Healthy People 2020 and Social Determinants of Health

NACCHO's partnership with Healthy People 2020 (HP 2020) is designed to support and increase the use of HP 2020 among local health departments (LHDs), non-profit hospitals, and other organizations related to community health assessment and improvement planning. All programmatic activities will be designed to support the HP 2020 ten-year agenda for improving the Nation's health.

With fewer resources and staff, many LHDs face significant challenges in providing essential services that ensure the health and safety of their communities. The HP 2020 approach offers an evidence-based, easy-to-use tool designed to aid LHDs and other organizations in community health assessment work. 

The HP 2020-NACCHO Partnership is sponsored by the U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion.

Below you will find resources to help your department apply HP2020 concepts and address the social determinants of health (SDOH).

Applications now closed

With support from the Office for State, Tribal, Local and Territorial Support within the Centers for Disease Control and Prevention (CDC), the National Association of County and City Health Officials (NACCHO) is pleased to offer a funding opportunity for LHDs. 

NACCHO is currently working to develop a training/technical assistance package to assist rural health departments in applying a SDOH lens to their community health improvement planning (CHIP) work. The package will include existing resources as well as guidance on how to apply them for rural context. The package will focus efforts on how to collect community data related to the social determinants as part of a larger Community Health Assessment effort, and then on how to make connections and apply that data in subsequent planning efforts in developing a Community Health Improvement Plan.

NACCHO is seeking LHDs to pilot the TA plan. Each LHD will be awarded $15,000 to put towards their CHIP. Each site will receive the TA package of resources, planning calls with NACCHO staff, and will be invited to attend an in-person training in Washington, DC. The training will review content provide in the package as well as guide attendees through an action planning process that is appropriate to their current stage of the CHIP. The training will provide core content related to assessment and planning using the SDOH, as well as community partnerships. Applicants will select one activity to focus on and implement by June 2018.

The RFP and application materials can be found below; please email with questions. An informational web conference was held on Wednesday, January 10th at 3pm EST/2pm CST/1pm MST/Noon PST.  The recording can be found here. A document containing questions and answers from the webinar can be found here.

RFP Social Determinants of Health in Rural LHDs

The Community Health Improvement Matrix (CHIM) was developed to gain a better understanding of the current state of Local Health Department's Community Health Improvement Plans and Non-profit Hospital's Implementation Plans in relation to Social Determinants of Health. For more information on the Matrix and related resources. The Model can facilitate collaboration between local health departments and non-profit hospitals on planning improvement/implementation activities, designating appropriate leads and addressing the social determinants of health.

Overview of the Community Health Improvement Model

Community Health Improvement Matrix: Research Brief 

Community Health Improvement Model Template 

NACCHO is continually developing stories from the field about health departments conducting a community health assessment and developing a community health improvement plan using Healthy People 2020. Check back often as new stories will be posted periodically.

NACCHO Annual 2013Audio-visual clips from five local health department on the use of Healthy People in community health assessment and improvement planning. Recorded during NACCHO's 2013 Annual Conference in Dallas, voices from Georgia, Florida, Kansas, Kentucky and Montana are included.

Plumas County Public Health Agency Collaborative CHA and CHIP: A look at how three hospitals, one local health department, and a tribal health clinic in this small, rural county are navigating past organizational mistrust, competing priorities, and strong intra-community identities to examine their community's health status and take action to improve health and well-being.

San Francisco Department of Public Health Collaborative CHA and CHIP: With collective impact as their primary goal, take a look at how eight hospitals, one local health department, and many other partners are working to identify the salient issues in their CHNA and taking action to improve the health of San Franciscans in implementing their CHIP.

Norwalk Health Department Collaborative CHA and CHIPA look at a strengths-based partnership between the local health department and the hospital in Norwalk, Connecticut, that embodies nearly seamless co-leadership of a community health improvement process yielding a community health (needs) assessment and CHIP. For this group, their ability to recognize their strengths and limitations is the foundation of their work.

NACCHO Annual 2013 Preconference SessionThe Florida Department of Health in Miami-Dade County used Healthy People in various Performance Improvement efforts, including strategic planning, quality improvement, accreditation, community health assessment and community health improvement planning. Recorded during NACCHO's 2013 Annual Conference in Dallas.

Using Healthy People 2020 to collaborate on assessment and planning: A look at the dynamic processes of community engagement and partnership efforts using the Mobilizing for Action through Planning and Partnerships (MAPP) framework. The Cobb & Douglas Public Health presentation  focuses on building strong relationships with schools, organizations, businesses and key decision-makers in the community to support “Healthier Lives. Healthier Communities."

Healthy! Capital Counties Collaborative CHA and CHIPIn the Greater Capital Area of Michigan, three local health departments and four hospital systems collaborated to complete a regional CHA and CHIP that emphasized addressing the root causes of poor health outcomes. Here is a look at how they worked together and how they're moving forward to take action to improve health.

Gallatin City-County Health Department Collaborative CHA and CHIP: A look at how a local health department and local hospital in Bozeman, Montana are working together to apply community health assessment results to improve health in a rural and large area in the heart of the Rocky Mountains.

NACCHO Annual 2013 Preconference Session: The Yellowstone County, MT local health department doing business as Riverstone Health, together with St. Vincent's Healthcare and Billings Clinic, used Healthy People in community health assessment and community health improvement planning activities for a community with both rural and urban challenges. Recorded during NACCHO's 2013 Annual Conference in Dallas.

Community Indicators Consortium: 2014 IMPACT Summit: A look at Cuyahoga County’s (Ohio) social justice approach to their collaborative community health improvement process, and how, as a result, they are addressing health inequities in the community. – Presentation recorded during the Community Indicators Consortium: 2014 IMPACT Summit, Washington, DC.

A look at how one community in Portland, Oregon is collaborating with four local health departments and 14 non-profit hospitals to conduct a regional community health needs assessment.

Hospitals, Public Health Creating Community ValuePractical Tools for Moving Into Implementation: Background on  Wisconsin (WI) communities are conducting the community health improvement process under the WI statutory requirement for health departments to develop a community health improvement plan and process (CHIPP) and an in depth look at two rural counties where hospitals and public health are collaborating in their CHIPP efforts.

The reports, webinars, and other tools listed below provide information to help local health departments (LHDs), non-profit hospitals, and other organizations conduct collaborative community health assessment and improvement processes using Healthy People 2020 (HP 2020).


The Community Health Improvement Matrix: an effective tool for implementation planning: These PowerPoint slides are taken from a presentation given at the Association for Community Health Improvement's 2015 Annual meeting. Presenters Barbara Laymon, Lead Program Analyst at NACCHO, Reena Chudgar, Program Analyst at NACCHO and Ed Gerado from Bon Secours Health System. The Healthy People 2020 Social Determinants of Health framework using the Community Health Improvement Matrix is highlighted.

Healthy People 2020: Local Action Leading to Better Health and Well-Being: These PowerPoint slides are from a presentation given by Barbara Laymon, Lead Program Analyst at NACCHO, at the American Public Health Association 2013 Annual meeting. The presentation was part of a session on Healthy People 2020: Addressing social determinants to achieve health equity.

Performance Improvement through Healthy People: These Powerpoint slides outline the application of the Healthy People framework to various aspects of performance improvement, including accreditation, quality improvement, performance management, community health assessment, community health improvement planning and agency strategic planning.

Social Determinants of Health in Community Health Assessment and Improvement Planning: These PowerPoint slides are taken from a presentation given at the Association for Community Health Improvement's 2014 Annual meeting. Presenters Barbara Laymon, Lead Program Analyst at NACCHO and Reena Chudgar, Program Analyst at NACCHO. The Healthy People 2020 Social Determinants of Health framework is highlighted.

Introduction to the Social Determinants of Health and Health Inequities: Click here to access the presentation slides.


Healthy People and MAPP: Survey Findings on Connections, Collaborations, and Challenges: NACCHO surveyed the 434 participants of the Mobilizing for Action through Planning and Partnerships (MAPP) social network site regarding their use of MAPP and HP 2020. This 18-page report describes the current MAPP activity of participants, their views of the impact of MAPP on community health assessment processes and health outcomes, and information regarding the use of HP 2020 within community health assessment activities.

HP2020 in assessment and planning 

How To Use Healthy People in Your Assessment and Planning Efforts. Community health assessment and improvement planning can be overwhelming, but HP 2020 can make it easier. NACCHO created a series of short videos, each under three minutes, to showcase how elements of HP 2020 can assist assessment and planning activities. There are five videos total, including topics such as:

Presentation: Identifying Effective Strategies to Address the Social Determinants of Health - This presentation describes the project and PHAB documentation requirements for strategy selection and implementation, discusses what types of actions will best address the root causes of health inequities or social determinants of health, discusses the role of policy change in addressing the social determinants of health, and more. Watch the free archived recording of this webinar.

Archived Webinar: Considering Health Equity in Community Health Improvement Planning

This 60 minute webinar is part of NACCHO''s Performance Improvement Technical Assistance Webinar Series and includes information on the importance of social justice in CHA and CHIP work, types of information necessary for assessing and addressing health inequities, tools for understanding and measuring health inequities as part of a community health improvement process, and more.

  • Watch the free archived recording of this webinar.
  • Access the presentation slides.

Recently, NACCHO convened partners and leaders from the local, state and national level for a working meeting on moving forward community health (needs) assessment and improvement planning as a field to assure the conditions in which people can be healthy. Materials and resources from the meeting can be found below. 



Provisions of the Patient Protection and Affordable Care Act (ACA) require each non-profit hospital facility in the United States to conduct a community health needs assessment (CHNA) and adopt an implementation strategy to meet identified community health needs. In conducting the CHNA, non-profit hospitals are required to take into account input from persons who represent the broad interests of the community served, including those with special knowledge of or expertise in public health.

NACCHO is committed to helping local health departments (LHDs) strategically align their community health assessment efforts with other assessment initiatives such as those of non-profit hospitals. The resources below provide information to help LHDs and non-profit hospitals utilize Healthy People 2020 (HP 2020) to conduct collaborative community health assessment and improvement processes.

Below are links to online resources and tools to help LHDs to assess and address social determinants of health

General sources of SDOH Indicators and data

1. AARP livability index The AARP Public Policy Institute promotes development of sound, creative policies to address our common need for economic security, health care, and quality of life. Their Livability Index measures community livability. Users can search the Index by address, ZIP Code, city, or county for livability scores in seven categories for every neighborhood in the US. The Index takes a holistic approach to understanding livability, including the health of residents and the quality of the built environment, but also considers engagement, opportunity, and the natural environment.

2. Brookings Institution Metro Monitor The Brooking Institution Metro Monitor measures the performance of the nation's major metropolitan economies in three critical areas for economic development: growth, prosperity, and inclusion. In response to increasing income inequality in U.S. cities, inclusive economies are those that offer opportunities for prosperity across the population. According to the Brookings model, inclusive economies are more equitable, participatory, growing, sustainable, and stable.

4. CDC data set directory of social determinants of health at the local level The directory contains an extensive list of existing data sets that can be used to understand social determinants of health. The data sets are organized in 12 categories of the social environment.

5. The Community Indicators Consortium The Community Indicators Consortium advances and supports the development, availability and effective use of community indicators for making measurable and sustainable improvements in quality of community life. The CIC has an online database of tools for community indicators as well as communities of practice.

6. County Health Rankings and Roadmaps The County Health Rankings & Roadmaps program is a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. The annual County Health Rankings measure vital health factors, including high school graduation rates, obesity, smoking, unemployment, access to healthy foods, the quality of air and water, income, and teen births in nearly every county in America.

7. US Census Bureau Under the U.S. Census Bureau are a range of surveys, data, and visualization tools for learning about the U.S. population. Within the Census, the American Community Survey (ACS) is an ongoing national survey of U.S. households that provides data to guide the distribution of federal funds. You can access data from the American Community Survey estimates, released every year in a variety of tables, tools, and analytical reports. 

8. NACCHO guide to Resources for Social Determinants of Health Indicators

When thinking about the social determinants of health, there are several perspectives you may take as you pursue data collection for the assessment component of your improvement process. This resource provides a brief description of key steps you may want to consider or take and provides a list of indicators you may want to consider using in your CHA to examine the social determinants of health.

9. Exercise: Social Determinants of Health in your community

This exercise can be used to assist you in determining if the types of data you have that describe health in your community are indicators of social inequities, institutional power, neighborhood conditions, risk behaviors, disease & injury, or mortality using the BARHII model.

Specialized sources of SDOH Indicators and data

1. AMCHP life course measures The Association of Maternal and Child Health Programs (AMCHP) is a national resource, partner and advocate for state public health leaders and others working to improve the health of women, children, youth and families, including those with special health care needs. Through a collaborative process, AMCHP has identified a standardized set of indicators that can be used to measure progress using the life course approach to improve maternal and child health. The final set of 59 indicators is available here, with guidance on measurement.

2. ASCE Report Card for America's Infrastructure The American Society of Civil Engineers releases a comprehensive assessment of the nation’s major infrastructure categories. It includes recommendations for raising the grades.

3. Economic Policy Institute EPI conducts research and analysis on the economic status of low-and middle-income working Americans and provides policy recommendations. Their website contains datasets and indicators on a range of issues affecting workers.

4. Kids Count Data Center A project of the Annie E. Casey Foundation, KIDS COUNT offers data on hundreds of indicators related to child and family well-being in the United States. You can download data and create reports and graphics on the KIDS COUNT Data Center.

1. American Planning Association

The American Planning Association produces knowledge and resources that planners use to make safer, greener, healthier, and more sustainable communities. They offer a list of policy guides for city and regional planning. In particular, the SmartGrowth policy statement advocates for the development of mixed use, mixed income livable communities and provides resources for planning that promotes public health and equity.

2. Healthy People 2020
Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. Their website provides these indicators as well as a collection of evidence-based practices for improving health outcomes.

3. Human Impact Partners
Human Impact Partners aims to increase the consideration of health and equity in decision-making. They offer free tools and resources for conducting a health impact assessment (HIA). They also offer training and technical assistance to build the capacity of impacted communities and their advocates, public agencies, and elected officials to take action on the social
determinants of health and equity.

4. Prevention Institute
The Prevention Institute offers many tools to guide communities in implementing collaborative, effective prevention strategies to create safer, healthier, and more equitable communities. Their guide to health equity metrics is one valuable resource.

5. Public Health Institute
PHI generates and promotes research, leadership and partnerships to build capacity for strong public health policy, programs, systems and practices. PHI hosts the Building Healthy Places Network, which supports collaboration across the health and community development sectors. Their MeasureUp microsite offers resources and tools to help you measure and describe your
programs’ impact on communities and health-related factors.

1. Community Health Commons Community Community Commons offers “data, tools, and stories to improve communities and inspire change.” Their Community Health Needs Assessment toolkit has a wealth of resources for mapping population demographics for your CHNA, including interactive maps and populationbased data reporting tools.

2. Community Health Maps The Community Health Maps blog is a collaborative effort among the National Library of Medicine, the Center for Public Service Communications, and Bird’s Eye View to provide information about low cost mapping tools for community organizations. The blog is meant to support both new and experienced GIS mapping users in enhancing their community mapping initiatives, even if they may be using other tools. The blog contains mapping apps/software reviews, best practices, and the experiences of those who have successfully implemented a mapping workflow as part of their work.

3. PolicyMap PolicyMap offers easy-to-use online mapping with data on demographics, real estate, health, jobs and more in communities across the US. With a paid subscription, you can create custom mapping tools using your own data and indicators in PolicyMap’s extensive database.

1. Atlanta's Neighborhood Quality of Life & Health Project The Atlanta Neighborhood Quality of Life and Health (NQOLH) Project provides data and analysis to show that the built environment impacts both quality of life and community health at the neighborhood level, making the case for investments in the built environment to improve quality of life and health. NQOLH is an example of a source of free and open data that allows residents, community groups, planners, and policy-makers to assess community needs and develop data-driven planning strategies. The Socioeconomic Conditions (SEC) Index groups Atlanta’s neighborhoods into three categories by community socioeconomic status, given the wealth of research linking SEC to health and quality of life.

2. Bay area regional health inequities initiative (BARHII) The Bay Area regional collaborative is dedicated to advancing health equity. They offers a social determinants of health indicator guide containing 15 SDOH indicator chapters: a table of 72 priority SDOH indicators and their data sources; and technical data appendices. They also have issue briefs on topics such as land use planning, minimum wages, and other topics related to advancing health equity. 

3. Socioeconomic hardship index, Chicago Department of Public Health The City of Chicago's Data Portal is dedicated to promoting access to government data and encouraging the development of creative tools to engage and serve Chicago's diverse community. The site hosts over 200 datasets presented about city departments, services, facilities and performance. This dataset contains a selection of six socioeconomic indicators of public health significance and a “hardship index” for the years 2008 – 2012. 

4. Virginia Commonwealth University Center on Society and Health The VCU Center on Society and Health in Richmond, VA studies the health implications of social factors such as education, income, community environmental conditions, and public policy. They have several interactive tools and publications demonstrating links between social factors and health.