Community Health Improvement Plan (CHIP) and Community Health Assessment (CHA)

CHIP people at marketmaking greater worcester a champion of health equity by 2026

Community Health Improvement Plan (CHIP)

The Greater Worcester Community Health Improvement Plan (CHIP) is a long-term regional strategic plan for addressing health disparities and improving community health based on the Greater Worcester Regional Community Health Assessment (CHA) and subsequent community conversations with local leaders and residents. The Worcester Division of Public Health (WDPH) and Coalition for a Healthy Greater Worcester collaborate to manage the CHIP's development and implementation across the Central Massachusetts Regional Public Health Alliance (CMRPHA). The CHIP also complements the CMRPHA municipalities’ strategic plans for healthy, thriving communities.

Some recent initiatives that have resulted in part from community implementation of previous CHIPs include:

  • Developing the Stigma Free Worcester mobile app.
  • Reducing re-hospitalization rates.
  • Enhancing access to playgrounds and recreational facilities.
  • Increasing numbers of farmers' markets accepting SNAP and WIC.
  • Decreasing violent incidents.

2021-2026 PLAN

The 2021-2026 CHIP was developed over a span of 16 months, and it is intended to be a living, breathing roadmap for health improvement and resource investment to support WDPH, hospitals and organizations that have a stake in improving health for the residents of CMRPHA communities. It was informed by data and priority health concerns presented by the 2018 Greater Worcester Regional Community Health Assessment, as well as 35 in-depth conversations with nearly 100 residents.

The 2021-2026 CHIP was shaped by four central principles:

  1. Invest first in the community.
  2. Elevate, listen to and respect the community's voice.
  3. Eliminate gaps between services.
  4. Honor trauma-informed approaches to care with equal measure to resilience approaches to care.

Compared to previous CHIPs, the 2021-2026 targets more focused, "upstream" systems that currently breed health inequity as opposed to a "downstream" list of individual programs or goals. Improving policy and root social determinants of health, such as access to education and housing, will lead to more sustainable and longer-term change. As you browse the 2021-2026 CHIP, it may be helpful to keep this Glossary of Racial Equity from the Partnership for Racial and Ethnic Health Equity handy in case you come across any terms you are unfamiliar with.

Overarching Goal: Health Equity

As stated in the CHIP's Letter to the Community, by virtue of being human, every single person in the Greater Worcester community deserves access to quality childcare, education, compassionate navigation through healthcare systems, access to healthy food and safe streets. Our past, present and futures matter, and to achieve health justice we must endeavor together to ensure our neighbors have full, healthy, valued lives.

Health equity is defined as "attaining full health potential and wellness as experienced and honored through one's many intersecting identities (race, sex & gender, sexuality, socio-economic status, ability status, immigration status, religion, etc.), and that of their family and communities" (Samantha Calero, adapted from the Boston Public Health Commission, 2019).

The CHIP intends to achieve its overall goal of health equity through three primary racial equity policies to ensure that municipal leaders are aligned with values, structures and tools to combat health disparities and equitably distribute resources:

  • Adopt community-led racial equity trainings for all staff, boards and commissions. 
  • Work with and compensate grassroots leaders in oversight and decision making. 
  • Use community-vetted equity tools in department, board and commission planning and decision making. 

Community-Wide Policy Change Campaigns

The CHIP will amplify and support 12 campaigns selected based on the CHIP's community conversations and that are already underway as locally-led legislative and advocacy priorities aimed to improve the health of our community. See each button below to learn more.

The "Cliff Effect" refers to a sudden and unexpected decrease in public benefits that can occur with small increases in earnings. In systemic poverty, wages have not kept up with inflation and the cost for basic human needs have skyrocketed. Within that, families need help and need work. We need to shift from thinking "getting off benefits" to "keeping people employed and increasing their financial freedom and security."
The "Cliff Effect" refers to a sudden and unexpected decrease in public benefits that can occur with small increases in earnings. In systemic poverty, wages have not kept up with inflation and the cost for basic human needs have skyrocketed. Within that, families need help and need work. We need to shift from thinking "getting off benefits" to "keeping people employed and increasing their financial freedom and security."
Most parents cannot afford high quality EEC; one parent usually has to drop out of the workforce (which is disproportionately women). Families facing economic hardship have less access to high quality EEC and may be less prepared for kindergarten than their peers coming from more affluent households.
There is longstanding evidence that families who receive home visiting services throughout their infant/toddlers' first two years have improved outcomes. By starting to implement one time home visits, our community steps closer to both destigmatizing AND assessing the actual needs in our community for longer-range programs that really are more about the longitudinal support in these early years.
Transportation is and continues to be a major barrier to care for folks without personal means, those with disabilities and those with young children. Increased capacity for services to provide quality and ADA compliant transportation to clients is necessary to ensure disability equity in our community.
offer free
The community expressed a need to categorize internet access as an essential service. This became highly apparent during the height of COVID-19, a crisis that revealed a major disparity between those who have uninterrupted access to communication and information via the internet, and those who do not.

The community reported that inequities in being able to access housing and rental assistance obtaining safe and affordable homes. In the community conversations, interview participants also expressed a need for rent control or some means to managing increasing housing and rental costs, as voucher programs are only able to cover rental payments that are within the Fair Market Rent (FMR).
Community members report a need for accessible travel modes.
The community reported a need for a specialized crisis response system to be put in place for crises involving mental health issues or substance use disorder issues, as an alternative to traditional public safety systems.
In our region and across the nation, lifespans are increasing, but good health indicators unfortunately are not. There are not currently services meeting the demands of the rapidly aging population.
Agencies report that with improved reimbursement rates, wages could increase leading to improved recruitment and retention rates - improving availability of services, reducing waitlists for clients and patients.
Youth report the need for comprehensive sex education within the school structure that they can rely on for accurate information. Youth also report feeling more secure knowing they have a trusted adult they can speak to about difficult topics like sex outside of their peer-groups.
The Coalition will support by implementing systems for understanding ongoing community priorities and respond to them.

Prioritized Strategy and Action Agenda

The CHIP will convene six working groups in collaboration with local community groups to address health issues persistent on the community level through the following service strategies. The will seek to tackle systemic issues with the goal of creating more equitable avenues to resources and care, and as a result, greater equitable health outcomes across race, ethnicity, gender and socioeconomic status.

busMobilize Community Health Services:
Community members report experiencing limited access to services due to barriers, including: transportation, translation, cultural humility, citizenship status, institutional trust and safe spaces.
call outOrganize Community-led Information Campaigns, Outreach and Education:
Community members reported need for multi translated resources distributed in frequented spaces and forums led by knowledge leaders.
peopleImplement Training on Principals of Anti-racism, LGBTQIA+ Acceptance, Cultural Humility and Empathetic Communication:
Community members reported experiencing implicit bias and racism, and poor customer service when in direct communication with service providers. 

Community members expressed a desire for anti-racism, trauma-informed training for residential counselors, customer service training for patient navigators and hospital admin; and having people with lived-experience co-lead trainings.
headphoneBroaden and Scale Resource Navigation Systems:
Community members expressed struggling with referrals made by PCP or LICSW due to: lack of transportation; lack of translation; not being able to reach a Care Coordinator through a phone tree/long wait times; discomfort speaking with Care Coordinators due to perceived impatience or lacking cultural responsiveness; uncertainty about insurance coverage/bills.
drDevelop Recruitment, Retainment and Advancement Strategies to Diversify Workforce:
The community reports feeling implicit biases, impatience and condescension when trying to communicate with patient navigators due to inadequate communication and cultural responsiveness. 
people with upwards arrowsDevelop Publicly Accessible Systems to Track Public Health Indicators and Illustrate Trends, and Increase Data-Driven Decision Making.
There is a clear identified need to not only collect local health data, but to properly communicate data to the broader community. The Coalition and CHIP partners recognize there's a severe lack of census level health data disaggregated by race and ethnicity, amongst other demographic factors. Without disaggregated data, health disparities are challenging to identify, and strategies to close those gaps are less targeted. 2018 CHA data limitations included availability of timely data, as much of the available data used was already 3+ years old. The quantitative data was not stratified by age, race/ethnicity or income, which severely limited the CHA's ability to identify the most at-risk segments of the population in an objective way. The qualitative data sources did allow us to explore these issues but the lack of objective quantitative data highly constrained this effort. 


Visit the full 2021-2016 CHIP Website for more details and to download the CHIP booklet and poster.

There are many ways to get involved to help implement the CHIP. You can...

  1. Join a Coalition Subcommittee or Working Group.

  2. Advocate for one of the 12 change campaigns.

  3. Use the CHIP reflection guide to see how your organization, business, or community group can align itself with the action agenda. [coming soon]

  4. Support fundraising efforts.

  5. Assist with data collection and usage.

  6. Reach out directly to Coalition leadership and let them know you want to help!



Learn about understanding key problems that impact health and assess the strengths of our community on our Greater Worcester Regional Community Health Assessment (CHA) page by clicking HERE.