Understand community needs, identify partners, and define a path to impact

When care and social supports aren’t connected, people are often left to navigate the healthcare system themselves. This section helps partners identify unmet needs, build on community assets, and engage the right stakeholders from the start.

• Tool 1: Needs assessment and gap analysis
  Identifies community needs and assets, as well as the gaps between them, to inform evidence‑based intervention design.
• Tool 2: Community listening facilitation guide
  Supports structured community listening to gather meaningful input that informs program decisions.
• Tool 3: Theory of change frameworks
  Clarifies how activities are expected to drive outcomes by linking goals, actions, and impact.
• Tool 4: Stakeholder mapping and planning tools
  Helps identify and engage key stakeholders by clarifying roles, influence, and alignment.

Design interventions that reflect community context, governance needs, and communication realities

Communities vary widely in health literacy, language preferences, and experiences with the healthcare system. This section includes tools that support inclusive design, clear communication, and strong governance so interventions are easier to navigate and more likely to last.

• Tool 5: Multilingual health material design strategies
  Guides planning for language access to ensure programs and materials are inclusive and accessible.
• Tool 6: Literacy-informed scripting
  Supports development of clear, actionable messages tailored to varying literacy levels.
• Tool 7: Community data profile and community participation guidance and examples
  Outlines key phases and considerations for planning long‑term intervention sustainability.
• Tool 8: Model fidelity tracker
  Tracks whether an intervention is implemented as designed to support quality and consistency.
• Tool 9: Governance charter template
  Defines roles, decision‑making, and accountability for effective partnership governance.
• Tool 10: Community intervention project template
  Provides a structured framework to plan, manage, and align community interventions.

Measure progress, understand impact, and support shared accountability

Effective measurement is critical to understanding what works and where adjustments are needed. This section includes tools to support mixed methods evaluation and responsible data sharing across partners.

• Tool 11: Data collection, analysis, and metrics
  Helps organizations select metrics and data sources to track progress and outcomes.
• Tool 12: Guide for data sharing across organizations
  Guides organizations in sharing data to measure the impact of community health interventions.
• Tool 13: Data dictionary template
  Provides a framework to ensure data is easily understood across partners.
• Tool 14: Example limited data sharing agreement
  Illustrates key considerations for responsible data sharing across partners.

Build durable programs and enable long term community impact

Communities deserve solutions that don’t disappear when short-term funding ends. This section helps partners plan for long-term viability through financing alignment, policy levers, and shared communication practices — so interventions can endure and scale.

• Tool 15: Sustainable community-informed healthcare
  Explores how value‑based care (VBC) principles can be applied in community settings.
• Tool 16: Sustainability checklist
  Assesses readiness for long‑term sustainability across funding, operations, and partnerships.
• Tool 17: Policy levers and advocacy guide
  Supports identification and planning of policy changes that enable community impact.
• Tool 18: Collaborative communication guide
  Strengthens partner alignment through clear collaboration and communication practices.