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100 Million Healthier Lives: Case Studies from Around the GlobeSCALE participants formed coalitions within theircommunities, partnered with improvement advisors, andidentified community champions who had lived experiencewith the problems the communities were tackling.They also participated in several Community HealthImprovement and Leadership Academies (CHILAs), whichoffered a deep dive into improvement methodologiesand leadership skills. Between three and four days inlength (or over an extended period of time if conductedvirtually), CHILAs enabled communities and organizationsto experiment with new skills and forge supportiverelationships that facilitate peer-to-peer learning in themonths and years after.Spreading Community Acceleratorsthrough Learning and EvaluationSCALE was jointly managed by four partnerorganizations, each of which brought theirown expertise. IHI offered its expertise in quality improvement,collaborative learning, and facilitation andconvening. Community Solutions helped participantssee the benefits of applying improvementscience to create practical solutions in thesocial sector and contributed knowledge aboutdesign thinking and building and sustainingmovements. Communities Joined in Action shared itsexperience with convening community membersand community coalitions to increase access tohealth care and reduce health disparities. The Network for Regional Health CareImprovement introduced new ways of learningand working together online, based on theorganization’s experience running the AligningForces for Change campaign, a communitybased quality improvement initiative funded bythe Robert Wood Johnson Foundation.During Action Periods, participants received coachingas they applied new approaches to goal setting, qualityimprovement, and leadership. Limited to three to fourmonths, these periods allowed participants to learn what wasor was not working and to make improvements in real time.Equity Action Labs leveraged community-wide collaborationand quality improvement techniques to advance equity,using a structured process that included engaging thosewith lived experience of inequities, co-designing and testingsolutions, and building upon them over a defined period oftime, often 100 days.2SCALE communities also served as peer coaches forone another, enabling them to learn from each other’ssuccesses and see firsthand the benefits of creating anenvironment in which teams felt safe enough to try newideas and learn from mistakes. This approach, known as“failing forward,” allows teams to learn faster and reachhigher levels of performance than they might otherwiseachieve.Community of Solutions FrameworkOver two years, a framework emerged from SCALE. Knownas the Community of Solutions, it takes its name from the1967 Folsom Report, which advocated for bridging thedivide between public health and medicine and engagingcommunities in addressing the social and environmentaldrivers of poor health. The new framework offers skills100 Million Healthier Lives is made up of change agents from acrossthe globe.Institute for Healthcare Improvement ihi.org/100MLives 6

100 Million Healthier Lives: Case Studies from Around the GlobeCommunity of Solutions FrameworkThe Community of Solutions framework offers a wide array of skills, tools, and behaviorsthat can be applied to accelerate community transformation.Leading for Outcomes: Support communities in applying design skills to co-create a theoryof change, identify measures, test the theory, and plan for implementation and scaling in away that makes these tasks easier.Leading for Equity: Engage those with lived experience of inequity in developing andtesting policy and programmatic changes that have the potential to disrupt systemsperpetuating racism and inequity.Leading Together: Create a safe space for collaboration that allows for difficultconversations and promotes effective teamwork.Leading from Within: Lean on joy, inspiration, and self-reflection to unlock leadershippotential in oneself and others.Leading for Sustainability: Put structures in place to promote ongoing transformationand scale successful models.Institute for Healthcare Improvement ihi.org/100MLives 7

100 Million Healthier Lives: Case Studies from Around the Globefor tackling what many see as intractable problems. Itreframes challenges by attempting to shift mindsets,putting the emphasis on identifying and leveraging theresources that exist in communities, rather than focusingon deficits. The Community of Solutions framework alsoencourages organizations to achieve progress by beginningsmall and applying new skills and behaviors to solvinglarger and larger challenges, using the tools of qualityimprovement such as driver diagrams and Plan-Do-StudyAct cycles.3 Taken together, they help people find new waysof working that encourage peer-to-peer learning, engendertrust through relationship building, and foster creativity inproblem solving, partly by recognizing the untapped talentsof those who have been marginalized.The case studies presented in this document highlight how10 organizations have used the Community of Solutionsframework to shift their organizational cultures, drill downto identify the root causes of inequity, find new allies, andmake progress. These cases are just a sampling of thehundreds of organizations around the world that are usingthe Community of Solutions framework to change theway they look at problems, partner with others to developand test solutions, and build systems for measuring theireffectiveness and spreading success. For clarity, we’vefocused on how these organizations have leveragedparticular skills and behaviors. But components of theCommunity of Solutions framework are not used inisolation; they reinforce one another, creating a positivecycle that sparks and sustains improvement. “The realstrength of the framework is that once embedded in acommunity, these skills are mutually reinforcing — providingthe necessary foundation for community transformation,”says Paul Howard, MPA, Senior Director at IHI.At the end of this document is a list of tools and resourcesdeveloped in partnership with 100MLives communities.Organized into five categories — CommunityTransformation, Advancing Equity, Measuring Impact,Engaging People with Lived Experience, and PopulationHealth Resources for Health Care Organizations — theseresources help support organizations, communities, andnetworks to advance health, well-being, and equity.Leading for OutcomesSupport communities in applying design skills to co-createa theory of change, identify measures, test the theory, andplan for implementation and scaling in a way that makesthese tasks easier.Community SolutionsAs one of the leaders of the 100 Million Healthier Livesmovement, the US-based nonprofit organization CommunitySolutions was instrumental in helping others see just howmuch of a difference the right measurement approach canmake. It was hard-won knowledge that emerged from itsyears of effort to end long-term or repeated homelessness,which is often referred to as chronic homelessness.Like other organizations, Community Solutions hadset an ambitious target — finding 100,000 new homesfor people experiencing chronic homelessness — andworked very hard to achieve it only to discover they werewinning the battle but losing the war. After four years ofits 100,000 Homes Campaign (2010 to 2014), housingadvocates across the US had created 106,000 new housingplacements, but the number of people experiencinghomelessness hadn’t budged; in some cities, that numberactually increased.Leaders at Community Solutions realized they neededa different approach that targeted root causes, andthat would require having a deeper understanding ofthe particular reasons why people experience chronichomelessness. They set a new target: rather than add upthe number of housing placements, they would count downuntil no one experienced chronic homelessness, whichthey refer to as “functional zero.” The name of the Built forZero campaign, launched in 2015, reflects this shift.Institute for Healthcare Improvement ihi.org/100MLives 8

100 Million Healthier Lives: Case Studies from Around the Globeled to substantial progress. Thus far, 13 communities haveachieved functional zero, making homelessness rare andbrief when it occurs; over half of the cities participatingin Built for Zero have substantially reduced the number ofindividuals experiencing chronic homelessness.This year, Community Solutions was named one of thefinalists in the MacArthur Foundation’s 100 million grant tofund a single proposal that promises real and measurableprogress in solving a critical problem of our time.Graphic: Community SolutionsHousing groups from across the US are working to end chronichomelessness in a campaign known as Built for Zero that relieson having real-time data on people living in the streets or shelters.The Health Improvement Partnershipof Maricopa CountyThe new target brought about a change in mindset thatushered in a new way of doing business. Participatinghousing groups from 80 different cities began to aggregatedata across all programs serving people experiencinghomelessness, enabling them to identify gaps — like areasof the city where no outreach teams reached — and modifytheir approaches accordingly. The result is that more than70 communities now have real-time, by-name data on everyperson experiencing chronic or veteran homelessnesson their streets and in their shelters. This had never beendone before, according to Jake Maguire, Built for Zero’sCo-Director. “It was an open question,” he says. “Couldyou track this incredibly dynamic, mobile, anonymouspopulation comprising people who often don’t want toengage with you. and do it in real time?” It required newoutreach strategies and coordination among agencies, aswell as detailed maps to pinpoint where people were beingmissed. It took one city a full year to come up with a list.Community leaders striving to improve public health oftenturn to community health needs assessments and local,state, and national health indicators to identify disparitiesand chart a path forward. The Health ImprovementPartnership of Maricopa County, a cross-sector coalitionwith representatives from the public health agency, healthsystems, businesses, schools, and community-basedorganizations in the Phoenix area, took this approach. Itsfirst action plan, published in 2012, focused on reducingrates of obesity, diabetes, lung cancer, and cardiovasculardisease and recommended dozens of strategies to reducethem. “While we wanted any potential partner to see howthey could contribute to the work, as we got into it, werealized these topics were too broad and our partnershipwas too new to support focused workgroups. Anything youwere doing could fit into those buckets, making it difficultto align the work of coalition members,” says Becky Henry,Performance Improvement Coordinator at Maricopa CountyDepartment of Public Health.Having the by-name lists of people experiencinghomelessness enabled housing advocates to categorizegroups by type (e.g., families, veterans, youth) and identifyshared hurdles, revealing for example that some veteranswere staying in shelters because it was the only way theycould get dental care. They used firsthand stories such asthese to redesign their engagement approaches and getmore people into homes. Reframing the problem not asone of supply (i.e., not enough housing) but of focus (i.e.,on the reasons particular people remain on the street) hasAs a result of participating in the SCALE initiative, coalitionmembers narrowed their focus on the upstream conditionsthat contribute to poor health and looked for concrete waysto actively engage community members in developing andimplementing shared solutions instead of just reportingon what individual agencies were doing. After completinga new community health needs assessment with greaterfocus on consulting with community members andconsidering equity issues and their root causes, they setgoals focused on expanding access to health care, makingInstitute for Healthcare Improvement ihi.org/100MLives 9

100 Million Healthier Lives: Case Studies from Around the Globeit easier for people to find healthy foods, and ensuringchildren grow up in safe and supportive environments. Theyalso focused targets and measurements on areas wheredisparities were greatest and recruited people with livedexperience to serve on committees developing solutions.Following the principle described in Chip and Dan Heath’sbook Switch of “shrinking the change” to gain traction andlearn by doing, they set incremental goals and assessedprogress at frequent intervals.4 “Instead of trying to climbthe mountain, we tried to focus on just getting to the nextmilepost,” says Henry. “For example, in one of our coalitionmeetings, we explored the key concepts in the Switch bookand asked, ‘If our goal was to get grandma and grandpa togo to the doctor, how do we create clarity, increase desire,and create an environment that makes it easier for anelderly couple to access basic primary care?’”The changes they sought also became more specific. Forexample, to increase access to healthy foods, coalitionmembers set a goal of making local produce available in 100stores, restaurants, schools, and daycares. Using the EquityAction Lab model, which offers a structured approach forengaging communities in designing solutions to inequities,they partnered with an urban farming group to distributeproduce that would otherwise go to waste to families inneed, setting an initial goal of reaching 50 families and fiveschools in 100 days.5 They then harvested lessons from that“sprint” to spread the program to the entire school district.“Now we’re looking at what it looks like to distribute foodthrough a community health center,” Henry says.Photo: Health Improvement Partnership of Maricopa CountyParticipants in Equity Action Labs convened by the Health ImprovementPartnership of Maricopa County set initial goals – including getting fivestreet lights fixed and distributing farm produce to 50 families in need –then figured out ways to achieve them and spread what worked.National Council on AgingBefore the National Council on Aging (NCOA), an advocacyorganization, joined 100 Million Healthier Lives, itsleaders had committed themselves to measuring theireffectiveness at improving the lives of older Americans. Totrack their progress in achieving their goal of making adifference in the lives of 40 million older Americans by2030, they counted: The number whose annual income increased orwhose annual expenses decreased by 1,200; The number enrolled in an evidence-based programshown to improve health and well-being; The number able to remain in the community insteadof being relocated to a nursing home; and The number who directly benefitted from a policychange linked to NCOA’s advocacy.In 2018, the NCOA took over the leadership of the AgingHub of 100 Million Healthier Lives, a collaborative thatincludes Area Agencies on Aging, Meals on Wheels, andother organizations that want to better understand andsupport older adults. In an effort to understand whatmatters to older adults, NCOA piloted the Well-BeingAssessment, a questionnaire created by the 100 MillionHealthier Lives Metrics Team that invites respondentsto rate their physical and mental health, as well as theirwell-being, including their finances and sense of purpose.6“Meaning and purpose, physical and mental health, andsocial connections are key ingredients for aging well,” saysDorothea Vafiadis, Director of NCOA’s Center for HealthyAging. “The Adult Well-Being Assessment is one way tomeasure these and other factors. We can then apply thefindings to scale services and programs that address thoseneeds.” Feedback from older adults led NCOA to tailor thesurvey by adding a question about loneliness, which is acommon experience among older adults and one that candegrade health. They also shortened the time period forwhich respondents are asked to envision their future fromfive to two years, since older adults said they had troublethinking too far down the road.Institute for Healthcare Improvement ihi.org/100MLives 10

100 Million Healthier Lives: Case Studies from Around the GlobeLeading for EquityEngage those with lived experience of inequityin developing and testing policy and programmaticchanges that have the potential to disrupt systemsperpetuating racism and inequity.Proviso Partners for HealthPhoto: Michael Paras, courtesy of National Council on AgingThe National Council on Aging piloted the Well-Being Assessmentamong older adults, then adapted it based on their feedback.NCOA then created a toolkit to help its partners in the100MLives Aging Hub, as well senior centers and othercommunity providers, use the Well-Being AssessmentTailored for Older Adults to measure whether their servicesare meeting seniors’ needs and take steps to addressshortfalls. The Baltimore County Department on Aging(BCDA) has fielded thousands of assessments and madechanges at its 20 senior centers based on results: addingmore opportunities to exercise and socialize in placeswhere low scores pointed to those gaps. And as thecoronavirus spread this spring, the BCDA used theassessment data to prioritize which seniors seemed mostvulnerable and should therefore receive the firstreassurance calls, reaching out to offer virtual programs,food deliveries, and referrals to other social services.The COVID-19 pandemic’s disproportionate impact onolder adults makes such efforts even more important,says Vafiadis. More organizations have begun using theassessment, including senior housing developers, volunteergroups, caregiving companies, and technology developers.Vafiadis hopes to partner with organizations servingSpanish-speaking seniors and other populations to continueto learn about the experiences of different groups. “We wantmore people to be able to measure what matters, becausethat way we can make comparisons and understand moreabout the needs of the people we’re serving,” she says.As of 2020, NCOA has reached 10 million older adultsand counting.When Lena Hatchett, PhD, the Co-Founder and ExecutiveLead of Proviso Partners for Health (PP4H), met LorettaBrown, a longtime resident of Maywood, Illinois, at acommunity meeting over a decade ago, she immediatelyrecognized a kindred spirit. Both women looked atMaywood, one of the poorest suburbs of Chicago, andthe surrounding towns that make up Proviso Townshipand saw diamonds in the rough. Yes, unemployment rateswere at an all-time high, half of its residents lived belowthe poverty level, and only two of five students graduatedfrom high school, but Hatchett and Brown shared a visionfor what Maywood could be if residents came to see theirown potential and work together to build a place where allresidents could thrive.The two women started small with a farmer’s market. Itdidn’t take off, but the public garden they cultivated acrossfrom a local high school did. Students tended plants thatbecame fo

Shannon Welch, and Joelle Baehrend for their support of 100 Million Healthier Lives and their editorial guidance in creating this content. How to Cite This Document: Hostetter M, Klein S. 100 Mil