• Introduction:

    The Community Health Improvement Plan (CHIP) is the second part of a two-part health improvement planning process. The first step was the completion of the 2019 Community Health Assessment (CHA) which evaluated health status and issues impacting Montgomery County’s population. Representatives from a variety of organizations throughout the county met to first select health priorities based on the issues identified in the CHA and then worked to collaboratively create workplans to select strategies to address these issues.

    The CHIP is a three-year community-driven plan that outlines goals and strategies that will be used by coalitions, task forces, organizations, and citizens to address the identified health priorities in the community.

Community Health Improvement Plan

The Community Health Improvement Plan (CHIP) is the second part of a two-part health improvement planning process. The first step was the completion of the 2019 Community Health Assessment (CHA) which evaluated health status and issues impacting Montgomery County’s population. Representatives from a variety of organizations throughout the county met to first select health priorities based on the issues identified in the CHA and then worked to collaboratively create workplans to select strategies to address these issues.

The CHIP is a three-year community-driven plan that outlines goals and strategies that will be used by coalitions, task forces, organizations, and citizens to address the identified health priorities in the community.

Community Health Improvement Plan

2020 – 2022 Community Health Improvement Plan

On Hold In Progress Complete No Change Baseline Positive Change Negative Change
Maternal & Infant Vitality

Maternal and Infant Vitality is a measurement of the overall health of the community. We believe that healthy moms and healthy babies will lead to a more educated, healthier community. We will leverage our resources to identify and target pregnant women, which will give us a starting point to improve the health of the overall community.

Goals
Infant mortality rate (per 1,000 live births)Overall infant mortality rate
Objectives
Reduce the rate of preterm births Maternal & Infant Vitality | 1/1/20 - 12/31/22
Strategies

Increase adequate prenatal care & education

Maternal & Infant Vitality | 1/1/20 - 12/31/22

Increase utilization of maternal & infant home visiting programs

Maternal & Infant Vitality | 1/1/20 - 12/31/22

Reduce substance misuese during pregnacy

Maternal & Infant Vitality | 1/1/20 - 12/31/22

Preterm birth rate

Preterm birth rate
Reduce the rate of sleep-related deaths Maternal & Infant Vitality | 1/1/20 - 12/31/22
Strategies

Increase utilization of maternal & infant home visiting programs

Maternal & Infant Vitality | 1/1/20 - 12/31/22

Reduce substance misuse during pregnancy

Maternal & Infant Vitality | 1/1/20 - 12/31/22

Strengthen access to data related to SUID for appropriate system partners

Maternal & Infant Vitality | 1/1/20 - 12/31/22

Implement Safe Sleep Ambassador Program

Maternal & Infant Vitality | Completed 2/29/20

Sleep-related death rate (per 1,000 live births)

Sleep-related death rate
Reduce the Black infant mortality rate disparity Maternal & Infant Vitality | 1/1/20 - 12/31/22
Strategies

Connect at-risk women to needed clinical and social services through Neighborhood Navigators (CHWs)

Maternal & Infant Vitality | 1/1/20 - 1/31/22

Convene community events to educate and inform priority populations

Maternal & Infant Vitality | 1/1/20 - 1/31/22

Increase social support for new families through parenting and fatherhood initiatives

Maternal & Infant Vitality | 1/1/20 - 1/31/22

Increase access and utilization of childbirth education

Maternal & Infant Vitality | 1/1/20 - 1/31/22

Black infant mortality rate disparity

Black infant mortality rate disparity
Implement the Communities Pathway HUB model in Montgomery County Maternal & Infant Vitality | 1/1/20 - 12/31/20
Strategies

Develop Agreements with care coordinating agencies

Maternal & Infant Vitality | Completed 12/31/20

Provide community education on what it is and how to use it

Maternal & Infant Vitality | Completed 12/31/20

HUB Model Progress

HUB model
Increase the rate of mothers breastfeeding at hospital discharge Maternal & Infant Vitality | 1/1/22 - 12/31/22
Strategies

Engage employers to provide support for breastfeeding in the workplace

Maternal & Infant Vitality | 1/1/21 – 12/31/22

Provide community education on the importantace and options for breastfeeding

Maternal & Infant Vitality | 1/1/21 – 12/31/22

Breastfeeding at hospital discaharge

Breastfeeding at hospital discaharge
Chronic Disease Prevention

Chronic Diseases have a large impact on residents of Montgomery County; they represent 7 of the top 10 leading causes of death, and chronic disease related healthcare costs have continued to rise. Risk factors for chronic disease that affect community members include poor nutrition, a lack of physical activity, and tobacco use. Making healthy lifestyle changes like improving nutrition, increasing physical activity, and quitting tobacco can help prevent people from developing these diseases. Differences in circumstances like income, zip code, and education can affect these behaviors, making it more difficult for some individuals to adopt healthy lifestyles.

Goals
Adults that are physically inactiveAdults that are physically inactive
Objectives
Increase the percent of Black adults in Montgomery County thatparticipate in any leisure time physical activity Chronic Disease Prevention | 1/1/20 - 12/31/22
Strategies

Increase walking among residents

Chronic Disease Prevention | 1/1/20 - 12/31/22

Activate underutilized parks

Chronic Disease Prevention | 1/1/20 - 12/31/22

Resource guide for neighborhood physical activity

Chronic Disease Prevention | 1/1/20 - 12/31/22

Expand bike share into predominantly Black communities

Chronic Disease Prevention | 1/1/20 - 12/31/22

Implement policy changes regarding park maintenance and safety

Chronic Disease Prevention | 1/1/20 - 12/31/22

Black adults that participate in leisure time physical activity

Black adults that participate in leisure time physical activity
Increase the percent of adults in Montgomery County that meet both physical activity guidelines (aerobic and muscle-strengthening activities). Chronic Disease Prevention | 1/1/20 - 12/31/22
Strategies

Public advertising campaigns

Chronic Disease Prevention | 1/1/20 - 12/31/22

Include "Health in All Policies" in land use plan

Chronic Disease Prevention | 1/1/20 - 12/31/22

Increase the percent of adults in Montgomery County that participate in any physical activities or exercises other than their regular job such as running, calisthenics, golf, gardening, or walking for exercise

Adults that meet both aerobic and muscle-strengthening activities
Adults who Smoke TobaccoAdults who Smoke Tobacco
Adults who use smokeless tobaccoAdults who use smokeless tobacco
Objectives
Reduce tobacco use among low income residents. Chronic Disease Prevention | 1/1/20 - 12/31/22
Strategies

Increase education on tobacco cessation

Chronic Disease Prevention | 1/1/20 - 12/31/22

Work with physicians to increase cessation services

Chronic Disease Prevention | 1/1/20 - 12/31/22

Increase incentive programs for quitting

Chronic Disease Prevention | 1/1/20 - 12/31/22

Implement policies to restrict tobacco use multiunit housing settings

Chronic Disease Prevention | 1/1/20 - 12/31/22

Low income residents who use tobacco

Low income residents who use tobacco
Heart Attack hospital-related visitsHeart Attack hospital-related visits
Hypertensive disease hospital-related visitsHypertensive disease hospital-related visits
Stroke hospital-related visitsStroke hospital-related visits
Cardiovascular disease hospital-related visitsCardiovascular disease hospital-related visits
Objectives
Reduce cardiovascular disease-related emergency department visits. Chronic Disease Prevention | 1/1/20 - 12/31/22
Strategies

Increase prevention education

Chronic Disease Prevention | 1/1/20 - 12/31/22

CHW outreach/collaboration with maternity programs/fatherhood program

Chronic Disease Prevention | 1/1/20 - 12/31/22

Explore increasing the percent of Blacks who identify having one person as their personal healthcare provider by exploring tel...

Chronic Disease Prevention | 1/1/20 - 12/31/22

Work with the faith community to implement policy change to promote healthy eating

Chronic Disease Prevention | 1/1/20 - 12/31/22

Heart Attack hospital ED visits

Heart Attack hospital ED visits

Stroke hospital ED visits

Stroke hospital ED visits

Hypertensive disease hospital ED visits

Hypertensive disease hospital ED visits

Cardiovascular disease hospital ED visits

Cardiovascular disease hospital ED visits
Food InsecurityFood Insecurity
Objectives

Align goals, strategies, and activities of existing coalitions andorganizations working, to address community food security anddetermine gaps

Chronic Disease Prevention | 1/1/20 - 12/31/22

Enhance communication and coordination between agencies and resources.

Chronic Disease Prevention | 1/1/20 - 12/31/22

Expand and focus public information efforts with consistent vocabulary to promote food equity.

Chronic Disease Prevention | 1/1/20 - 12/31/22

Coordinate, improve, and expand community food security resources and activities.

Chronic Disease Prevention | 1/1/20 - 12/31/22

Develop shared measurements to evaluate efforts.

Chronic Disease Prevention | 1/1/20 - 12/31/22
Behavioral Health

Behavioral Health encompasses both mental health and substance use disorder. We can help improve the behavioral health of Montgomery County residents by promoting resilience and well-being, treating mental and substance use disorders, and supporting those who are experiencing or are in recovery from these conditions - along with their families and communities.

Goals
Suicide death rate (per 100,000)Suicide death rate (per 100,000)
Objectives
Decrease suicide rates across the lifespan. Behavioral Health | 1/1/20 - 12/31/22
Strategies

Implement Zero Suicide Framework across two healthcare system

Behavioral Health | 1/1/20 - 12/31/22

Advocate for mandated universal screening tools in schools

Behavioral Health | 1/1/20 - 12/31/22

Develop education and outreach to inform Montgomery County on the community impact of trauma and the resources available

Behavioral Health | 1/1/20 - 12/31/22

Suicide Rate (per 100,000)

Suicide Rate (per 100,000)
Increase the number of culturally competent mental healthproviders in the LGBTQ community Behavioral Health | 1/1/20 - 12/31/22
Strategies

Redistribute Healthcare Provider Competency Survey to mental health providers in the county to identify those who are provi...

Behavioral Health | 1/1/20 - 12/31/22

Provide cultural competency training to interested providers

Behavioral Health | 1/1/20 - 12/31/22

Add names of culturally competent providers to the Pride Providers list

Behavioral Health | 1/1/20 - 12/31/22

Work with providers to collect data on sexual orientation and gender identity of patents to begin to access access to care in th...

Behavioral Health | 1/1/20 - 12/31/22

Culturally competent mental health providers

Culturally competent mental health providers
Depression-related hospital visits (per 1,000)Depression-related hospital visits (per 1,000)
Anxiety-related hospital visits (per 1,000)Anxiety-related hospital visits (per 1,000)
Objectives
Implement Parks Rx Program in Montgomery County Behavioral Health | 1/1/20 - 12/31/22
Strategies

Work with Five Rivers MetroParks to implement program

Behavioral Health | 1/1/20 - 12/31/22

Implementation Progress

Implementation of Parks Rx Program
Create a community resource guide that connects individuals and families to social support activities Behavioral Health | 1/1/20 - 12/31/22
Strategies

Develop educational materials and advertising that support social activities for individuals and families

Behavioral Health | 1/1/20 - 12/31/22

Develop a system infrastructure that will disseminate information on free and low-cost activities

Behavioral Health | 1/1/20 - 12/31/22

Utilize asset map created by MVPRC

Behavioral Health | 1/1/20 - 12/31/22

Resource Guide Creation Progress

Creation of resource guide
Mental Health ProvidersMental Health Provider ratio
Objectives
Advocate for policies that would improve the accessibility of behavioral healthcare Behavioral Health | 1/1/20 - 12/31/22
Strategies

Advocate for changes in telehealth policies

Behavioral Health | 1/1/20 - 12/31/22

Advocate for changes in Medicare credentialed providers

Behavioral Health | 1/1/20 - 12/31/22

Implement a county-wide system to determine the barriers to equitable accessibility of behavioral healthcare and identify undersevered groups

Behavioral Health | 1/1/20 - 12/31/22

Policies

Policies to improve accessibility
Increase the number of new healthcare settings offering behavioral health prevention, intervention, and/or treatment services Behavioral Health | 1/1/20 - 12/31/22
Strategies

Identify opportunities to support universal parenting program such as Triple P

Behavioral Health | 1/1/20 - 12/31/22

Hire additional behavioral healthcare staff within healthcare settings to increase capacity

Behavioral Health | 1/1/20 - 12/31/22

Healthcare Settings

Healthcare Settings
Number of Overdose DeathsNumber of Overdose Deaths
Objectives
Align goals, strategies, and activities of existing coalitions andorganizations working, to address community food security anddetermine gaps
Behavioral Health | 1/1/20 - 12/31/22
Improve multi-agency communications through the exchange of COAT-related information and situational awareness data.
Behavioral Health | 1/1/20 - 12/31/22
Expand and focus public information efforts.
Behavioral Health | 1/1/20 - 12/31/22
Coordinate and improve opioid prevention and education activities
Behavioral Health | 1/1/20 - 12/31/22
Improve methods for response, intervention, treatment, and recovery efforts
Behavioral Health | 1/1/20 - 12/31/22

Frequently Asked Questions

While the CHIP is a community-driven and collectively owned health improvement plan, Public Health provides administrative support, tracks and collects data, and prepares quarterly and annual progress reports.

Using this online dashboard, the progress of each strategy will be reported quarterly and the status toward achieving the goals and objectives are updated annually.

A next assessment of the community’s health will be completed by 2021 and over the next year, the community will begin the process of selecting new health priorities with new workplans. A new community health improvement plan will be completed and ready for implementation by the beginning of 2023.

  • Documents