Background
As a means for examining public health service provision and outcomes, the Community Health Report Card for Miami-Dade County presents the health status of county residents in relation to the larger state and nation.  The project was launched by the Health Council of South Florida, Inc. (Council) in May of 2005.  The Council conducted research on existing report card models gathered nationwide finding that over 115 communities in the United States use report cards.  Of them, 25 were chosen as reference points and narrowed down further to a final 5 that served as models:

• The Well-Being of Children and Youth in Philadelphia
• The Los Angeles Latino Scorecard: Grading the American Dream
• San Diego County Child and Family Health and Well-Being
• Arundel County, MD: Building Healthier Communities Report Card
• The Greater Kansas City Partnership for Children Report Card

Models were chosen based on the following criteria: a) application of established methods; b) demonstration of comparable socioeconomic status and population demographics; c) relation to an urban setting; d) history of a regular publishing schedule; and e) partnerships with major area institutions.  Additional documents such as community need assessments and health status reports were considered. 

Indicator Selection
A Technical Advisory Panel, comprised of health care experts from area institutions, was convened over the course of eight months to review and consider the major health-related issues of Miami-Dade County.  Key health issues, access to care, and health disparities were chosen for measurement based on the following eight community health goal areas:

1. Children and Mothers are Healthy, Utilize Healthcare and Available Social Services
2. Adults and Youth Avoid Risky Behaviors
3. Residents Practice Healthy Behaviors
4. Families Utilize Healthcare Services When Needed and in the Most Cost-Effective Setting
5. Residents Effectively Prevent Chronic Disease and Illness
6. Residents Have a Wide Range of Health Insurance Options and Readily Access Coverage
7. Families Live in Safe and Supportive Communities and Environments
8. Elders are Healthy and Utilize the Healthcare System Effectively and Efficiently

Data were gathered and closely examined related to each health measure or indicator.  As an example from the first goal, low birth weight and infant mortality help to assess the state of maternal and child health within a community.  Health indicators such as this were selected based on their relevancy to county population demographics, and the community health objectives for the county. 

Developed in part by the Institute of Medicine (Institute of Medicine (IOM), Division of Health Promotion and Disease Prevention, Committee on Leading Health Indicators for Healthy People 2010), the following ten criteria for indicator selection were used to evaluate available data:

   1.   Data Availability
   2.   Data Reliability 
   3.   Geographic Levels
   4.   Tracks a Problem according to:

Relative Importance of Community Problems 
a. Lack of Health Insurance
b. Poverty
c. Overweight/Obesity
d. Physical Inactivity
e. Sexually-Transmitted Diseases
f.  Drug Abuse   
g. Depression
h. Domestic Violence
i.  Unemployment
j.  Crime

Relative Importance of Community Services
a. Health Care Access
b. Health Screening
c. Child Health Care for Low-income Families
d. Nutrition Counseling and Education
e. Prenatal Care for Low-income Women
f.  Child Care
g. Youth Programs
h. Crime Prevention
i.  Sexually-Transmitted Disease Prevention
j.  Promotion of Physical Activity 

(Consortium for a Healthier Miami-Dade and the Health  Council of South Florida, Inc. (2005).  “Leader Opinion Survey Summary Report: October 2005”),

   5.   Impact
   6.   Diversity
   7.   Subpopulation Impact
   8.   Actionable
   9.   Feasibility
  10.  Capacity Building

The Technical Advisory Panel (TAP) carefully considered and chose each of the separate indicators based on the availability, usefulness and reliability of applicable data.  The Council also conducted an analysis of indicators identified as leading health measures in local community reports such as: the Comprehensive Assessment for Tracking Community Health (CATCH); Hispanic CATCH; the Social Services Master Plan (SSMP); the Leader Opinion Survey; the District XI Comprehensive Health Plan; and the Long-Range Program Plan.  Panel members added indicators in other pertinent areas such as emergency room visits, behavioral health, transportation, and refugee issues.  Indicators were deleted from the analysis when insufficient data existed, or where an insignificant number of persons were represented.  An original list of 717 indicators from 25 sample report cards was honed to a final 28 domains; with two to five domains represented per goal.  Each domain can be broken down further into 113 separate indicators, representing relevant county health topics.

Data Derivations
The Council drew from community health assessments conducted by the following local and national organizations to extract data for each health indicator and contracted with the firm, Professional Research Consultants to conduct a countywide telephone survey garnering otherwise unavailable data.  Where possible, health indicators are paired with national statistics taken from Healthy People 2010. 

Community Health Status     
   1    Florida Communicable Disease Reports
   2.   Florida Cancer Data System
   3.   Hospital Discharge Data
   4.   Living Healthy, Living Longer 2006 survey
        
Health Promotion and Wellness    
   1.   County BRFSS
   2.   State BRFSS
   3.   Florida Youth Risk Behavior Survey
   4.   Florida Youth Substance Abuse Survey
   5.   Florida Youth Physical Activity and Nutrition Survey

Predictive Indicators     
   1.   Profiles of Florida School Districts
   2.   Uniform Crime Reports
   3.   Florida Crash Records Database

Access to Care
   1.   Florida Health Insurance Study
   2.   County Medicaid Data
   3.   National Vital Statistics Report
   4.   Ambulatory Outpatient Data
   5.   Hospital Beds and Services Utilization Statistics
   6.   Nursing Home Bed Utilization Statistics

Socioeconomic Status
   1.   US Census Bureau
   2.   Florida Housing Data Clearinghouse

Benchmarking, Grading and Rating
The concept of benchmarking is based primarily on evidence-based practice, or data-driven decision making.  Using benchmark data in order to conduct comparisons with local health outcomes aids strategic planning processes, allows progress to be tracked, and demonstrates that higher levels of performance are possible.  Achieving a benchmark may help eliminate disparities, which is a national goal set forth by Healthy People 2010. 

To assure a reasonable level of comparability, four key demographic characteristics for Miami-Dade County, including economic status; percentage of the population under the age of 65; percentage of the population over the age of 65; and race distribution were contrasted with each of the top ten recipients of Morgan Quitno’s Annual Healthiest State Award.  While no state can match Miami-Dade County’s unique socio-economic characteristics and cultural diversity, Massachusetts was identified as offering the highest level of comparability among the uppermost performers.  Annual Healthiest State Award publishers provide state rankings by rigorously testing available data on multiple health measures and assessing states based on how they compare to the national average.  Through this tested approach, the national benchmark data is applied to set goals that are within reach for Miami-Dade County.  In cases where adequate data for the benchmark were not available, the composite values for Miami-Dade’s peer counties of Broward, Duval, Hillsborough, and Orange were utilized.

 

Morgan Quitno 2004 Annual Healthiest State Award Rankings: Best and Worst 1. Vermont 41. Florida 2. New Hampshire 42. Alabama 3. Minnesota 43. South Carolina 4. Maine 44. Georgia 5. Iowa 45. Oklahoma 6. Massachusetts 46. Texas 7. Nebraska 47. Nevada 8. Utah 48. Louisiana 9. Connecticut 49. New Mexico 10. Hawaii 50. Mississippi

As a means for developing best practices, benchmarking provides a guide for Miami-Dade County in its health care priorities and goal setting for years to come.  It is also a means for measurement of achievements in the long-term.  The comparable population profile and health outcomes of the state of Massachusetts provide an ideal that is instructive in designing delivery, finance and planning system tools to address issues such as the elimination of barriers to care; improved assessment and evaluation, promotion of innovation, and integrated data systems and information sharing in the County and the state as a whole.

The Kansas City Assessment and Grading Criteria found in The Partnership for Children 2005 Report Card & Data Briefing Book were used to evaluate data for the Miami-Dade County report card.  Grades for the report card are based on a four point scale utilizing the traditional “A-F” grading system.  When unable to provide an indicator with a grade due to insufficient data, a rating of “INCOMPLETE” and a score of “1” is given to that indicator.  Four-year trend analyses of Miami-Dade data are evaluated and given a composite grade as outlined below, as are Miami-Dade County indicators in relation to the benchmark state of Massachusetts.  These assessments were used to develop recommendations to be achieved in the community setting.  Where adequate data for Massachusetts were not available, the composite values for Peer Counties were utilized.    

 

Indicator scoring   Improvement for 3 consecutive years or more Improvement for 2 most recent years Numbers are stabilizing Decline for 2 years most recent (or Worsen) Decline for 3 years or more (or Worsen) 4 Points 3  Points 2  Points 1  Points 0  Points Better than Benchmark data for 2 or more consecutive years Better than Benchmark data for one year Same as Benchmark Worse than Benchmark for one year Worse than Benchmark  for 2 or more years 4 Points 3  Points 2  Points 1  Points 0  Points Add column, divide by two 4+4 = 8 /2 3 2 1 0 4 Points (4.0 = A) 3 Points (3.0 = B) 2 Points (2.0 = C) 1 Point (1.0 = D) 0 Points (0.0 = F)   Grading scale   A 3.8-4.0 C 1.8-2.0 A- 3.5-3.7 C- 1.5-1.7 B+ 3.1-3.4 D+ 1.1-1.4 B 2.8-3.0 D 0.8-1.0 B- 2.5-2.7 D- 0.7 C+ 2.1-2.4 F 0.0-0.6

Goal grades are derived from an average that is the total of the individual indicator ratings, divided by the total number of indicators for that chapter.  All scores are based on the indices previously described (i.e., the four-year trend; benchmark state/peer county comparison).  Data for Miami-Dade’s peer-counties, the state of Florida and the nation, as well as the federal Healthy People 2010 goal for that indicator, are included in the report card and data appendix for informational and adjunct planning purposes, providing additional means for community health status measurement.  Peer-counties are referenced because studies have found that differences in health status can be explained by variations in age, race and poverty level.  A fairer comparison can be made by using these four peer-counties with similar demographic and socioeconomic values.

Additionally, information derived from a separate data set, the Living Healthy, Living Longer 2006 survey, maps health disparities by race and ethnicity; incorporates pertinent mental health data; and considers lifestyle factors that correlate to leading causes of death from the Report Card data set.  Living Healthy, Living Longer survey results are provided to enrich our understanding and buttress the Report Card.  The full version of the 127-question Living Healthy, Living Longer survey and its final report can be accessed by clicking here.

Related Links:
Miami-Dade County Community Health Report Card: Full Report