Tools and Methods for Aligning Community Health Planning with Primary Care and Policy Interventions: Lessons Learned from Hard to Reach Frontier Communities along the U.S.-Mexico Border

While effective community assessment tools are vital for improving population health, less is known on how to align community data with primary care and policy interventions. As part of a larger strategy to align primary care with population health strategies for preventing chronic conditions among medically underserved Latinos living in a frontier border region, the Hidalgo Medical Services and Health Council, Robert Wood Johnson Center for Health Policy and Prevention Institute adapted a tool for assessing socio-determinants of health. This presentation focuses on key challenges and lessons learned and how the partners modified the THRIVE survey (Tool for Health & Resilience in Vulnerable Environments), a community engagement tool for assessing upstream socio-determinants of health. The survey was implemented in 2011 to assess: (1) equitable opportunities (racial justice, jobs and education); (2) people (social networks and acceptable cultural behaviors); and (3) place (built environment, parks and open space, neighborhood safety, healthy food). Key findings from 357 completed surveys showed that safety, jobs, housing and education rated among the top health issues. Of particular interest is how the local health consortium (providers, services agencies, law enforcement, schools, religious leaders) aligned the findings into existing county-wide strategic planning and primary care delivery. The tool also cultivated an open dialogue regarding the context of health in the border including violence and immigration. Insights can be used by other communities seeking to integrate social interventions with primary care as a means to promote prevention and wellness, and to develop comprehensive health policies in frontier environments.