey question development Challenges Reducing the gaps identified in the stakeholder population Reaching vulnerable unhealthy populations in the community to serve Desire to reach diverse populations to survey Let’s talk more about the results of the survey. There were strengths to the report in that there were Healthy Cities criteria that guided the development of survey questions. However, there were challenges apparent that the HMCT stakeholders were not representative of the citizens at large in the Memphis community and both HMCT ED and the CON would have preferred to reach the diverse populations in our community. It was decided early on that that would be very costly and not easily completed with 4 distance students.

20 Limitations Survey open for only 2 weeksSample size limited to registered HMCT supporters Computer access and skills were necessary Those without technical skills were excluded Those not registered with HMCT were excluded Criteria used to inform survey (Healthy Cities) unfamiliar to consortium members Media coverage of criteria may influence perceptions, e.g., violence Survey problems Likert scale term “neutral” difficult to interpret The survey’s compound questions created confusion Of course there were limitations... beginning with the fact that the survey was open for only 2 weeks. The sample size was limited to registered HMCT supporters and computer access and skills were necessary. That means that those without technical skills were excluded and those not registered with HMCT were excluded. Plus, the criteria used to inform the survey (e.g., Healthy Cities) was unfamiliar to students as well as the consortium members. However, through a review of the literature and continuing dialogue with the faculty, the students were soon experts on Healthy Cities. During the presentation to the board, the students brought up that the media coverage of criteria may have influenced perceptions of the respondents, e.g., violence. There was also a limitation with the survey – there was a term “neutral” that was chosen by the students and they found it was difficult to interpret. Also there was an attempt to create brevity to the survey, but the survey’s compound questions created some confusion.

21 Project Outputs Expanded evidence-based survey Report DisseminationUse in future by HMCT Based on notion of “Healthy Cities” Report 52 pages Included Appendices Dissemination Poster ACHNE Presentation APHA The clear winner was the HMCT but the PHN DNP students met many of the core competencies through the development of an expanded evidenced based survey. This survey can and is being used by HMCT as the foundation for the next steps. They learned what makes a healthy city. The students wrote a 52 page report that included graphs, figures and appendices. They learned about the editorial framework for writing that would be required for their capstone project.

22 PHN Core Competencies MetAnalytical Assessment Policy/Program Development Communication Skills Cultural Competence Skills Community Dimension of Practice Basic Public Health Science Skills Financial Planning & Management Leadership & Systems Thinking When it was all said and done, this particular project included evaluation of programs and mastery of performance measures within these core competencies.

23 ACHNE 2010 Dissemination is a large part of our efforts and the students presented this poster at ACHNE in Some of you may have seen it.

24 REPORT: Quest for a Healthy CityThis slide has small letters, but the report is available if you are interested in the work of the students. I also have copies of the poster for anyone who is interested. Renee tells me that since this student project, the CEO has now asked the Board Advisory Committee to establish a region wide dash board which tracks the process to Become One of America’s Healthiest City. They, in partnership with UT will help HMCT pick metrics for the dashboard. This dash board will not just track outcomes, but what policy, system, and environment changes are making a difference in the Health and health care of our community. HMCT will also engage organizations who doing work to address specific changes in Memphis: farmers markets, bike trails, primary care services to the poor, and other activities which are being instituted by the many community based, and government initiatives to make Memphis a City of choice. This dash board will be posted to create a sense of ownership and purpose for the work everyone is doing to improve our greater community. So, connecting people to the work is another purpose of the dashboard as well. The Mayor of Memphis is working hard to achieve the City of Choice Status and Health will be a critical factor in receiving that designation.

25 Conclusion Partnerships between academic institutions and community agencies can minimize the challenges that each face and meet each other's needs. The project met all domains and many performance measures in the PHN Core Competencies for the Class of 2009 Let’s talk about partnerships between academic institutions and community agencies. When working toward the community agency’s goals, these partnerships can build capacity external to the organization, and help minimize the challenges faced by the organization. In turn, the challenges faced by PHN DNP graduate programs to find complex and challenging community projects are daunting when there are few qualified preceptors. Therefore, in this case, the partnership helped meet both the community agency need and the PHN DNP practicum needs. The agency distributed the full report to the agency's Board of Directors for further action where the expanded and evidence based survey provided information to the HMCT Board of Directors and Advisory Group. The report created considerable discussion about the differences between the consortium and the population served by the consortium among other topics. The recommendations from the student activity were few, but the recommendation to survey the general population at risk was considered to be the most important by the students, particularly since gaps between the members of the consortium and the community at large were identified, e.g., race, education, and income. However, the finances to complete an expanded project, the time necessary to implement it, and organization member’s lack of will created constraints at the time. As I said earlier, this recommendation has been implemented and personnel hired to insure these recommendations are implemented. In summary, the relationship between the HMCT and the university remains strong and this project helped the PHN DNP students (who graduated in 2009) meet all domains and many performance measures in the PHN Core Competencies.

26 Thank you... And Questions?...and a special thank you to Renee’ Frazier, CEO who worked with the faculty and students to bring the information to the HMCT Board of Directors and continues to plan and seek funding for HMCT initiatives for our community Renee’ responds “It is an honor to have UT support us in this work, and please share this with the group at this important national meeting.”