Community Health Needs Assessment / Community Health Improvement Plan


The legislation that created Coordinated Care Organizations (CCOs) to provide services to Oregon Health Plan (OHP) beneficiaries in Oregon included provisions requiring that the CCOs’ Community Advisory Councils, composed of a majority of Oregon Health Plan members, oversee a Community Health Needs Assessment (CHA) and Community Health Improvement Plan (CHP) every three years.

The purpose of the CHA and CHP is to reduce health disparities, promote health equity and improve overall population health in the region served by the CCO. This assessment document supports strategies that are intended to benefit the broad Tri-County community with particular focus on issues that disproportionately impact our Members.

Prioritized Needs

Health Share of Oregon’s Community Advisory Council has recommended two Community Health Needs to be prioritized and addressed through our Community Health Improvement Plan:

  • Behavioral Health
  • Chronic Disease preventable through physical activity and nutrition

You can read the full Community Health Needs Assessment.

Needs Assessment Methodology and Process

The assessment included two processes: health needs identification and health needs prioritization. Health needs were identified through a community-wide process conducted by the Healthy Columbia Willamette Collaborative, of which Health Share is a member. Health needs were prioritized through Health Share’s Community Advisory Council’s CHA Committee, by identifying community-led self-assessments with data describing what health issues are a priority for them. These two steps enabled us to use public health and hospital data to identify needs and to also validate that impacted communities recognize certain health needs as a priority.

Initially, the CHA Committee had selected Mental Health as one of the two prioritized needs.  After obtaining feedback from the Community Advisory Council’s Mental Health & Addictions Subcommittee and from Health Share’s Board of Directors, the CHA Committee determined to change the priority to Behavioral Health in order to be inclusive of substance use and addictions.  The CAC and Board of Directors recognize that the relationship between mental health and substance abuse is very strong. Additionally, changing the scope to Behavioral Health is aligned with the prioritized health needs of the Healthy Columbia Willamette, which is discussed further in this document.

Community Health Improvement Plan (CHP)

Health Share’s CHP utilizes the Community Readiness Model, a framework created by Colorado State University’s Tri-Ethnic Center for Prevention Research, based upon the “Stages of Change” in recovery from addictions. This is a multi-dimensional model that integrates a community’s culture, resources and level of readiness into the design of prevention interventions.

Based upon key informant interviews and Health Share member focus groups, the Community Advisory Council assessed communities’ readiness to address Chronic Disease and Behavioral Health as well as the communities’ stages of readiness for change, and identify the interventions most likely to successfully improve the health of communities experiencing health disparities. 

Most common diagnosis among members:

  • Adults: High Blood Pressure, Tobacco Use, Complex MH Disorder, Diabetes, Obesity, Asthma
  • Children: Obesity, Asthma, ADD, PTSD, Complex MH Disorder, Depression 

CHP Process Emphasized Community Engagement

The Community Advisory Council and Health Share staff prioritized these principles in the CHP process:

  • Seek input from communities impacted by disparities about what investments would be most impactful, and matching them to the community’s stage of change;
  • Align investments with transformation activities underway at Health Share partners;
  • Measure improvements in health outcomes for members as a result of investments;
  • Use the Community Readiness Model, a process that included interviewing over 40 Health Share members and community stakeholders for input and identification of level of community readiness to address both priority needs;
  • Use findings from community-led self assessments to identify needs and strategies in addition to our CHNA findings.

Community Health Improvement Plan Health Priorities

1. Behavioral Health: Mental Health and Substance Use Disorders
2. Chronic Disease related to physical activity and nutrition

Health Share’s CHP resources culturally-specific Community Health Workers and Peer Mentors. Our CAC convened a Community Health Needs Assessment Committee, who worked with staff on out CHNA and CHP strategies. We developed a Request for Proposals to invite Community-Based Organizations with culturally-specific programs to apply for funds to support Year 1 Activities of our CHP.

From July-September 2014, Health Share conducted our RFP process that resulted in new partnerships with 4 community-based organizations and coalitions. In addition to working on specific projects within their organizations, our partners meet to collaborate together and exchange information as part of addressing health disparities in behavioral health and chronic diseases related to physical activity and nutrition.

Culturally-Specific Traditional Health Worker Strategies

1. Increase the availability of culturally-specific Peer Support Workers to Health Share members who identify as people of color, who speak a preferred language other than English, who identify as LGBTQI, who have a disability or who are young or elderly, or who have been diagnosed with a severe persistent mental illness.

2. CBOs train primary care provider teams on peer resources, and referral to Peer Support Workers.

3. Culturally-Specific CBOs employ Peer Support Workers to provide education and outreach to communities and individuals about mental health and addictions generally, as well as specific programs and services available to Health Share Members.

4. Culturally-Specific CBOs host community discussions about mental health and addictions issues, in order to engage community members in a preventative manner.

Northwest Family Services

Clackamas & Multnomah Counties: Hispanic/Latino. Northwest Family Services and the National Alliance on Mental Health Illness – Clackamas County will work to provide education and outreach in the Latino and LGBTQI communities through peer resources, peer support workers, and host group culturally specific and competent staff.

Center for Intercultural Organizing

Washington County: Asian/Pacific Islander, Latino, Russian speaking, war torn regions of Africa & Middle East. The margins to Mainstream project is a collaboration that centers around developing and employing a trained base of immigrant and refugee “wellness life guides,” or traditional health workers/organizers – assisted and supported by a team of social service agencies, community based organizations, and health care providers – that aid newcomers in acquiring the facilitative and communicative skills necessary to interact, understand, and cope with their needs in relation to their adopted environment, and work collaboratively toward institutional change.

Chronic Disease preventable through physical activity and nutrition


1. Increase the availability of culturally-specific Community Health Workers to Health Share Members who identify as people of color, who speak a preferred language other than English, who identify as LGBTQI, who have a disability or who are young.

2. Culturally Specific Community Health Workers share information about and lead healthy eating and physical activity groups in their communities

3. CBOs train Community Health Workers on chronic disease outcomes and clinical services related to the CCOs Quality Improvement Plan

4. CBOs train providers on culturally and linguistically appropriate care and Chronic Disease prevention and management in the primary care setting, including how to integrate the use of Community Health Workers into their practice.

North by Northeast Community Health Services

Multnomah County: African-American. Ongoing inclusion of Community Health Workers (CHWs) in efforts to improve the health of African-American patients and eliminate health disparities. CHW helps patients identify barriers to health improvement, set goals, understand medication regimens and adhere to follow-up plans.

Familias en Acción

Clackamas, Washington & Multnomah Counties: Hispanic/Latino. Provide the Community Health Worker program, Senderos Hacía su Salud/Pathways to Your Health, for Hispanic members of Health Share by partnering with several clinics.

You can read the full Community Health Improvement Plan.