Community Health Improvement Plan by Jefferson County Public Health

Jefferson County, Colorado Community Health Improvement Plan 2014 - 2018 Updated December 2015

Table of Contents Acknowledgements ........................................................................................................................ 2 Executive Summary ...................................................................................................................... 5 Introduction ................................................................................................................................... 6 Community Description ................................................................................................................ 8 Social Determinants of Health ..................................................................................................... 9 Age Distribution ..................................................................................................................................... 9 Racial and Ethnic Distribution ........................................................................................................... 10 Education .............................................................................................................................................. 11 Income ................................................................................................................................................... 12 Health Equity........................................................................................................................................ 13

Jefferson County Community Health Improvement Plan Goals and Objectives ................. 15 Physical Activity ................................................................................................................................ 16 Healthy Eating ................................................................................................................................... 17 Psychosocial Well-being.................................................................................................................... 19 Goal 1: To increase physical activity, healthy eating, and psychosocial well-being among low-income families with children ages 0-18. ......................................................................................................... 20 Goal 1, Strategy 1: Active Living Policy .......................................................................................... 22 Goal 1, Strategy 2: Food Access ........................................................................................................ 24 Goal 1, Strategy 3: Healthy Beverage................................................................................................ 26 Goal 1, Strategy 4: Health in Early Childhood .................................................................................. 28 Goal 1, Strategy 5: School Wellness.................................................................................................. 31 Goal 1, Strategy 6: Preventive Care and Mental Health Resources................................................... 34 Goal 2: To implement a collective impact approach in Jefferson County to increase healthy eating, active living, and psychosocial well-being. ......................................................................................... 36 Goal 2, Strategy 1: Common Goals ................................................................................................... 38 Goal 2, Strategy 2: Mutually Reinforcing Activities ......................................................................... 39 Goal 2, Strategy 3: Shared Measures ................................................................................................. 40 Goal 2, Strategy 4: Shared Communication ...................................................................................... 41 Goal 2, Strategy 5: Backbone and Structural Support from JCPH .................................................... 42

Next Steps ..................................................................................................................................... 43 Resources to Continuously Develop and Implement the CHIP and Support Core Public Health Services .................................................................................................................................................. 43 Continuous Evaluation, Updating and Planning Processes.............................................................. 43

Conclusion .................................................................................................................................... 44 Appendix A: Community Partnerships..................................................................................... 46 Appendix B: Data Sources .......................................................................................................... 48 Appendix C: The Community Health Improvement Planning Process ................................. 58 References .................................................................................................................................... 64

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Acknowledgements Jefferson County Public Health (JCPH) gratefully acknowledges the contributions of a wide range of residents and organizations to the community health improvement planning process. Target Population Work Group Members Melissa Broudy, Jefferson County Public Health Holly Camp, Jefferson County Public Schools Jennifer Cullingford, King Soopers Becky DeHerrera, Jefferson County Housing Authority Dennis Dempsey, Jefferson County Planning and Zoning Cynthia Farrar, Metro Community Provider Network Summer Gathercole, Share our Strength Max Gibson, Jefferson County Public Health Pamela Gould, Jefferson County Public Health Amy Gresham, United Health Care Molly Hanson, Jefferson County Public Health Colleen Hatton, Exempla Lutheran Medical Center Analiese Hock, Jefferson County Planning and Zoning Margaret Huffman, Jefferson County Public Health Rachel Hultin, LiveWell Wheat Ridge Wilma Jones, resident Kelly Keenan, Jefferson County Public Health Lisa Knoblauch, Living City Block Will Lebzelter, Jefferson County Open Space Sara Lemley, Jefferson County Public Health Tom Livingston, Jefferson County Economic Development Corporation

Elise Lubell, Jefferson County Public Health Diana Maier, Jefferson Center for Mental Health Ana Marin, Jefferson County Public Health Michael McLoughlin, resident Nancy Murray, resident Andy Nowak, CO Farm to School Task Force Dr. Lorrie Odom, resident Jessica Osborne, GP Red Emily O’Winter, Jefferson County Public Schools Jim Rada, Jefferson County Public Health Gloria Raigoza, Centura Health/St. Anthony Hospital Carol Salzmann, Exempla Lutheran Medical Center Foundation Shannon Spurlock, Denver Urban Gardens Stephanie Stephens, Colorado Parks and Recreation Association Linda Stoll, Jefferson County Public Schools Bethany Thomas, Calvary Episcopal Church Mae Thompson, Ralston Valley High School Cynthia Vitale, resident Laurie Walowitz, Mountain Resource Center Van Wilson, Seniors’ Resource Center Gaye Woods, Centura Health/St. Anthony Hospital

Jefferson County Health Council Members Stephen Boucher, Clear Creek Valley Medical Society Jeff Brickman, Centura Health/St. Anthony Hospital Alan Feinstein, Jefferson County Housing Authority Faye Griffin, Jefferson County Board of County Commissioners Harriet Hall, Jefferson County Mental Health Tom Hoby, Jefferson County Parks Department and Open Space Division Lynn Johnson, Jefferson County Human Services Mark Johnson, Jefferson County Public Health Kevin McCaskey, Jefferson County Economic Development Corporation Bonnie McNulty, City of Edgewater Dave Myers, Metro Community Provider Network Jacki Paone, Colorado State University Extension Susan Pharo, Kaiser Permanente Colorado

Donald Rosier, Jefferson County Board of County Commissioners Pete Roybal, City of Lakewood Scott Shields, Family Tree Saoirse Charis-Graves, City of Golden Ryan Stachelski, Arvada Economic Development Association Stephanie Stephens, Colorado Parks and Recreation Association Cindy Stevenson, Jefferson County Public Schools Bethany Thomas, Calvary Episcopal Church Casey Tighe, Jefferson County Board of County Commissioners Max Tyler, Colorado House of Representatives Grant Wicklund, Exempla Lutheran Medical Center John Wolforth, Jefferson County Planning and Zoning John Zabawa, Seniors’ Resource Center

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JCPH also extends thanks to JVA Consulting, Spark Policy Institute, and the Colorado Department of Public Health and Environment’s Office of Planning and Partnerships for technical assistance. Special thanks to the many Jefferson County residents and workers who participated in our community engagement meetings and online survey. Jefferson County Board of Health We thank the Jefferson County Board of Health for their support of this process and for their commitment to improving health across the county. Bonnie McNulty Maureen Sullivan Beverly Dahan (former member) Greg Deranleau Linda Reiner (former member) Lane Drager Jefferson County Public Health Staff We appreciate the support of JCPH’s leadership team throughout this process. Dr. Mark Johnson, Executive Director Jody Erwin, Director of Administrative Services Elise Lubell, Director of Health Promotion and Lifestyle Management Jim Rada, Director of Environmental Health Services Norma Tubman, former Director of Community Health Services Margaret Huffman, Director of Community Health Services Special thanks to Elise Lubell, Jody Erwin, Ana Marin, Erika Jermé, Molly Hanson, Kelly Keenan, Kim Buettner-Garrett, Pamela Gould and Sophie West for your significant contributions to this plan.

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December 29, 2015 Dear Jefferson County Resident, Jefferson County is a special place, with vibrant communities, great schools, a high quality medical system, and a strong economy. Most importantly, Jefferson County is home to over half a million residents, and many more who come to the county to work, study or recreate. In Colorado, public health departments have been identified as the governmental entities responsible for assessing the health of their communities and convening broad-based assemblies of residents, public health professionals, businesses, elected officials, and a range of local agencies and other organizations in an effort to develop community health improvement plans. To accomplish this, Jefferson County Public Health completed both a comprehensive Community Health Assessment and a Public Health System Capacity Assessment in 2013. Using this data, priorities for county-wide action were selected by a process that included the Jefferson County Health Council, community members, partnering organizations, and experts at Jefferson County Public Health. These groups selected healthy eating, active living, and psychosocial well-being as priority areas of focus for improving community health. In addition, low-income families with children 0-18 were selected as a priority population. Jefferson County Public Health released an initial Jefferson County Community Health Improvement Plan (CHIP) in 2014. In 2015, the Jeffco Community Health Improvement Network was established to further the goals outlined in the CHIP and to enhance partnerships among a diverse group of organizations and community members. This document represents an update to the original CHIP and outlines how the Network will work toward making a measurable impact on the health of our community by aligning efforts across the county. Jefferson County Public Health is committed to a collaborative approach to public health. No single organization in Jefferson County can make all the needed improvements alone. However, working together, I believe that we will be able to make Jefferson County a truly healthy place to live, work, learn, and play.

Mark B. Johnson, MD, MPH Executive Director, Jefferson County Public Health Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 4

Executive Summary The purpose of Jefferson County’s Community Health Improvement Plan (CHIP) is to describe how organizations throughout Jefferson County plan to collaboratively and strategically work together to improve the health and well-being of our community. Jefferson County, with a growing population of 558,503 residents, includes urban, suburban, and rural areas. County residents are generally well-educated and have a high median income. However, despite an overall decrease in poverty rates, poverty levels are increasing among households with children. While the county has many assets, a 2013 Jefferson County Community Health Assessment revealed that chronic diseases such as cardiovascular diseases and cancers are the leading causes of death in the county, and that these leading causes of death are linked to five common risk factors: poor diet, physical inactivity, tobacco use and exposure, alcohol use, and chronic psychosocial stress. This document details the community’s plan for addressing chronic disease and improving quality of life for all residents in Jefferson County through county-wide partnerships. The plan includes two broad goals: 1. To increase physical activity, healthy eating, and psychosocial well-being among lowincome families with children ages 0-18; and, 2. To implement a collective impact approach in Jefferson County to increase healthy eating, active living, and psychosocial well-being. Each goal includes strategies, objectives and activities, along with specific outcome measures and completion date targets. The first goal directly addresses improving health outcomes in Jefferson County through a variety of activities that will be undertaken by the Jeffco Community Health Improvement Network. This network is comprised of six coalitions: Active Living, Food Policy, Health in Early Childhood, School Wellness, Healthy Beverage, Preventive Care and Mental Health Resources. Working together, these coalitions will pursue the strategies outlined in this plan. This Network will allow us to collaborate successfully across sectors to have the greatest impact possible. The second goal outlines how Jefferson County Public Health (JCPH) will align efforts with partners through the Jeffco Community Health Improvement Network and by using a collective impact approach. As JCPH continues to work with partners to improve the health of our community, we are committed to updating this document regularly to reflect our progress. By aligning efforts with partners across Jefferson County, our community can take significant steps toward ensuring that Jefferson County’s residents have equitable access to healthy foods, places to engage in physical activity, and the resources they need to achieve and maintain psychosocial well-being.

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Introduction The purpose of Jefferson Countyâ&#x20AC;&#x2122;s Community Health Improvement Plan (CHIP) is to describe how organizations throughout Jefferson County plan to collaboratively and strategically work together to improve the health and well-being of our community. Jefferson County Public Health (JCPH) initiated the development of this plan in response to Senate Bill 08-194, the Public Health Act of 2008, requiring each public health department in the state to develop a CHIP every five years. The goal of this law is to ensure core public health services are available to all Coloradans across the state, and to increase the quality of these services. Developing a health improvement plan provides the opportunity to assess health in our county, identify our strengths and weaknesses as a public health system, work with the community to identify health priorities, and address identified priorities with evidence-based strategies. In the original version of this plan published in 2014, we identified four preliminary goals for using a collective impact approach to increase access to healthy food and physical activity, using psychosocial stress as a lens. Significant progress was made toward these goals, including: securing staffing and funding; creating stronger partnerships throughout the community; and launching the Jeffco Community Health Improvement Network as a systematic approach for enhancing alignment and partnerships among those working on similar goals in our community. Please see the appendix for details about the process used for creating this plan. Because we recognize that improving health in our county will require collective action by many diverse partners, the Jeffco Community Health Improvement Network will provide a forum for aligning efforts, communicating, and sharing data. The mission of the Network is to partner across sectors to enhance and promote health for all in Jefferson County, Jefferson County. Working together within the Network, Colorado rather than as individual organizations operating in silos, will allow us to reduce redundancies and impact health at the population level. To further increase the impact of this initiative, the Network seeks â&#x20AC;&#x153;upstreamâ&#x20AC;? solutions that affect policies, systems, and environments and to make healthy choices accessible for residents across the county. Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 6

This document meets the requirements of Senate Bill 08-194.1 The following sections provide a brief community description, outline how the social determinants of health influence health outcomes in Jefferson County, and, finally, define the actions the Jeffco Community Health Improvement Network intends to take in an effort to address these health concerns. Additionally, the appendix includes letters of support from key community partners, a detailed description of the community health improvement process used in Jefferson County, and a table providing source information for measures and indicators used throughout this document. We see the CHIP as a living document and are committed to updating this plan yearly in collaboration with Jeffco Community Health Improvement Network partners. We hope that this plan will serve as a guide for community partners and residents to engage actively in making Jefferson County a healthier place to live, learn, work, and play.

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Community Description* The Great Plains meet the Rocky Mountains in Jefferson County, Colorado, which is known as the “Gateway to the Rocky Mountains.” Jefferson County is the 4th largest county in Colorado, with a population of 558,503 residents in 2014. The county’s population increased 4.5% between 2010 and 2014 and continues to grow. Once an agricultural and mining area, Jefferson County is now a thriving mix of urban, suburban, and mountain communities on the west side of the Denver metro region covering 764 square miles and including 12 cities and towns. The county is home to a variety of vibrant business, industrial, and residential communities. Jefferson County has many assets that make it a wonderful place to live, learn, work, and play. It boasts more than 53,000 acres of open space with a trail system that spans 230 miles.2 Jeffco Schools educate approximately 7% of Colorado K – 12 students, and these students consistently have higher scores than state averages in all grade levels and content areas on statewide standardized tests.3 However, Jefferson County’s 2013 Community Health Assessment revealed that chronic diseases such as cardiovascular diseases and cancers are the leading causes of death in the county, and that these leading causes of death are linked by five common risk factors: poor diet, physical inactivity, tobacco use and exposure, alcohol use, and chronic psychosocial stress. As will be described in detail throughout this document, far too many Jefferson County residents, including many children, have risk factors that increase their chances of eventually being burdened by chronic disease. Coordinated, strategic actions by leaders, stakeholders and organizations throughout the county can prevent many of these risk factors and ultimately save lives.

See Appendix B for data sources.

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Social Determinants of Health† Exposure to risk factors that lead to chronic disease is not determined solely by individual choices and behaviors. Our social world powerfully influences our exposures to risk factors and, therefore, our health. Social experiences influence the physiological stress response, which, in “Social determinants of health are life-enhancing addition to effecting mental health, has a direct 4 resources, such as food supply, housing, economic influence on the development of disease. and social relationships, transportation, education

These social experiences occur throughout the life and health care, whose distribution across course, from before birth to the end of life, and populations effectively determines length and quality stem from a variety of factors, including: cultural of life.” and social norms, educational and economic opportunities, the physical environment including S. James in Promoting Health Equity: A Resource to housing and infrastructure, and social factors Help Communities Address Social Determinants of including exposure to violence and racism.5 Health, CDC, 2008 Health related daily choices, including dietary selections, exercise, tobacco use, and alcohol consumption, take place within the social context that we live in and are greatly influenced by:  Social influences that either support or discourage behaviors;  The availability and accessibility of various options; and,  How the environment either reduces or produces environmental stressors that, in turn, lead to the need for coping mechanisms. In this way, our social environment greatly influences behaviors, and, therefore, physical and mental health outcomes. If, as a county, we can positively influence the environment in which all citizens live, learn, work, and play, we will be able to have both a healthier and more productive county.

Age Distribution Chronic diseases usually take years to develop and health in childhood is the foundation for future physical and economic health. Thus, community health improvement efforts geared toward prevention of chronic disease must work across the lifespan to provide a healthy place for everyone in our community to live, learn, work, and play. Many efforts that are geared toward specific age groups will have a positive effect across the lifespan. For example, safe street crossings near schools make walking or biking more accessible for children going to school, but are also helpful to older adults and families with young children.

†

See Appendix B for data sources.

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Compared to Colorado as a whole, Jefferson County’s median age of 40.4 years is somewhat older than Colorado’s median age of 36.1 years. Approximately 20% of Jefferson County residents are under the age of 18, and 15% are over age 65. The county’s population distribution makes taking steps to maintain or improve the health of an increasing number of seniors, aged 65 and up, critical. However, our age distribution also highlights the need to invest in the health of Jefferson County’s children and families in order to ensure that our children, and their parents and caregivers are not burdened by preventable chronic diseases. Age Distribution in Jefferson County, 2014 100+ 95 to 99 90 to 94 85 to 89 80 to 84 75 to 79 70 to 74 65 to 69 60 to 64 55 to 59 50 to 54 45 to 49 40 to 44 35 to 39 30 to 34 25 to 29 20 to 24 15 to 19 10 to 14 5 to 9 0 to 4 0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

Racial and Ethnic Distribution The majority (78.8%) of Jefferson County residents identify as white, but not Hispanic or Latino. Hispanics and Latinos make up 15.2% of the population. Asians account for 2.6% of the population, African-Americans for 1.3%, and American Indian/Alaska Natives for 1.2%. Another 2.3% of the population identifies with two or more races.

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There are a number of health concerns that disproportionately affect racial and ethnic minorities.6 For example, Hispanics are almost twice as likely as non-Hispanics to have diabetes.6 Racial and ethnic minorities can be subject to discrimination which can lead to both psychological distress and adverse health behaviors.4 Language barriers can pose a significant challenge to accessing and receiving quality health care and other services.7 In addition, many health concerns affecting ethnic and racial populations are related to a systemic lack of social and economic opportunities which lead to income and educational differences.4

Education Education is closely linked to health outcomes. Studies show that those with higher educational attainment have lower death rates from the most common chronic diseases, independent of basic demographic and employment factors.8 Educational attainment is correlated with lowered levels of obesity, diabetes, and coronary heart disease among adults;8 while childhood health is correlated with parental educational attainment.9 Educational level is also closely correlated with income levels, which also influences health and will be discussed in the next section. Overall, Jefferson County residents are well-educated. As of 2013, 93.7% of residents age 25 or older are high school graduates. However, there are large racial and ethnic disparities in graduation rates. During the 2013-2014 school year graduation rates were highest for Asian (93%) and non-Hispanic white students (85.7%), but much lower for American Indian/Alaska Native (76.2%), Hispanic (74.4%), and Black or African-American (74.3%) students. Educational Attainment in Jefferson County (for ages 25 years and older) Graduate or professional degree 15%

9th grade or less 2%

Bachelor's degree 26%

Completed some high school, but did not graduate 4%

Completed high school (or equivalency) 21%

Some college or an associate's degree 32%

High school graduation, combined with post-secondary educational attainment, is crucial for future employment. According to the Bureau of Labor Statistics, the national jobless rate in 2014 Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 11

for recent high school dropouts was 30.3% and the national jobless rate for recent high school graduates not enrolled in college was 28.8%. By 2020, some level of post-secondary education will be required for 74% of Coloradoâ&#x20AC;&#x2122;s jobs.10 Ensuring that all students complete high school and have access to higher education, regardless of their race or ethnicity, is essential to supporting health and the long-term economic vitality of Jefferson County. Additionally, ensuring that everyone in the county, regardless of educational attainment or employment status, has equal opportunities to live a healthy lifestyle will reduce disparities between those who have had the opportunity to attain higher levels of education and those who have not.11

Income

Percent

Socio-economic inequality leads to health inequity across the life-span.4 Lower income is associated with poorer health and greater risk of premature mortality, stemming from higher levels of chronic conditions, including type 2 diabetes and Percent of Children Under 18 Living in Families high blood pressure.4, 12 with Income Below Poverty Level, Jefferson County, 2006-2013 14 The cost of childcare, 12.2 12.7 12.6 11.4 11.1 housing, food and other basic 12 10.6 9.6 expenses requires an income 8.9 10 of more than three times the 8 federal poverty level for a 6 family to be self-sufficient in 4 Jefferson County (i.e., to meet all basic needs without public 2 or private support).13 In 2013, 0 Jefferson Countyâ&#x20AC;&#x2122;s median 2006 2007 2008 2009 2010 2011 2012 2013 annual household income was $68,984. However, many Jefferson County households have incomes significantly below this median income. In 2013, 36% of Jefferson County households earned less than $50,000 and 15.3% of households earned less than $25,000. Denver Metro Area Counties Median Household Yearly The jobless rate in Jefferson County, as of September 2015, was 3.0%. The jobless rate has been steadily Incomes, 2009-2013. (In 2013 inflation-adjusted dollars) improving since 2010 when rates reached highs of over Denver $50,313 8%. Adams $56,270 In 2013, 12.6% of Jefferson County children under the Arapahoe $60,651 age of 18 lived in families with incomes below the Boulder $67,956 federal poverty line ($23,550 for a family of four in Jefferson $68,984 201314), up from 8.9% in 2006 before the recession. In Broomfield $77,998 contrast, in 2013 8.6% of all residents in Jefferson Douglas $101,591 County were living below the federal poverty line, which Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 12

was a decline from 9.2% in 2012. Thus, while Jefferson County as a whole is experiencing a decrease in poverty rates, the number of children living in poverty is increasing. Moreover, families with incomes above the poverty line but below the self-sufficiency wage may still struggle to meet basic needs for food, housing, transportation, healthcare, and childcare.13 In fact, for every family in Colorado which falls under the official federal poverty line, there are two families who are above it but still cannot pay for their most basic needs.13 In Jefferson County:    

An average of 15.3% of Jefferson County households earned less than $25,000; 33.6% of individuals report paying 30% or more of their household income on housing costs; 10.4% of adults report not seeing a doctor due to cost; and, An adult supporting a preschooler and an infant would need to earn $33.75 an hour, or $71,263 annually.13

Recognizing that increasing numbers of families in our county live in low-income households and that socio-economic status impacts the health of individuals, Jefferson County’s community health improvement efforts must focus on building health equity.

Health Equity Because each member of our community has different challenges, opportunities, exposures, and influences, the burden of chronic diseases are not evenly distributed among Jefferson County residents. One important goal for Jefferson County is to increase health equity among residents in our community. According to the National Partnership for Action to End Health Disparities, health equity can be defined as: “the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.”15 In practice, health equity means that every person has opportunities to achieve optimal health regardless of:  The color of their skin  Level of education  Gender identity  Sexual orientation  The job they have  The neighborhood they live in  Whether or not they have a disability  Income level

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At a Jeffco Community Health Improvement Network meeting in August 2015, which was attended by over 80 community stakeholders, the Network selected the following priorities for health equity:  Involve those who are most affected by the issue (those who may experience the greatest health inequities or burdens) in defining the problem and shaping the solution;  Ensure effective implementation of identified strategies across population groups and communities;  Focus on evidence-based program models; and,  Account for and address unintended consequences of any actions taken, particularly among populations experiencing health inequities.

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Jefferson County Community Health Improvement Plan Goals and Objectives‡ The 2013 Jefferson County Community Health Assessment found that five of the top nine causes of death in Jefferson County are chronic diseases, each of which are strongly correlated with obesity and, more specifically, lifestyle factors that lead to obesity including unhealthy eating, physical inactivity and high stress levels.16 In order to improve the health of Jefferson County residents, the underlying causes of chronic disease and obesity must be addressed. Top 10 Causes of Death in Jefferson County, 2014 Influenza and pneumonia 3% Suicide

Diabetes 3%

Parkinson's disease 2%

3% Alzheimer's disease 6% Heart disease 29%

Cerebrovascular diseases, including stroke 7% Unintentional injuries 9%

Chronic lower respiratory diseases 10%

Cancer 28%

Obesity is caused by multiple factors, including genetics, alcohol consumption, overconsumption of calories, physical inactivity, mental health, and stress.17 Obesity increases an individual’s risk for:17  Heart disease  Type 2 diabetes  High blood pressure  High cholesterol  Stroke  Certain types of cancer ‡

See Appendix B for data sources.

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Jefferson County Residents

Obese

Overweight or Obese

Adults (age 18 years and over) Children (ages 2 – 14 years)

19%

53%

12.1%

21.3%

High School Students

Not measured in Jefferson County; 11.3% for Colorado

Not measured in Jefferson County; 34.2% in Colorado

We tend to think of health as being based solely on individual behaviors, yet health begins in the places where we live, learn, work, and play. In fact, 40% of health is impacted by social and economic factors, including income, education, neighborhood, etc.18, 19 For that reason, this plan focuses on changes that will influence community-wide health. Additionally, social and economic factors, known as the social determinants of health, which lead to health inequities between the “haves” and the “have-nots” in our society,12 will be addressed by utilizing health equity as a core principal within each action step. As described in detail in Appendix C, input from the Jefferson County community led to the selection of healthy eating, physical activity and mitigating psychosocial stress as focus areas for community health improvement efforts in Jefferson County from 2014-2018. Addressing these issues at a policy, systems, and environment level aligns with two of Colorado’s Flagship Priorities from the statewide Colorado Health Improvement Plan: Health Eating, Active Living and Obesity Prevention; and Mental Health and Substance Abuse.17 The following sections detail plans for addressing chronic disease and obesity and improving quality of life in Jefferson County through county-wide partnerships. The plan includes two broad goals: 1. To increase physical activity, healthy eating, and psychosocial well-being among low-income families with children ages 0-18; and, 2. To implement a collective impact approach in Jefferson County to increase healthy eating, active living, and psychosocial well-being. The first goal directly addresses improving health outcomes in Jefferson County through a variety of activities, while the second goal outlines how Jefferson County Public Health will work with partners to accomplish those activities by spearheading the Jeffco Community Health Improvement Network. Physical Activity According to the World Health Organization, physical activity is defined as “any bodily movement produced by skeletal muscles that require energy expenditure,” and includes various forms of exercise as well as movement that takes place in daily life while working, playing, doing chores, traveling, and engaging in recreational pursuits.20

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Physical activity is strongly correlated with maintaining a healthy weight, improving mood/mental health, lowering risks for chronic diseases, improving bone and muscle strength, and increasing the ability to perform daily activities.21 Jefferson County has many assets that allow residents to be active. However, many residents do not get the recommended amounts of physical activity: 

 

Although 84.3% of individuals report that the sidewalks or shoulders on the roads in their neighborhood are sufficient to safely walk, run or bike, only 0.6 % of workers commute to work by biking and 1.6% by walking. Also, 78.0% of Jefferson County’s workforce drives alone to work. While 97.3% of parents feel their child is usually or always safe in their community or neighborhood, only 24.3% of Jefferson County children (aged 1-14 years) bike, walk or skateboard to school at least one day a week. Although 68.0% of Jefferson County residents live within a half mile of a park, Jefferson County has only 1 recreation center per 10,000 people.

In Jefferson County, physical activity rates can be improved by addressing convenience and safety for walking, biking and other forms of active transportation; encouraging children to walk or bike to school; ensuring access to parks and recreation facilities; and incorporating provisions that encourage physical activity into policies and planning documents. Furthermore, time spent engaging in physical activity can be increased when a systematic approach is used to enable families, individuals, employers, educators, care-providers, and decision-makers to support and encourage physical activity where people live, learn, work, and play. To increase physical activity rates in Jefferson County, partners throughout the county plan to identify and reduce barriers to being active and promoting systems that make physical activity an easy, enjoyable, and accessible choice. Measures to be Improved Through Goal 1 Strategies 39.1% of children (aged 5-14 years) were physically active for at least 60 minutes/day for the past 7 days 64.8% of adults get recommended amounts of physical activity each day 24.3% of Jefferson County children (aged 1-14 years) bike, walk or skateboard to school at least one day a week Healthy Eating The USDA Center for Nutrition Policy and Promotion defines a healthy diet as including fruits, vegetables, whole grains, fat-free or low-fat dairy products, and protein foods such as poultry, fish, beans, eggs, nuts and lean meats. They also recommend selecting foods that are low in saturated fats, sodium, and added sugars.22 Diet is one of the major modifiable risk factors for chronic disease.23 Healthy diets have been found to decrease mortality from all causes, as well as chronic conditions such as cardiovascular disease and cancer.24 Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 17

Unfortunately, not all residents of Jefferson County consume an optimal diet:   

In Jefferson County, few people eat the recommended amount of fruits and vegetables per day (see table); Almost 1 in 5 children, ages 2 – 14, drink one or more sugar-sweetened beverages each day; and, Almost 1 in 4 babies are breastfeed for only four weeks or less.

Throughout Colorado, 23% of adolescents report drinking one or more sodas per day. At the same time, a national research study found that 54.5% of children were dehydrated. One important factor in dietary intake is the cost and availability of healthy food options. Food programs can make a healthy diet more affordable and accessible for low-income individuals:    

31.8 % of Jeffco Schools’ students are eligible for free or reduced school lunch; 15.2% of Jefferson County children live in households with Supplementary Security Income (SSI), cash public assistance, or SNAP benefits; 73.1% of Jefferson County residents who qualify receive nutrition education and vouchers for healthy foods through the Special Supplemental Nutrition Program for Woman, Infants & Children (WIC) Program. 4.3% of low-income Jefferson County residents do not live close to a grocery store (less than one mile for urban or ten miles for rural).

Eating healthy food and drinking water or low-fat milk is made easier when there are not barriers to accessing healthy foods and beverages. Healthy foods and beverages are considered accessible when they are affordable, nutritious, easy to get to, and culturally appropriate.25 In Jefferson County, healthy food access can be improved by addressing the availability of healthy foods, the cost of healthy foods, access to healthy foods in schools and childcare settings, and the use of food programs. Healthy beverage consumption is increased when free drinking water is readily available and sugary beverages are not promoted or sold in public venues.26 Furthermore, individuals can be influenced to consume healthy foods and beverages when policies and social norms encourage healthy choices and a systematic approach is used to communicate with families, care providers and decision makers. Jefferson County partners plan to work together to increase the amount of healthy foods and beverages, and decrease the amount of unhealthy foods and beverages, consumed in Jefferson County, with particular focus on low-income families. Additionally, partners plan to increase support for breastfeeding. Measures to be Improved Through Strategies as Outlined Under Goal 1 17.7% of adults consume less than one serving of vegetables per day 35% of adults consume less than one serving of fruit per day 10.2 % of children (ages 2-14) eat fruit 2 or more times per day and vegetables 3 or more times per day 19.1% of children (ages 2-14) consume sugar sweetened beverages 1 or more times per day 19.8% of infants are breastfed for 4 weeks or less Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 18

Psychosocial Well-being Well-being is defined as an individual achieving a balance between challenges faced and the available resource pool for meeting those challenges.27 Psychosocial well-being refers to a state in which thoughts, emotions, and behaviors are balanced by social resources, environmental or system supports, coping mechanisms, and access to needed services.28

Resources

Challenges

Physical

Social

Social WELLBEING

Psychological

Chronic stress can undermine psychosocial well-being and mental health. Chronic stress leads to changes in emotional, physiological, and behavioral responses that can increase the risk of developing a range of diseases including depression, cardiovascular disease, and some cancers.29 Chronic stress also diminishes creativity, memory, and attention, and impairs problem-solving abilities.30 Stress levels can be lowered through physical activity, consuming a healthy diet, and increasing the amount and quality of sleep.31 Children under the age of five are undergoing rapid brain development and are particularly susceptible to the effects of stressful experiences in early childhood, often called toxic stress. A child’s present and future psychosocial well-being is affected by exposure to adverse childhood events (ACE), including verbal, physical or sexual abuse or significant family dysfunction.32 Unfortunately, by the time they reach age five, half of Colorado children have dealt with one or more adverse experiences-- and by the time they reach the age of 18, 33% of Colorado children have experienced physical abuse or significant family dysfunction.32 Sleep is also a key factor in achieving psychosocial well-being and is closely linked with physical health. Specifically, insufficient sleep has been linked to an increased risk for diabetes, hypertension, stroke, coronary heart disease, obesity, and depression33. Increasing sleep among adolescents has been shown to improve mental health, reduce risk behaviors, and improve school performance.34,35 While countywide measures specifically gauging psychosocial well-being are not available, local, state, and national data indicate that this focus is warranted:   

21.3% of parents report behavioral or mental health problems in children aged 1-14 years; Jefferson County adults report an average of 3.5 mentally unhealthy days per month; 24.3% of Colorado adolescents felt so sad or hopeless almost every day for two consecutive weeks during the past 12 months that they stopped doing some usual activities; Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 19

ď&#x201A;ˇ ď&#x201A;ˇ

6.6% of Colorado adolescents attempted suicide one or more times in the past 12 months; and, Nationally, 59% of middle school students and 87% of high school students get less than the recommended amount of sleep.34

In Jefferson County, we can increase psychosocial well-being by creating systems and policies that address social and emotional health, including: connecting community members to mental health and preventive resources, addressing community needs for improved health equity, and addressing policy, systems, and environmental barriers to healthy eating, active living, getting recommended amounts of sleep, and addressing healthy stress-management.

Goal 1: To increase physical activity, healthy eating, and psychosocial well-being among low-income families with children ages 0-18. Systems

Physical activity, healthy eating, and psychosocial well-being are influenced by individual choices. However, those individual choices are mediated by the policies, systems, and environments where individuals live, learn, work, and play. For example, people who live in a neighborhood that has limited access to healthy food, are likely to find that limited availability of healthy food impacts their psychosocial well-being. Likewise, if a person is living in a stressful environment, they are less likely to exercise.

Policies

Environments

Healthy Food

Psychosocial well-being

Physical activity

In order to achieve population-wide, equitable health improvements, organizations throughout Jefferson County must work together to address priority issues by changing policies, improving systems, and enhancing the environments where we live, learn, work, and play. Additionally, to achieve the greatest impact, the social determinants of health must be addressed using evidencebased practices. To encourage strong partnerships and alignment of efforts, this CHIP will be implemented through a network of coalitions that are each part of the Jeffco Community Health Improvement Network. The work of these coalitions is described in the strategies below.

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Goal 1 To increase physical activity, healthy eating, and psychosocial wellbeing among low-income families with children ages 0-18.

Strategy 1: Active Living Policy

Advance a “health in all policies” framework for decision making related to local and county land use, transportation and community development initiatives, and develop strategies to increase access to physical activity.

Strategy 2: Food Access

Promote sustainable, evidencebased policies or programs that increase equitable access to affordable, healthy foods in Jefferson County.

Strategy 3: Healthy Beverage

Create collective, strategic and efficient approaches to increase healthy beverage consumption in Jefferson County.

Strategy 4: Health in Early Childhood

Strategy 5: School Wellness

Strategy 6: Preventive Care & Mental Health Resources

Align efforts across organizations to improve the health and wellbeing of Jefferson County's youngest children, as well as their families and caregivers.

Coordinate efforts across organizations to improve the health and wellbeing of Jefferson County’s K 12 students and staff by supporting school wellness efforts and providing needed health and wellness resources.

Establish methods and measures for the coordination of the provision of preventive care and mental health care.

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 21

Goal 1, Strategy 1: Active Living Policy Goal 1: To increase physical activity, healthy eating, and psychosocial well-being among lowincome families with children ages 0-18. Focus Area: Active Living Policy Strategy 1: Advance a “health in all policies” framework for decision making related to local and county land use, transportation and community development initiatives, and develop strategies to increase access to physical activity.

Background

Active Living Coalition

The rise of obesity and certain chronic disease rates are related to a host of factors, including decreased levels of physical activity.

This strategy is being implemented through the creation of the Active Living Coalition. The Active Living Coalition, formerly called the HEAL Policy Team, is a community coalition that has been meeting since the summer of 2013.

This strategy is focused on creating a Health in all Policies framework aimed at increasing opportunities for Jefferson County residents to integrate active living into their daily lives by increasing access to safe streets, parks and recreational facilities, public transit, and other opportunities for physical activity.

Partners include a wide variety of municipal, county, and state staff and officials; health care systems; land use, transportation, and parks; trails and recreation facilities; advocacy organizations; funders; leaders of nonprofit organizations; and community members.

Alignment with Local, State, and National Priorities:  Colorado’s Winnable Battles/ Healthy Colorado: Shaping a State of Health  Healthy People 2020 Goals  LiveWell HEAL Cities & Towns designations (multiple municipalities)  Municipal planning documents (multiple) Objective 1: Formalize a multi-sector Active Living Coalition that represents a diverse group of stakeholders. Activity Timeline Performance Indicator 1. Develop a steering August 2016 Documents completed and disseminated committee that will serve as leadership for this coalition, and will develop a variety of organizing documents, e.g., mission, vision, charter, Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 22

partnership agreements, etc. 2. Administer a baseline August 2016 Assessment administered and results capacity assessment for the disseminated coalition 3. Identify and fund one local August 2016 Coalition or project identified and active living coalition and/or funded demonstration project Objective 2: Develop a regional active living policy framework that leads to enhanced access to walking, biking, and other physical activity. Activity Timeline Performance Indicator 1. Assess current local barriers August 2016 Multiple local assessments completed to active living in a and disseminated electronically to designated region of relevant agencies and partners Jefferson County using a variety of environmental and policy assessments 2. Provide capacity building, August 2016 Information shared with 30 partners in technical assistance and a two or more formats forum to share updates, best practices and lessons learned across partners on a variety of land use, transportation and programmatic issues to foster healthy and active places where people live, learn, work, and play 3. Provide technical assistance August 2016 Provide technical assistance two or more to local and regional times governments on policy and metric selection in a variety of planning, land use regulation, and fiscal prioritization related to active living 4. Conduct an evidence-based August 2016 Review conducted and disseminated practice review

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Goal 1, Strategy 2: Food Access Goal 1: To increase physical activity, healthy eating, and psychosocial well-being among lowincome families with children ages 0-18. Focus Area: Healthy Food Access Strategy 2: Promote sustainable, evidence-based policies or programs that increase equitable access to affordable, healthy foods in Jefferson County.

Background

Food Policy Council

This strategy addresses the need to increase food access, food security, and local food systems throughout Jefferson County, specifically focusing on decreasing barriers to nutritious food in lowincome populations.

This strategy is being implemented through the creation of a Food Policy Council. Partners in implementation include:  Colorado State University Extension  Jefferson County Public Health  County and municipal elected officials and staff members  Non-profit organizations  Food producers and markets  Members of faith-based communities  Anti-hunger advocates

The rise in obesity and certain chronic disease rates are related to a host of factors including diet, nutrition, and food access. Community partners are working together to increase access to healthy foods and decrease access to unhealthy foods.

Alignment with Local, State, and National Priorities:  Colorado’s Winnable Battles/ Healthy Colorado: Shaping a State of Health  Healthy People 2020 Goals  National Prevention Strategy  LiveWell HEAL Cities & Towns designations (multiple municipalities) Objective 1: Create an action-oriented council with representation from local governments, organizations, agencies, non-profits, health care providers, schools, faith-based organizations, and producers and distributers across the food system. Activity Timeline Performance Indicator 1. The council will develop a August 2016 Documents completed and disseminated variety of organizing on website documents, e.g., mission, vision, charter, partnership agreements 2. Develop a multi-year August 2016 Evaluation plan submitted evaluation plan to measure Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 24

the impact of the council Objective 2: Develop sustainable, evidence-based policies or programs that increase equitable access to affordable, healthy foods in Jefferson County. Activity Timeline Performance Indicator 1. Support local partners to August 2016 One assessment completed and assess food systems, policies, disseminated electronically to relevant programs and networks using agencies and partners a variety of processes and methodologies to identify gaps and areas for potential change 2. Develop a multi-year plan to August 2016 Creation of plan address policies and programs to increase access to nutritious food, which could address a myriad of policy or program interventions 3. Compile and review reports August 2016 Two or more action steps identified and assessments completed in the past two years on SNAP and WIC enrollment action steps 4. Increase the number of August 2016 One or more farmer’s market that farmer’s markets accepting previously did not have capability offers SNAP benefits; encourage the SNAP redemption; rates of SNAP use of SNAP benefits at redemption average $150 per day at markets that accept SNAP farmer’s markets offering SNAP benefits redemption 5. Provide capacity building, August 2016 Convene up to eight Food Policy Council technical assistance and a meetings, events and/or training professional forum to share sessions updates, best practices and lessons learned

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Goal 1, Strategy 3: Healthy Beverage Goal 1: To increase physical activity, healthy eating, and psychosocial well-being among lowincome families with children ages 0-18. Focus Area: Healthy Beverage Strategy 3: Create collective, strategic and efficient approaches to increase healthy beverage consumption in Jefferson County.

Background

Healthy Beverage Coalition

Sugar-sweetened beverages, including soda, sports drinks, sweetened waters and teas, energy drinks and fruit drinks, have been identified as the primary source of added sugars in Americans’ diets.§ Increased consumption of sugar, especially in the form of sugar-sweetened beverages, is connected to variety of health concerns including weight gain and metabolic disorders.

A local coalition is being formed in Jefferson County to support strategies encouraging healthy beverage choices and healthy beverage availability. The local coalition will work in partnership with the Metro Healthy Beverage Partnership, Delta Dental, the HEAL Cities and Towns Campaign, and the Colorado Healthy Hospital Compact.

Health care, local governments, schools, public health, youth-serving organizations, parks and recreation facilities, and other organizations play a vital role in shaping beverage environments and options for children and adults. By systematically limiting sugar-sweetened beverage availability, and increasing healthy beverage, e.g., water, availability, communities can foster healthier options and environments for all ages, demographics and incomes. Alignment with Local, State, and National Priorities:  Colorado’s Winnable Battles/ Healthy Colorado: Shaping a State of Health  Healthy People 2020 Goals  National Prevention Strategy  Guide to Community Preventive Services  Metro Healthy Beverage Partnership §

http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_462755.pdf)

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Objective 1: Formalize an action-oriented coalition with representation from a broad range of stakeholders. Activity Timeline Performance Indicator 1. Formalize an action-oriented, county-wide August 2016 List of members, including coalition with representation from a documentation of inclusion variety of agencies, organizations, sectors of specified groups and segments of our community. The coalition will collaborate their efforts with the Colorado Healthy Hospital Compact, as well as the Metro Healthy Beverage Partnership 2. The group will develop an operating August 2016 Documents completed and agreement to include leadership structure, disseminated criteria for participation, timeline, mission, vision, and goals 3. Develop a multi-year evaluation plan to August 2016 Plan created measure the impact of the coalition, including an effectiveness survey Objective 2: In partnership with the Metro Healthy Beverage Partnership, promote healthy beverage options (including water) for children and adults. Activity Timeline Performance Indicator 1. In partnership with other organizations, August 2016 Six assessments completed; the coalition will assess a variety of public identify two settings to environments to determine beverage adopt healthy beverage environments experienced by children and organizational policies adults in Jefferson County 2. Support development of communications, August 2016 Communication plan education, and engagement strategies completed 3. Disseminate information to a variety of August 2016 Twenty or more stakeholders, elected officials, business stakeholders, elected leaders, youth-serving organizations and officials, business leaders, agency partners on the link between youth-serving organizations unhealthy beverage consumption and poor or agency partners are health supplied information 4. Assist with developing a regional August 2016 One or more messages educational messaging campaign on the developed; educational benefits of healthy beverages messages delivered to target populations

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Goal 1, Strategy 4: Health in Early Childhood Goal 1: To increase physical activity, healthy eating, and psychosocial well-being among lowincome families with children ages 0-18. Focus Area: Health in Early Childhood Strategy 4: Align efforts across organizations to improve the health and wellbeing of Jefferson County's youngest children, as well as their families and caregivers.

Background

Health in Early Childhood Collaborative

The World Health Organization identifies early childhood as the “most important phase in life which determines the quality of health, well-being, learning, and behavior across the life span.”

Many organizations in Jefferson County are heavily invested in the health and well-being of young children. Some of the partners already working together include: • Triad Early Childhood Council • Culture of Wellness in Preschools • The Special Supplemental Nutrition Education Program for Woman, Infants, Children (WIC) • Jefferson County Public Health • GoFarm to Families Program • Metro Early Childhood Partnership • Jefferson Center for Mental Health • Lutheran Medical Center

Investment in improvements in healthy eating, active living, and psycho-social stress in early childhood health lays the foundation for lifelong wellness. There are approximately 29,200 children under the age of five living in Jefferson County.

Alignment with Local, State, and National Priorities:  Colorado’s Winnable Battles/ Healthy Colorado: Shaping a State of Health  Colorado Early Childhood Obesity Prevention  Healthy People 2020 Goals  National Prevention Strategy  World Health Organization  Colorado Early Childhood Framework Objective 1: Collaborate with early childhood education centers and programs serving young children to increase healthy eating and active living. Activity Timeline Measure 1. Partners work October 2016 One or more staff members of 5-10 child collaboratively with Early care programs in low-income areas Childhood Education receive coaching regarding these topic Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 28

centers to promote physical activity, healthy eating, responsive feeding, sleep, and reduced screen time

areas and demonstrate improved knowledge, skills and practices as evidenced by pre- and postassessments; 3-5 child care centers make and implement policy changes in one or more topic areas as evidenced by policy implementation assessments after one, six, and 12 months Fifty families provided low-cost vegetables one or more times

2. In collaboration with other August 2017 partners, the GoFarm to Families program will provide low-cost vegetables to childcare centers and families Objective 2: Work with partners to coordinate HEAL and toxic stress messaging to parents, guardians, care-providers, and medical providers. Activity Timeline Performance Indicator 1. Create a campaign August 2016 Create one webpage; Disseminate to 100 informing parents and careor more caretakers and parents takers about the importance of feeding young children fruits and vegetables, encouraging physical activity, limiting television, and avoiding sugar-sweetened beverages 2. In collaboration with a August 2016 Presentation at Network meeting and/or metro-wide network of information in Network email update partners, disseminate coordinated messaging to the Jeffco Community Health Improvement Network about the effects of toxic stress on the development of young children Objective 3: Increase breastfeeding rates and duration. Activity Timeline Performance Indicator 1. With partners, create a August 2017 Create campaign plan community-wide breastfeeding promotion campaign focused on increasing awareness of Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 29

breastfeeding policies, and promoting breastfeeding initiation 2. Develop and disseminate August 2017 model policies and programs that protect, promote and support breast-feeding friendly environments 3. With partners, coordinate August 2017 increased access to breastfeeding support for new parents in a group setting 4. Support Lutheran Medical August 2018 Centerâ&#x20AC;&#x2122;s commitment to promoting breastfeeding for new mothers, including offering lactation services during and after hospitalization, to increase breastfeeding success rates

Dissemination of model policy to 10 or more stakeholder organizations

Creation of at least one additional breastfeeding support group for parents

Participation in campaign (see activity 1) and increasing access to breastfeeding support (see activity 3)

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Goal 1, Strategy 5: School Wellness Goal 1: To increase physical activity, healthy eating, and psychosocial well-being among lowincome families with children ages 0-18. Focus Area: School Wellness Strategy 5: Coordinate efforts across organizations to improve the health and well-being of Jefferson County’s K - 12 students and staff by supporting school wellness efforts and providing needed health and wellness resources.

Background

Jeffco School Wellness Coalition

Schools play a vital role in supporting the lifelong wellness of children by encouraging students to practice healthy behaviors. Eating healthy food, drinking healthy beverages, getting enough physical activity and preventing or managing stress are all essential elements that support well-being and learning.

This strategy is being implemented through the Jeffco School Wellness Coalition. Members include:

This coalition will support Jeffco Schools’ efforts to create the healthiest possible school environment, to ensure that students can achieve academic success and grow up with healthy habits. Healthier students are better equipped to achieve academically, have good attendance rates, and be good citizens. Changing the school environment may also positively influence family and community health-related behaviors.

        

Jeffco PTA Centura Health/St. Anthony Hospital Jefferson County Public Health CDOT-- Safe Routes to School Program Denver Area Council, Boy Scouts of America InvolvedDad MCPN Jefferson County Girl Scouts Jeffco Schools District Health Advisory Council (DHAC)

There were 86,571 students enrolled in 154 Jeffco Public Schools for the 2014-2015 school year.** Alignment with Local, State, and National Priorities:  Jeffco Schools 2020 Vision  Centura/St. Anthony Hospital CHNA  Jeffco PTA Health and Wellness Priorities  Jeffco Schools District Wellness Policy  Colorado’s Winnable Battles/ Healthy Colorado: Shaping a State of Health  Colorado Healthy Schools Collective Impact **

<http://www.jeffcopublicschools.org/schools/profiles/district_profile.html>

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ď&#x201A;ˇ Healthy People 2020 Goals ď&#x201A;ˇ National Prevention Strategy Objective 1: Work with partnering organizations to support efforts to improve school wellness. Activity Timeline Performance Indicator 1. Continue monthly meetings August 2016 Monthly meetings notes and agendas of a multi-sector coalition made up of organizations that support school wellness 2. Establish a systematized August 2016 Tool created; Monitor success by network tool to enhance recording reported collaborations partnerships between partners Objective 2: Support school system efforts to increase healthy eating and physical activity in public schools among students and staff members. Activity Timeline Performance Indicator 1. Complete environmental May 2016 Assessments completed at 12 schools; assessments of free water create plan for addressing needs found access in schools; plan in assessments; apply for funding to interventions to encourage supply resources identified as prioritized water access needs 2. Prioritize potential coalition August 2016 Develop a list of potential strategies and strategies and activities for activities from among best-practices that partnering with schools to focus on policy, systems and increase student and staff environments; prioritize strategies and time spent engaging in activities physical activity, including encouraging and enabling students and staff to walk and bike to and from school 3. Prioritize potential coalition August 2016 Develop a list of potential strategies and strategies and activities for activities from among best-practices that partnering with schools to focus on policy, systems and support consumption of environments; prioritize strategies and healthy foods and activities beverages Objective 3: Support school system efforts to address social-emotional health and personal safety issues among adolescents in public schools. Activity Timeline Performance Indicator 1. Explore opportunities for, August 2017 Create a report including: list of school and barriers to, addressing start times, research-based strategies for sleep issues among increasing adolescent sleep, advantages adolescents in Jefferson of increasing sleep time, and barriers to Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 32

County

2. Prioritize potential coalition strategies and activities for partnering with schools on strengths-based youth development programs to address social-emotional health and personal safety

August 2018

increasing average sleep time; disseminate findings; advocate for one or more policy change(s) Develop a list of potential strategies and activities from among best-practices that focus on policy, systems and environments; prioritize strategies; one or more opportunities identified for partnership

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Goal 1, Strategy 6: Preventive Care and Mental Health Resources Goal 1: To increase physical activity, healthy eating, and psychosocial well-being among lowincome families with children ages 0-18. Focus Area: Preventive Care and Mental Health Resources Strategy 6: Establish methods and measures for the coordination of the provision of preventive care and mental health care.

Background

Preventive Care Working Group

Over 87% of Jefferson County residents have insurance coverage; however, levels of obesity, chronic disease, depression and suicide incidence indicate that many residents are not getting all the care they need to prevent health problems or the resources they need to address health problems at early stages.

This strategy will be implemented through the creation of a working group consisting of representatives from public health, hospitals, primary care providers, oral health care providers, and mental health care providers.

By integrating and networking services, primary care providers will be able to better direct their patients to preventive care, resources, and services. This group will build on work already taking place throughout the county, including: multiple Jefferson County Human Services programs and initiatives, the Jefferson County Hot Spotting Alliance, Jefferson Center for Mental Health’s Project LAUNCH and SIM work, the Child and Youth Leadership Commission (CYLC) Health Subcommittee and Prevention Subcommittee. Alignment with Local, State, and National Priorities:  Colorado’s Winnable Battles/ Healthy Colorado: Shaping a State of Health  Healthy People 2020 Goals Objective 1: Formalize an action-oriented coalition or network with representation from local health care providers and programs. Activity Timeline Performance Indicator 1. The coalition will meet two August 2016 Meeting minutes and sign in lists times with at least six partners at each meeting 2. The coalition group will August 2016 Documents completed and disseminated Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 34

develop a partnership among partners agreement and set of goals. 3. Develop a data base of August 2017 Data base including 10 or more primary and preventive care preventive care providers resources Objective 2: Create a comprehensive, county-wide plan to connect patients to comprehensive and cohesive preventive care, including mental health. Activity Timeline Performance Indicator 1. Assess community August 2018 Assessment created resources and needs for information connecting preventive care to available services and identify barriers to accessing preventive care 2. Create a system for August 2018 Electronic and print tool created connecting preventive care to available services that might include use of health information technology 3. Develop a multi-year August 2017 Evaluation plan completed evaluation plan to measure key indicators for connected care, as established by the coalition

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Goal 2: To implement a collective impact approach in Jefferson County to increase healthy eating, active living, and psychosocial well-being. In order to make an impactful and measureable difference in the health outcomes of low-income families in Jefferson County, significant improvements will be needed across multiple sectors including a wide range of changes in policies, systems, and environments. No single agency will be able to accomplish these changes independently; however, we can impact the future of Jefferson County by aligning efforts in a systematic way.

â&#x20AC;&#x153;The purpose of the

community health improvement plan is to describe how the health department and the community it serves will work

Collective impact is a widely-recognized framework for using a together to improve the collaborative approach to solve complex problems by engaging health of the population.â&#x20AC;? partners from multiple sectors who have agreed to work together to define the problem, set an agenda, align communication efforts, and share data.36 Because partnership and alignment of Public Health Accreditation Board efforts are vital to successfully improving the health of Standards and Measures Version 1.5 residents,37 collective impact will be used as a framework for implementation of Goal 1. Jefferson County Public Health is committed to providing backbone support and leadership for a county-wide collective impact effort. The Jeffco Community Health Improvement Network was formed in August 2015 to use a collective impact approach to increase healthy eating, active living, and psychosocial well-being in Jefferson County using health equity as a lens. The Network aims to create system-level and policy-level changes that make healthy choices easier for Jefferson County children and families. It is made up of six coalitions, called Coalitions Integrated into the Network, or CoINs, including a CoIN focused on each of the strategies described in Goal 1: Active Living, Food Policy, Healthy Beverage, Health in Early Childhood, School Wellness, and Preventive Care and Mental Health Reourcs. More information on the Network is available at www.healthypeoplehealthyplacesjeffco.com.

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living, and psychosocial well-

Goal 2 Implement the collective impact approach in Jefferson County to increase healthy eating, active living, and psychosocial well-being.

Strategy 1: Common Goals

Jeffco Community Health Improvement Network partners share common goals to increase healthy eating, active living, and psychosocial well-being.

Strategy 2: Mutually Reinforcing Activities

Jeffco Community Health Improvement Network partners each contribute to mutually reinforcing activities based on their resources, area of influence, and expertise.

Strategy 3: Shared Measures

Strategy 4: Shared Communication

Strategy 5: Backbone and Structural Support

Jeffco Community Health Improvement Network partners create shared measures and use a coordinated system to track output and outcome measures.

Jeffco Community Health Improvement Network partners communicate with each other using network tools to report successes, share ideas, and address and support each otherâ&#x20AC;&#x2122;s advocacy efforts.

JCPH commits to coordinate the Jeffco Community Health Improvement Network via facilitation, assisting with Network communicatio n needs, supporting partnerships, and leveraging funding.

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Goal 2, Strategy 1: Common Goals GOAL 2: Implement a collective impact approach in Jefferson County to increase healthy eating, active living, and psychosocial well-being. Focus Area: Common Goals Strategy 1: Jeffco Community Health Improvement Network partners share common goals to increase healthy eating, active living, and psychosocial well-being. Objective 1: Organizations throughout Jefferson County coordinate planning efforts when creating goals. Activity Timeline Performance Indicator 1. Strategic priorities are August 2018 Priorities aligned among Jefferson aligned across community County CHNAs and CHIPS health needs assessments (CHNAs) and future Jefferson County community health improvement plans (CHIPs) 2. Network organizations have August 2017 Six or more goals are aligned among one or more organizational community partners participating in one goals, objectives or or more CoINs strategies that align with one or more Network CoIN priorities 3. A steering committee is August 2016 Steering committee established; steering established to create committee meets three times Network-wide strategies and objectives for 2017

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Goal 2, Strategy 2: Mutually Reinforcing Activities GOAL 2: Implement a collective impact approach in Jefferson County to increase healthy eating and active living, while decreasing the impacts of psycho-social stress. Focus Area: Mutually Reinforcing Activities Strategy 2: Jeffco Community Health Improvement Network CoIN members each contribute to mutually reinforcing activities based on their resources, area of influence, and expertise. Objective 1: Network CoINs create and implement plans that draw on the health equity and use evidence-based strategies to change policies, environments, and systems. Partners work together to implement the plans. Activity Timeline Performance Indicator 1. CoINs have diverse August 2016 Five or more CoIN partnership lists partnerships with a variety of organizations and stakeholders that are working on policies, environments and systems together 2. CoIN members use a health August 2016 A tool is created and adopted by two or equity framework to more Network CoINs and is shared with analyze potential activities, five or more community partners programs or initiatives to assess impacts on disparately effected populations 3. CoIN members update CHIP August 2016 Updated CHIP objectives and measures objectives and activities yearly, including plans to change policies, environments, and systems 4. Each CoIN coordinates with August 2016 Two areas of alignment are identified for other CoINs to identify cross-CoIN collaboration areas of alignment, mutual projects, and/or share information

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Goal 2, Strategy 3: Shared Measures GOAL 2: Implement a collective impact approach in Jefferson County to increase healthy eating, active living, psychosocial well-being. Focus Area: Shared Measures Strategy 3: Jeffco Community Health Improvement Network partners create shared measures and use a coordinated system to track output and outcome measures related to CHIP activities. Objective 1: Identify common data measures to monitor progress towards improving health outcomes and to address data gaps. Activity Timeline Performance Indicator 1. Jeffco Community Health August 2016 Data tracking system established; data Improvement Network tracking system is updated quarterly CoINs collect and record output and outcome measures 2. CoINs utilize a shared August 2016 Three or more CoINs utilize measures measures tracking system tracking system Objective 2: Inventory health-related measures or data available in the county and facilitate measure sharing across partners. Activity Timeline Performance Indicator 1. Establish a multi-sector February 2016 Group meets four times work group to identify data needs for tracking health outcomes 2. Provide at least one training August 2016 Training or technical assistance provided or technical assistance four or more times opportunity to each CoIN 3. Identify gaps in available August 2016 Report of data gaps disseminated among data, including youth health Network partners and equity data, and develop a report to share with partners 4. Assess the feasibility of August 2017 Assessment completed Jefferson County's municipalities and unincorporated areas obtaining detailed health outcome data within their municipal boundaries 5. The work group will review August 2017 Report will be included in data gaps county results from the report (above) Healthy Kids Colorado Survey (HKCS) Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 40

Goal 2, Strategy 4: Shared Communication GOAL 2: Implement a collective impact approach in Jefferson County to increase healthy eating, active living, psychosocial well-being. Focus Area: Shared Communication Strategy 4: Jeffco Community Health Improvement Network CoINs communicate with each other using network tools to report successes, share ideas, and support each otherâ&#x20AC;&#x2122;s advocacy efforts. Objective 1: Network CoINs report to the Network about plans that draw on health equity and use evidence-based strategies to change policies, environments, and systems (PES). Activity Timeline Performance Indicator 1. Each CoIN shares August 2016 Three reports are disseminated to information about activities Network members, each containing a list and progress with the of activities from each CoIN; Network and in one or Presentation by each CoIN annually more presentations at Network meetings 2. CoINs provide input for August 2016 yearly Network report 3. CoINs request action steps August 2016 that can be taken by Network partners, including advocating for policy, systems, and environmental change

Yearly Network report prepared and disseminated Three action steps requested, through Network communications, by one or more CoIN(s)

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 41

Goal 2, Strategy 5: Backbone and Structural Support from JCPH GOAL 2: Implement a collective impact approach in Jefferson County to increase healthy eating, active living, and psychosocial well-being. Focus Area: Backbone and Structural Support Strategy 5: JCPH commits to coordinating the Jeffco Community Health Improvement via facilitation, assisting with Network communication needs, supporting partnerships, and leveraging funding. Objective 1: JCPH aligns internal resources, functions, and organizational priorities to serve as the backbone organization. Activity Timeline Performance Indicator 1. Creates a plan to support January 2016 Plan created coordinated communication efforts of the Network and CoINs when communicating with the public, stakeholders and partners 2. Creates a plan to support March 2016 Plan created coordinated partnership efforts of the Network and CoINs 3. Creates a plan to support May 2016 Plan created progress and output evaluations of CoINs and Network goals, including performance management goals 4. Plan implementation August 2016 Initial implementation completed Objective 2: JCPH supports the administration and coordination of the Jeffco Community Health Improvement Network. Activity Timeline Performance Indicator 1. JCPH hosts three Network August 2016 Three Network meetings meetings 2. JCPH maintains a database August 2016 Network membership grows to 100 of community partners and individuals; each network meeting is encourages participation by attended by 30 or more participants a variety of stakeholders in accomplishing CHIP/Network goals 3. JCPH planner or designee August 2016 Planner attends 75% CoIN meetings attends CoINs meeting to facilitate alignment and coordination Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 42

Next Steps Resources to Continuously Develop and Implement the CHIP and Support Core Public Health Services The capacity assessment completed in 2013 demonstrated that Jefferson County has multiple resources for improving the health of the community, with particular strength in diagnosing and investigating health problems and health hazards in the community; informing, educating, and empowering people about health issues; and linking people to needed personal health services. Core public health services are funded, in large part, through Jefferson County funds. At the time of the capacity assessment in 2013, partnerships between key organizations working on public issues was found to be a weakness. Resources for implementation of the plan were also lacking. As a result, several important steps were taken between 2014 and this update to secure resources needed to implement the goals, strategies, objectives and activities outlined in the plan. Specifically, new and ongoing resources for implementing the CHIP include:  Jefferson County Public Health, in cooperation with the HEAL Policy Team made up of a broad cross-section of partners, applied for and received grant funding from the Cancer, Cardiovascular and Chronic Pulmonary Disease Grants Program (through Amendment 35 Tobacco Taxes) to support Health in All Policies work related to healthy eating, healthy beverage, and active living  Jefferson County Public Health is the recipient of ongoing Maternal and Child Health Block Grant Funding to support health in early childhood  Jefferson County Public Health is a member of the Metro Healthy Beverage Partnership (MHBP), a regional effort to reduce obesity and chronic diseases in seven counties in the Denver metropolitan area.  Increasingly strong partnerships throughout the community  Continuously growing membership in the Jeffco Community Health Improvement Network, as well as increasingly action-oriented partnerships within Network CoINs  A county-funded, full-time Health Planner at Jefferson County Public Health Additionally, formal commitments of support have been received from the following partners (see Appendix C):  Lutheran Medical Center  Centura/St. Anthony Hospital

Continuous Evaluation, Updating and Planning Processes The Jeffco Community Health Improvement Network, with backbone support from JCPH, will continue to measure the health status of our community by conducting a community health assessment every three to five years and continuously monitoring the implementation of the CHIP. Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 43

2014 2015 2016 2017 2018 2019 2014-2018 CHIP released

Implementation, including establishing Jeffco Community Health Improvement Network

Implementation Implementation

2019 -2023 CHA/CHIP released

Implementation

CHIP Update

Community Health Assessment data and input compiled Implementation begins

CHIP update

Implementation begins

CHIP update Prioritization process for goals for next CHIP

The CHIP is a living document that will be revised yearly, with input from each Network CoIN, to include new partners, strategies, and activities, as well as new data. We will generate an annual report for the community and partners to share our progress. This report will be disseminated through the Jeffco Community Health Improvement Network. By evaluating health in our county regularly, monitoring our progress toward reaching our goals, and incorporating lessons learned, we will build continuous quality improvement into our CHIP process. In addition, we plan to conduct a community input process and release a new Community Health Assessment and CHIP every three to five years. The time line above represents a timeframe that complies with state regulations1 and Public Health Accreditation Board Standards.37 However, Jefferson Countyâ&#x20AC;&#x2122;s next CHIP may be created sooner, in cooperation with community partners and with community input on priorities. Implementation of the 2014-2018 CHIP will continue until the next CHIP is released.

Conclusion In summary, some troubling trends have emerged in Jefferson County with the potential to significantly impact health in our county and decrease our quality of life. Over the past several Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 44

years, we have worked with partners to assess the health of residents, identify health priorities, and work in partnership to create strategies to address priorities. The increasingly strong partnerships being formed through the Jeffco Community Health Improvement Network, and the six coalitions that form the Network, offer a promising opportunity to improve the health of our community. By aligning efforts with partners across Jefferson County, we can take significant steps toward ensuring that Jefferson Countyâ&#x20AC;&#x2122;s residents have equitable access to healthy foods, places to engage in physical activity, and the resources needed to achieve and maintain psychosocial well-being.

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 45

Appendix A: Community Partnerships

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 46

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 47

Appendix B: Data Sources INDICATOR

PERCENT / NUMBER

POPULATION

DATA SOURCE

DATE

Community Description

558,503 People

Jefferson County, Colorado

U.S. Census Bureau: State and County QuickFacts.

2014

Community Description

4.5% Increase in population

Jefferson County, Colorado

U.S. Census Bureau: State and County QuickFacts.

20102014

LINK

Community Description

764.21 Square miles

Jefferson County, Colorado

U.S. Census Bureau: State and County QuickFacts.

2010

LINK

Community Description

53,000 Acres of open space

Jefferson County, Colorado

Open Space Fact Sheet.

2014

LINK

Community Description

230 Miles of trail systems

Jefferson County, Colorado

Open Space Fact Sheet.

2014

LINK

Age Distribution

20.9% or 116,727 (calculated) Persons under 18 years of age 14.7% or 82,100 (calculated) Persons 65 years and over

Jefferson County, Colorado

U.S. Census Bureau: State and County QuickFacts.

2014

LINK

Jefferson County, Colorado

U.S. Census Bureau: State and County QuickFacts.

2014

LINK

US Census Bureau Website; Jefferson County, Colorado Quick Facts

93.7% High school graduate or higher (percent of persons age 25 plus) High School Graduation Rate Ethnicity: 93% Asian Students

Jeffco Public Schools

U.S. Census Bureau: State and County QuickFacts.

20092013

LINK

US Census Bureau Website; Jefferson County, Colorado Quick Facts

Jeffco Public Schools

Colorado Department of Education Graduation Statistics.

20132014

LINK

Colorado Department of Education Website; Graduation Statistics; Graduation and Completion data; District Level Data; Graduates and Completers by District, Gender and

Age Distribution Educational Attainment

Educational Attainment

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 48

LINK

ACCESSED THROUGH US Census Bureau Website; Jefferson County, Colorado Quick Facts US Census Bureau Website; Jefferson County, Colorado Quick Facts US Census Bureau Website; Jefferson County, Colorado Quick Facts Jefferson County Website; Open Space; About Us: Open Space Fact Sheet Jefferson County Website; Open Space; About Us: Open Space Fact Sheet US Census Bureau Website; Jefferson County, Colorado Quick Facts

Race/Ethnicity (excel sheet)

Educational Attainment

High School Graduation Rate Ethnicity: 85.7% Non-Hispanic White Students

Jeffco Public Schools

Colorado Department of Education Graduation Statistics.

20132014

LINK

Educational Attainment

High School Graduation Rate Ethnicity: 74.3% African American Students

Jeffco Public Schools

Colorado Department of Education Graduation Statistics.

20132014

LINK

Educational Attainment

High School Graduation Rate Ethnicity: 76.2% American Indian/Alaska Native Students

Jeffco Public Schools

Colorado Department of Education Graduation Statistics.

20132014

LINK

Employment

30.3% Jobless rate for high school drop outs 28.8% Jobless rate for recent high school graduates 78.8% White alone, not Hispanic or Latino

National

Bureau of Labor Statistics

2014

LINK

Colorado Department of Education Website; Graduation Statistics; Graduation and Completion data; District Level Data; Graduates and Completers by District, Gender and Race/Ethnicity (excel sheet) Colorado Department of Education Website; Graduation Statistics; Graduation and Completion data; District Level Data; Graduates and Completers by District, Gender and Race/Ethnicity (excel sheet) Colorado Department of Education Website; Graduation Statistics; Graduation and Completion data; District Level Data; Graduates and Completers by District, Gender and Race/Ethnicity (excel sheet) BLS.Gov

National

Bureau of Labor Statistics

2014

LINK

BLS.Gov

Jefferson County, Colorado

U.S. Census Bureau: State and County QuickFacts.

2014

LINK

US Census Bureau Website; Jefferson County, Colorado Quick Facts

2.8% Asian alone

Jefferson County, Colorado

U.S. Census Bureau: State and County QuickFacts.

2014

LINK

US Census Bureau Website; Jefferson County, Colorado Quick Facts

Employment

Racial & Ethnic Distribution Racial & Ethnic Distribution

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 49

Racial & Ethnic Distribution

1.3% African-American alone

Jefferson County, Colorado

U.S. Census Bureau: State and County QuickFacts.

2014

LINK

US Census Bureau Website; Jefferson County, Colorado Quick Facts

Racial & Ethnic Distribution

1.2% Indian/Alaska Natives alone

Jefferson County, Colorado

U.S. Census Bureau: State and County QuickFacts.

2014

LINK

US Census Bureau Website; Jefferson County, Colorado Quick Facts

Racial & Ethnic Distribution

15.2% Hispanic or Latino of any race

Jefferson County, Colorado

U.S. Census Bureau: State and County QuickFacts.

2014

LINK

US Census Bureau Website; Jefferson County, Colorado Quick Facts

Racial & Ethnic Distribution

2.3% Two or More Races

Jefferson County, Colorado

U.S. Census Bureau: State and County QuickFacts.

2014

LINK

Income

$68,984 Median Household income

Jefferson County, Colorado

U.S. Census Bureau: State and County QuickFacts.

20092013

LINK

US Census Bureau Website; Jefferson County, Colorado Quick Facts

Income

$36,087 Per capita income in past 12 months (2013 dollars) 36% of households earned less than $50,000

Jefferson County, Colorado

U.S. Census Bureau: State and County QuickFacts.

20092013

LINK

Jefferson County, Colorado

U.S. Census Bureau, 20092013 5-Year American Community Survey.

20092013

LINK

Income

15.3% of households earned less than $25,000

Jefferson County, Colorado

U.S. Census Bureau, 20092013 5-Year American Community Survey.

20092013

LINK

Income

12.6% of children under 18 lived in families with incomes below the federal poverty line ($23,550 for a family of 4)

Jefferson County, Colorado

US Census Bureau Small Area Income & Poverty Estimates (SAIPE).

2013

LINK

US Census Bureau Website; Jefferson County, Colorado Quick Facts US Census Bureau Website; State and County QuickFacts; Jefferson County, Colorado QuickLinks; American Community Survey: Economic Characteristics US Census Bureau Website; State and County QuickFacts; Jefferson County, Colorado QuickLinks; American Community Survey: Economic Characteristics Census.gov; Population; SAIPE Main; SAIPE Data; Interactive SAIPE Data and Mapping Tool.

Income

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 50

Income

10.4% of adults report they did not see a doctor due to cost

Jefferson County, CO

BRFSS

20062012

LINK

CHSI CDC

Income

8.6% of persons lived below the Federal Poverty Line

Jefferson County, Colorado

US Census Bureau American Community Survey.

2013

LINK

Age Distribution

Jefferson County’s median age is 40.4 years (somewhat older than Colorado’s median age of 36.1 years) See table in text

Jefferson County, Colorado

U.S. Census Bureau, 20092013 5-Year American Community Survey.

20092013

LINK

Jefferson County, Colorado

U.S. Census Bureau, 2014 Population Estimates Program

2014

LINK

Income

3% jobless rate

Jefferson County, Colorado

US Bureau of Labor Statistics; Local Area Unemployment Survey

2015 (Sept.)

LINK

Dietary Intake

17.7% of adults consume less than one serving of vegetables per day 35% of adults consume less than one serving of fruit per day 10.2 % of children (ages 2-14) ate fruit 2 or more times per day and vegetables 3 or more times per day

Jefferson County, CO

BRFSS

20112012

LINK

Jefferson County, CO

BRFSS

20112012

LINK

Jefferson County, CO

Colorado Child Health Survey (CCHS)

20112013

LINK

US Census Bureau Website; State and County QuickFacts; Jefferson County, Colorado QuickLinks; American Community Survey: Economic Characteristics US Census Bureau Website; American Community Survey; American FactFinder;Jefferson County, Colorado Community Facts; Age US Census Bureau Website; American Community Survey; American FactFinder;Jefferson County, Colorado Community Facts; Age US Bureau of Labor Statistics (bls.gov); BLS Data View, Unemployment Rates Jefferson County, Local Area Unemployment Survey Colorado Department of Public Health and Environment; Full BRFSS Query Colorado Department of Public Health and Environment; Full BRFSS Query Colorado Department of Public Health and Environment; Health Indicators

Age Distribution

Dietary Intake

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 51

19.1% of children (ages 2-14) consume sugar sweetened beverages 1 or more times per day Out of 4000 children surveyed, 54.4% of children were inadequately hydrated 23% of adolescents drink soda daily

Jefferson County, CO

Colorado Child Health Survey (CCHS)

20112013

LINK

United States

American Journal of Public Health

2015

LINK

Colorado

Youth Risk Behavior Surv System

2011

LINK

Dietary Intake

19.8% of infants are breastfeed for 4 weeks or less (note: small sample size)

Jefferson County, CO

Pregnancy Risk Monitoring System (PRAMS)

2011

LINK

Dietary Intake

43% of infants are breastfeed for 4 weeks or less (note: small sample size) 31.8 % of Jeffco Schoolâ&#x20AC;&#x2122;s students are eligible for free and reduced school lunch (K-12) 40 % of parents whose child is obese, in contrast to less than 30% of other parents, reported that they had to rely on lowâ&#x20AC;?cost food to feed their children due to financial constraints

Jefferson County, CO

WIC records

Jefferson County, CO

Colorado Department of Education

1 month sample 2015 2014

LINK

Colorado

Colorado Child Health Survey (CCHS)

Report does not have inform ation

LINK

4.3% of individuals who are low-income also do not live close (less than 10 miles rural or 1 mile urban) to a grocery store.

Jefferson County, CO

Economic Research Service (ERS), U.S. Department of Agriculture (USDA).

2010

LINK

Dietary Intake

Food Insecurity

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 52

Colorado Department of Public Health and Environment; Health Indicators

CDC Nutrition, Physical Activity, and Obesity: Data, Maps, Trends Colorado Department of Public Health and Environment; Colorado Health Information (CoHID); Full PRAMS Data base inquiry Personal communication with County WIC coordinator

CDPHE Website; Colorado Health Indicators; Economic Opportunity, Income, Jefferson County, Colorado. Colorado Maternal Child Health Needs Assessment Report

CDC Website: Community Health Status Indicators; Jefferson County, Colorado; Physical Environment; Limited access to Healthy Food

Food Insecurity

Preventive Care and Mental Health Resources

Causes of death Obesity and Overweight

Obesity and Overweight

Built Environment

15.2% of children live in households with Supplemental Security Income (SSI), cash public assistance income, or Food Stamp/SNAP benefits Jefferson County’s WIC program is serving 73.1% of Jefferson County residents whose income level would qualify them. Over 87% of Jefferson County residents have insurance coverage

Jefferson County, CO

2009-2013 American Community Survey 5-Year Estimates

20092013

LINK

U.S. Census Bureau Website; American FactFinder; Community Facts Jefferson County, Colorado; Income; 2013 American Community Survey; Poverty/Children Characteristics.

Jefferson County, CO

County report of participants, as sent to state

August 2015

Jefferson County, CO

2009-2013 American Community Survey 5-Year Estimates

20092013

LINK

U.S. Census Bureau Website; American FactFinder; Community Facts Jefferson County, Colorado; Income; 2013 American Community Survey; Selected Economic Characteristics.

Jefferson County, CO

BRFSS

20112013

LINK

Colorado Department of Public Health and Environment; Health Indicators

Jefferson County, CO

BRFSS

20112013

LINK

Colorado Department of Public Health and Environment; Health Indicators

Jefferson County, CO

BRFSS

2011

LINK

Colorado Department of Public Health and Environment; Health Indicators

Personal communication with County WIC coordinator

See separate tab 19% of adults are obese (Body Mass Index (BMI) ≥ 30); 53% of adults are overweight or obese (Body Mass Index (BMI) ≥ 25) 12.1% of children (ages 2-14 yrs) are obese (Body Mass Index (BMI) ≥ 95th percentile); 21.3% of children (ages 2-14 yrs) are overweight or obese (Body Mass Index (BMI) ≥ 85th percentile) 84.3% of individuals report sidewalks or shoulders of the road in their neighborhood are sufficient to safely walk,

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 53

run, or bike

Built Environment

78% of Jeffcoâ&#x20AC;&#x2122;s workforce drives alone to work

Jefferson County, CO

U.S. Census Bureau, 20092013 5-Year American Community Survey

2013

LINK

Built Environment

0.6 % of workers commute to work by biking

Jefferson County, CO

U.S. Census Bureau, 20092013 5-Year American Community Survey

2013

LINK

Built Environment

1.6 % of workers commute to work by walking

Jefferson County, CO

U.S. Census Bureau, 20092013 5-Year American Community Survey

2013

LINK

Built Environment

68.0 % of Jefferson County residents live within a half mile of a park

Jefferson County, CO

CDC: Community Health Status Indicators (CHSI)

2015

LINK

Built Environment

The county has 1 recreation center per 10000 people

Jefferson County, CO

CDC: Community Health Status Indicators (CHSI)

2015

LINK

Built Environment

Only 24.3% of Jeffco children (aged 1-14 years) bike, walk or skateboard to school at least one day a week Only 39.1% of children get recommended amounts of physical

Jefferson County, CO

Colorado Child Health Survey (CCHS)

20112013

LINK

Jefferson County, CO

Colorado Child Health Survey (CCHS)

20112013

LINK

Physical Activity

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 54

U.S. Census Bureau Website; Community Facts Jefferson County, Colorado; Business and Industry; 2013 American Community Survey; Commuting Statistics By Sex. U.S. Census Bureau Website; Community Facts Jefferson County, Colorado; Business and Industry; 2013 American Community Survey; Commuting Statistics By Sex. U.S. Census Bureau Website; Community Facts Jefferson County, Colorado; Business and Industry; 2013 American Community Survey; Commuting Statistics CDC Website: Community Health Status Indicators; Jefferson County, Colorado; Physical Environment; Access to Parks. CDC Website: Community Health Status Indicators; Jefferson County, Colorado; Physical Environment; Access to Parks; Recreation Access. Colorado Department of Public Health and Environment; Health Indicators

Colorado Department of Public Health and Environment; Health Indicators

activity each day Physical Activity

64.8% of adults get recommended amounts of physical activity each day

Jefferson County, CO

Colorado Behavioral Risk Factor Surveillance System (BRFSS)

20112013

LINK

Physical Activity

17.9% of adolescents report no leisure time activity The average number of reported mentally unhealthy days is 2.9 days per a month, per person Nearly one-quarter (24.3%) of Colorado high school students reported that they felt sad or hopeless almost every day for at least two weeks within the past 12 months 6.6% of Colorado high school students reported attempting suicide in the past 12 months 33% of children experience one or more adverse childhood events 13.4% of adults report inadequate social support 33.6% of individuals with high housing costs 10.4% percent of adults who did not see a doctor due to cost

Colorado

Youth Risk Behavior Surv System

2013

LINK

Jefferson County, CO

BRFSS

20062012

LINK

Colorado

HKCS

2013

LINK

University of Colorado Healthy Kids Survey

Colorado

HKCS

2013

LINK

University of Colorado Healthy Kids Survey

Colorado

NSCH

20112012

LINK

Child Trends

Jefferson County, CO

BRFSS

LINK

CHSI CDC

Jefferson County, CO

U.S. Census Bureau, ACS

LINK

CHSI CDC

Jefferson County, CO

BRFSS

20062012 20082012 20062012

LINK

CHSI CDC

Mental Health

Psychosocial Stress Psychosocial Stress Psychosocial Stress

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 55

CDPHE Website; Colorado Health Indicators; Health Behaviors and Conditions, Physical Activity, Jefferson County, Colorado. CDC Nutrition, Physical Activity, and Obesity: Data, Maps, Trends CHSI CDC

Psychosocial Stress

Psychosocial Stress Psychosocial Stress

Psychosocial Stress

59% of middle schoolers and 87% of high schoolers in the US get less than the recommended amount of sleep 90% of brain development occurs before age 5 97.3% of parents feel their child is usually or always safe in their community or neighborhood The average number of days (in the past 30 days) experienced by adults of poor physical or mental health that kept them from doing usual activities is 3.5 24.3% of Colorado adolescents felt so sad or hopeless almost every day for two consecutive weeks during the past 12 months that they stopped doing some usual activities. (Jefferson County specific data is not available at this time.) 6.6% of Colorado adolescents attempted suicide one or more times in the past 12 months (Jefferson County specific data is not available at this time.)

United States

AAP

2015

LINK

American Academy of Pediatrics

International

Neuropsychology Review

2010

Jefferson County, CO

Colorado Child Health Survey

20112013

LINK

Colorado Department of Public Health and Environment; Health Indicators

Jefferson County, CO

BRFSS

20112013

LINK

Colorado Department of Public Health and Environment; Health Indicators

Colorado

Healthy Kids Colorado Survey (HKCS)

2013

LINK

Colorado Department of Public Health and Environment; Health Indicators

Colorado

Healthy Kids Colorado Survey (HKCS)

2013

LINK

Colorado Department of Public Health and Environment; Health Indicators

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 56

Psychosocial Stress

Top Causes of Death Top Causes of Death Top Causes of Death Top Causes of Death Top Causes of Death Top Causes of Death Top Causes of Death Top Causes of Death Top Causes of Death Top Causes of Death

21.3% of parents Jefferson County parents report behavioral or mental health problems in children aged 1-14 years 1-Heart disease

Jefferson County, CO

Healthy Kids Colorado Survey (HKCS)

20112013

LINK

Colorado Department of Public Health and Environment; Health Indicators

Jefferson County, CO

2014

LINK

CoHID

2-Malignant neoplasms

Jefferson County, CO

2015

LINK

CoHID

3-Chronic lower respiratory diseases 4-Unintentional injuries

Jefferson County, CO

2016

LINK

CoHID

2017

LINK

CoHID

5-Cerebrovascular diseases 6-Alzheimer's disease

Jefferson County, CO

2018

LINK

CoHID

2019

LINK

CoHID

7-Suicide

Jefferson County, CO

2020

LINK

CoHID

8-Influenza and pneumonia 9-Diabetes mellitus

Jefferson County, CO

2021

LINK

CoHID

2022

LINK

CoHID

10-Parkinson's disease

Jefferson County, CO

Colorado Health Information Data Set Colorado Health Information Data Set Colorado Health Information Data Set Colorado Health Information Data Set Colorado Health Information Data Set Colorado Health Information Data Set Colorado Health Information Data Set Colorado Health Information Data Set Colorado Health Information Data Set Colorado Health Information Data Set

2023

LINK

CoHID

Jefferson County, CO

Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 57

Appendix C: The Community Health Improvement Planning Process Developing a Community Health Improvement Plan (CHIP) requires extensive research to assess the health of the community as well as engagement with members of the public and representatives of partner organizations. Jefferson County’s CHIP was created using the phases outlined in the Colorado Health Assessment Planning System (CHAPS). The following sections describe the process to develop Jefferson County’s CHIP.

Plan and Organize the Process In late 2011, Jefferson County Public Health began a process to assess the health of Jefferson County and to develop and implement a plan to improve the overall health of the community. The process began in response to a statutory requirement under Colorado Senate Bill 08-194 to develop a community health improvement plan and quickly grew into an effort to engage JCPH staff, partners, and the community to generate true change in the county’s health.

Identify and Engage Stakeholders First, we established a steering committee comprised of JCPH staff from all divisions to help guide the process. We also partnered with the Colorado School of Public Health (CSPH) to guide us through an initial employee engagement process, interview key community stakeholders, and summarize County demographic information.

Conduct a Community Health Assessment Next, we collected and analyzed data that would clearly define the health of our community and published a comprehensive 2013 Community Health Assessment (CHA),16 which is available as a separate document. To begin the assessment process, a steering committee convened in early 2012. The committee reviewed data to identify priority health issues that could be improved by the public health system and helped define community partners involved in promoting community health. Using robust data from the Colorado Department of Public Health and Environment (CDPHE), the committee identified the leading causes of death in the Jefferson County. The committee opted to focus the CHA on the diseases that were among the top ten causes of death Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 58

in Jefferson County, are partially preventable, and share common risk factors. These included: cardiovascular disease, cancer, unintentional injuries, chronic lower respiratory disease, suicide and mental health, and diabetes. The diseases selected continue to be among the leading causes of death as of 2014. Next, technical experts within JCPH reviewed the final draft of the assessment and the assessment was published. In May 2013, we released the CHA at a public event at Jefferson High School that attracted a variety of community members and partners. The community health assessment is available at www.healthypeoplehealthyplaces.com.

Conduct a Public Health System Capacity Assessment In addition to assessing health within the county, we assessed the capacity of the public health system to impact health. The capacity assessment was performed using the National Public Health Performance Standards (NPHPS) tool, which helps state and local jurisdictions evaluate their performance against a set of optimal Public Health’s 10 Essential Services standards. The tool is based on the “10 Essential Public Health Services” and is intended to measure 1. Monitor health status. the capacity not only of the local public health 2. Diagnose and investigate health department, but the entire public health system. problems and hazards. Through this tool, partners assessed the 3. Inform, educate, and components, activities, competencies, and empower people. capacities of the public health system, 4. Mobilize community partnerships. encompassing the activities of all public, private, 5. Develop policies and plans that and voluntary entities that contribute to public support health. health within the community. 6. Enforce laws and regulations that protect health and safety. To complete the assessment, questions from the 7. Link people to personal health NPHPS tool were input into an Excel file for ease services. of organization. JCPH staff involved in the CHIP 8. Assure a competent public health process answered the questions they felt they could workforce. answer with confidence. We also enlisted the help 9. Evaluate effectiveness, of the Board of Health and JCPH leadership, accessibility, and quality of including directors and supervisors, to help answer personal and population-based many of the questions. health services. 10. Research for new insights and Unanswered questions were assigned to partner innovative solutions. organizations whose work most closely relates to the issues. In order to simplify the process and use partners’ time as effectively as possible, we conducted the capacity assessment using a QuestionPro online survey. To gather candid responses, we did not require that participants give their name. However, we did ask that they provide their sector so we were able to see from what area of the public health system their response came. For each question, participants were asked to rank the public health system’s level of capacity on a scale of no activity, minimal, moderate, significant, or optimal, and provide a brief explanation for their responses and/or or a notation of strengths, weaknesses, or Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 59

gaps in the system. Survey participants could also choose “unsure” to ensure greater accuracy by eliminating guess responses. The assessment showed that Jefferson County’s public health system has significant activity in three areas: diagnosing and investigating health problems and health hazards in the community; informing, educating, and empowering people about health issues; and linking people to needed personal health services and assuring the provision of health care when otherwise unavailable. On the other hand, significant improvements are needed on the evaluation, effectiveness, accessibility, and quality of personal and population-based health services, as well as the development of community partnerships.

Facilitate a Prioritization Process In early 2013, JCPH invited partners to join a Health Council to help guide the community input process and help select priority health issues for inclusion in the CHIP. The Health Council included top executives from businesses, nonprofits, hospitals, and local governments, as well as elected officials. The Health Council met four times in 2013 to prioritize health concerns, suggest areas of focus, and assign members of their staff to serve on CHIP work groups. In order to gather input on health priorities for the CHIP from a diverse group of Jefferson County residents, we solicited formal input from multiple stakeholders in a variety of settings, including Health Council meetings, community meetings, and online surveys. During input sessions, each group was asked to select priority areas for health improvement, using the 2013 Community Health Assessment which describes health in Jefferson County and some of the factors that influence health.16 More specifically, the community health assessment showed that most of the leading causes of death in Jefferson County – including cardiovascular disease, cancer, unintentional injury, chronic lower respiratory diseases, suicide, and diabetes – are preventable and share common risk factors. Those risk factors include: poor diet, physical inactivity, tobacco use and exposure, alcohol use, and psychosocial stress. Therefore, the participants in this prioritization process were asked to prioritize those five risk factors. Each meeting included a 15-minute presentation about the CHIP process, the leading causes of death in the county, and the underlying risk factors associated with the causes of death. Participants were then asked to divide $100 in play money across the five risk factors according to their perception of each risk factor’s importance to health in their community combined with their perception of where investments could have the greatest impact. After a few minutes of individual brainstorming, participants broke into small groups, to come to consensus around how to spend the $100 and why, and reported out to the large group. This process first took place during one of the Health Council meeting, with 30 members participating. Next, JCPH hosted five community meetings across Jefferson County between July and August 2013, with JVA Consulting as a neutral facilitator. In order to reduce barriers to participation in these meetings, a healthy dinner was provided at each session. In addition, we provided free Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 60

child care at two meetings, and one meeting had simultaneous English- and Spanish-language sessions. Venues were geographically dispersed across the county, with meetings in Edgewater, Columbine, Conifer, Arvada, and Lakewood. Most venues were accessible by public transportation. Outreach efforts inviting community members to participate included the placement of ads in local newspapers and through social media channel, press releases, targeted invitations to local organizations, flyer distribution in neighborhoods and local businesses, and electronic invitations to partners and engaged residents. In total, the meetings attracted 99 community members. Finally, we engaged the public through an online webinar and survey that contained the information provided at meetings and asked how participants would spend $100 across the five risk factors and why. Survey participants were recruited through e-mail, social media, and a press release. The survey drew 117 participants, of whom 74 completed the full survey. To participate in the survey, individuals were required to live or work in Jefferson County. The results of this community process were consistent across all groups, with physical inactivity, psychosocial stress, and poor diet being of greatest general concern. Based on all responses combined and averaged, if we divided $100 among the five risk factors, $27.37 would be spent on physical inactivity, $26.24 on psychosocial stress, $25.84 on poor diet, $10.64 on alcohol use, and $9.91 on tobacco use. Participants felt that tobacco and alcohol already had significant investments, whereas work to promote healthy eating and physical activity was lacking in the county. Physical inactivity and poor diet were seen as key contributors to the leading causes of death and disease in the county, while psychosocial stress was seen as a contributor to poor health behaviors. Following the selection of priorities, we conducted additional outreach to collect feedback from more people. This additional engagement included asking the Jefferson County Head Start Policy Council about the barriers Head Start families face in eating healthy food and being physically active, and the Jefferson County Student Health Advisory Council and Youth Leadership Jefferson County about ways to promote healthy eating and physical activity at schools.

Develop a Local Community Health Improvement Plan (CHIP) Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 61

With the results of our public meetings and online survey clearly showing that the public sees poor diet, physical inactivity, and psychosocial stress as the most pressing health issues in Jefferson County, we set up two working groups to identify ways to increase access to healthy food and physical activity while reducing stress. Given the complex nature of these topics, we wanted the work groups to include members from many sectors. To recruit members, we reached out to our Health Council and other regional partners, as well as to the community members who participated in the prioritization phase. Members were divided into two groups: access to healthy food (19 members), and physical activity (22 members). The groups met seven times between September and December 2013, with the goal of identifying specific populations who would benefit the most from CHIP interventions. Spark Policy Institute facilitated the work groups. Work group meetings included presentations on the CHIP process; policy, systems, and environmental change; local health data related to socioeconomic factors, healthy eating, and physical activity; and the results from a survey of local decision makers’ opinions related to healthy eating and active living (HEAL) work. Each meeting included small group as well as large group discussion. Each group sought to address psychosocial stress by considering the barriers to eating healthy food and being physically active, particularly among those with the greatest burden of poor health. To identify target populations, members participated in an online survey that asked them to rank various population groups stratified by age, race/ethnicity, education level, and income using six criteria: likelihood of health impact, expected reach, external political support, community support, capacity to implement, and impact on health disparities. Survey results demonstrated a nascent consensus among participants, and through discussion each group came to consensus on focus populations. The Healthy Food Access Work Group identified low-income households with children ages 0 - 18 as their focus population, and the Physical Activity Work Group identified low-income families with children ages 2 - 18 as their focus population, which was combined into one priority population: low-income households with children ages 0 – 18. Using priorities selected from the community prioritization process and the work groups, a preliminary CHIP that focused on creating capacity for moving forward with identified goals and partnerships was published in December 2013.

Implement, Promote, and Monitor the Plan As part of monitoring and evaluation the CHIP, yearly updates will be made, with the present update published in December 2015 (see Next Steps section, below, for projected timeline). This update includes significant shifts due to progress having been made on several original goals and objectives, including new or extended grant funding and County-funded FTE support for updates and implementation, along with a strong interest from both JCPH and the community in creating collaborative partnerships. Changes contained within in this update include:  Inclusion of an organization created to implement the CHIP, the Jeffco Community Health Improvement Network, which was formed in August 2015 to better align health Jefferson County | 2014-2018 Community Health Improvement Plan (2015 Update) 62

    

improvement efforts across stakeholder organizations throughout the county and includes over 100 community partners; A revised work plan, with inclusion of strategies, objectives and measurable activities from six health improvement coalitions that make up the Network; Inclusion of additional activities geared toward policy change; Inclusion of activities involving a wide-range of partners; Greater alignment with other Jefferson County health improvement plans, including hospital and school system plans; and, More alignment with state, national, and international health improvement plans.

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