A Community Health Improvement Plan (CHIP) is meant to turn a community needs assessment into practical action. During one CHIP process Crescendo conducted with a health system and its local health collaborative, a small idea surfaced that could make better use of services already available in the community.
The collaborative included service organizations, community providers, housing advocates, senior services, and other local partners. Together, the group reviewed findings from the community needs assessment to identify actionable strategies.
Chronic Disease Management Was a Priority, But Services Already Existed
Chronic disease emerged as a priority in the community needs assessment. During the CHIP process, partners began discussing what programs already existed to help residents manage conditions like hypertension and diabetes.
One organization described its free chronic disease programming, including blood pressure and blood sugar checks, walking clubs, and chair yoga classes. The organization designed these programs to support residents managing chronic conditions in the community.
However, participation in the programs was low.
The conversations during the CHIP suggested that the issue was not a lack of services, but a lack of connection between patients and programs already available in the community.
A Practical Connection
During the planning process, a medical provider from the health system spoke with the program director. The issue became clear quickly.
Providers were not directing patients leaving the hospital to these programs.
One simple solution emerged: include the organization’s contact information on discharge paperwork for patients with certain diagnoses. This would give patients a clear path to programs supporting chronic disease management outside the clinical setting.
Community Health Improvement Plan in Action
During community needs assessments, we often hear about a “lack of awareness of services.” Communities may have strong programs in place, but residents don’t always know they exist.
For this community, the CHIP process created space for partners to connect those dots. In this case, the outcome was not a new program or additional funding. It was a practical step that could help patients find services already designed to support their health.
At a time when many communities are working with limited resources, solutions like this matter. Sometimes the most effective fix is not building something new, but making better use of what is already there.
A Community Health Improvement Plan works best when organizations move beyond identifying needs and focus on practical ways to connect people with existing services and resources.
If your organization is preparing for the next phase after a community needs assessment, Crescendo supports both the research and planning that lead to meaningful community action.
- Community Needs Assessments: Learn how Crescendo conducts community needs assessments that identify priority health issues and inform planning.
- Strategic Planning: Learn how Crescendo works with communities to develop Community Health Improvement Plans and other strategic initiatives.