BHA-FPX4108 Assessment 4: Community Health Action Plan


Information technology, specifically electronic health records (EHR) and patient portals, are helping to empower patients to take a more active role with their health care (Nash, Fabius, Skoufalos, & Clarke, 2016). Information technology is also supporting collaborative efforts among multiple health care stakeholders, including providers, insurers, community health agencies, and policy makers (Nash, Fabius, Skoufalos, & Clarke, 2016). 

The use of decision support systems facilitates the mining of large amounts of data in population health, including data measurement and analysis. Three purposes of measurement include improvement, accountability, and research (Nash, Fabius, Skoufalos, & Clarke, 2016). Decision support systems can also be used for predictive modeling to improve performance and predict potential outcomes (Nash, Fabius, Skoufalos, & Clarke, 2016). 

As information technology and decision support systems become more sophisticated, and larger amounts of data are captured, the potential to further the IHI Triple Aim initiatives discussed previously in the course increases.

Population health continues to evolve, and the Affordable Care Act (ACA) introduced several new regulations and models. The IHI Triple Aim initiative will be an ongoing area of focus, and information technology offers new ways to engage patients in their own health. Smart phones, health and wellness apps, and smart watches will give patients new ways to monitor their behaviors. 

As providers educate themselves on behavioral change models and economics, they can help patients change unhealthy behaviors. Nash, Fabius, Skoufalos, and Clarke (2016) predict that the next few years will likely result in an updated health risk assessment that includes additional determinants of health and performance, including stress and anxiety, and increased recognition of the importance of thriving and health. Beyond five years, we will likely see shared values among employers, employees, and the community.

Taking measurements, regulations, current and evolving technology, and models of care into account is critical to help ensure sound design of population and community health plans. Without a well-thought-out design, a well-thought-out and implementable action plan will prove difficult to impossible. So, these are critical considerations as you approach the Community Health Action Plan assessment.


  • Nash, D. B., Fabius, R. J., Skoufalos, A., & Clarke, J. L. (2016). Population health: Creating a culture of wellness (2nd ed.). Burlington, MA: Jones & Bartlett Learning.

Demonstration of Proficiency

Competency 1: Integrate principles of epidemiology, population health, and community engagement to plan interventions.

  • Evaluate an organization best suited to implement a community-health intervention.

Competency 2: Differentiate and evaluate evidence-based treatment models and prevention models designed to promote wellness and disease management for population health.

  • Formulate criteria for evaluation of task completion.

Competency 3: Create an action plan to promote wellness and disease management in a diverse population.

  • Define a goal for an action plan.
  • Identify roles, tasks, and timeframes required to implement a plan.
  • Identify human, capital, and material resources needed to complete tasks in a plan.

Competency 4: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with expectations for health care professionals.

  • Write clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics. 
  • Write following APA style for in-text citation, quotes, and references.

Note: It is recommended that you complete the assessments in this course in the order they are presented.


This assessment brings together aspects of the other three assessments in the course. The goal is to create an implementable action plan to achieve a SMART goal addressing the community-health need you have been exploring throughout the course.

  • To prepare to successfully create your Community Health Action Plan, it is recommended you complete the following:
  • Familiarize yourself with the Action Plan Template you will be completing as your assessment artifact.
  • Consult your previous assessments, and the feedback you received on them, to focus on what areas you should focus on when completing the template.
  • It may be helpful to complete the Community Health Programs formative activity.


For this assessment, create a detailed action plan to promote wellness and disease management by addressing your chosen health problem you have been working on throughout this course. Based on feedback received on your previous assessments, design a plan you could implement in a healthcare organization (such as a hospital, physician practice, or federally qualified health center) to address a specific SMART goal.

  • Make sure you download and complete the Action Plan Template. Only submit the completed template for your assessment. Do not submit a paper for this assessment. Papers will not be graded.
  • Consult the scoring guide to ensure that you are addressing all criteria at the level to which you desire. When completing the template, be sure you address the following:
  • Define a goal for an action plan.
  • You may want to review either (or both) of the media pieces related to SMART goals to help in addressing this criterion: SMART Goals | Transcript.
  • Evidence-Based Strategies and SMART Goals | Transcript.
  • Evaluate an organization best suited to implement a community-health intervention.
  • Identify a specific organization best suited to address the problem and implement the potential solution you have selected based on your work in the other assessments in the course.
  • Why is the organization best suited to address your chosen health problem? Why is the organization best suited to implement your potential solution?
  • How is the organization best suited to engage and help the affected populations in the community?
  • Identify roles, tasks, and time frames required to implement a plan.
  • This criterion is related to the first two columns in the template.
  • Be sure to detail the specific tasks that must be completed based on the research you have conducted in the first column.
  • Identify the roles of all stakeholders needed to implement your plan. Explain why they are needed.
  • For each task, be sure to identify an appropriate and realistic timeframe to complete the task in the second column.
  • Formulate criteria for evaluation of task completion.
  • This criterion is related to the third column of the template.
  • Make specific connections between these criteria and evidence-based strategies to promote wellness and disease management for a population.
  • Identify human, capital, and material resources needed to complete tasks in a plan.
  • This criterion is related to the fourth column of the template, as well as the Key Stakeholders section.

For the stakeholders:

  • Which stakeholders are required to complete each task? What are the roles of the stakeholders?
  • In other words, why are the specific stakeholders needed?
  • Additionally, make sure you identify any other people, capital, materials, and so on, needed to complete a task.
  • Write clearly, with correct spelling, grammar, and syntax, and good organization. Apply proper APA formatting and style