Health Equity Investment Framework

The City of Long Beach (CLB) is a costal southern California city located along the Los Angeles County‐Orange County corridor. According to the US Census Bureau (2021), the CLB is home to over 465,000 residents and is the second largest city in Los Angeles County and the seventh largest city in California by population.  Long Beach has a diverse population with an overall racial/ethnic breakdown of 40% Hispanic or Latino, 28% White, not Hispanic or Latino, 13%% African American or Black, and over 13% Asian/Pacific Islander. The CLB is also home to the largest Cambodian population living outside of Cambodia.

Established in 1906, the City of Long Beach Department of Health and Human Services (LBDHHS) is one of three city-operated health jurisdictions in California. The department's mission is to improve the quality of life by promoting a safe and healthy community in which to live, work, and play.  LBDHHS provides locally administered programs and implements policies that address the social determinants of health using an equity lens.

Health status indicators examined in LBDHHS's 2019 Community Health Assessment show overwhelming disparity in health conditions of individuals living in north (90805), west (90810), central (90806), and southwest (90802, 90804, and 90813) Long Beach.  Collectively, these neighborhoods comprise the largest concentration of the city's African American/Black, Latino, and Asian populations.  Furthermore, LBDHHS' 2016-2020 Vital Statistics data reports that life expectancy for those living in zip codes 90805, 90810, 90806, 90802, 90804, and 90813 is lower by nearly ten years as compared to east Long Beach zip codes (90808 and 90803).  Looking at neighborhood-level data, this gap further widens to as much as 17 years.

The COVID-19 pandemic disproportionately impacted these same zip codes and communities, deepening disparities and inflicting further burden of adverse health and economic experiences.  To reduce these inequities and poor health outcomes, LBDHHS sought to create an investment model that would center community, speak to multiple stakeholder groups, amplify strategic planning, and encourage a neighborhood level approach to capacity building.  This model, named the Health Equity Investment Framework¹ (Framework), directed strategic investments toward building capacity of community organizations to access funding and to address underlying factors as well as the impacts of these inequities in order to achieve positive short- and long-term health and life outcomes.

The Framework was developed to guide the allocation of the second round of COVID-19 recovery investments.  The Long Beach Recovery Act² (LBRA) was designed to fund major economic, public health, and fiscal initiatives for residents, business owners and workers critically impacted by the pandemic in three specific categories: Economic Recovery, Healthy and Safe Community, and Securing Our City's Future.  LBDHHS took learnings after the first round of emergency support investments (CARES Act) and sought to ensure that LBRA funds were allocated with more intentionality.  Community experience and voice was central to the development of the Framework, and equity was the focus in every step of the process.  Special attention was paid to building capacity across the neighborhoods most impacted by the COVID-19 pandemic.  City staff worked to decrease barriers to accessing funds and to provide technical assistance specifically for smaller, less established organizations who were doing critical work in the community.

The goals of the Framework include 1) creating a model which serves to align investments with strategic plans and needs assessments, and 2) driving investments that make a positive impact on population health outcomes through addressing health inequities.  This Framework strategically aligns with the CLB's Racial Equity and Reconciliation Initiative³ which identifies strategies to improve health and wellness in the city by eliminating social and economic disparities in the communities most impacted by racism.

The Framework is driven by data related to a specific condition, the root causes/contributing factors of that condition and outcomes of that condition.  Together, these data inform the menu of potential categories of programs and interventions to improve short- and/or long-term health and life outcomes.  The first application of the Framework was developed using incidence rates of COVID-19 hospitalizations within the CLB.  From there, a Request for Proposal (RFP) was announced.  Through the entire procurement process, close attention was paid to reducing barriers by simplifying the RFP application and providing technical assistance for community organizations.

Initial evaluation of the relevance and efficacy of the Framework indicates encouraging results. Investments made through the LBRA funds show strong alignment with the strategic plan for LBDHHS. Early process data show new partnerships with community organizations and positive impacts from provision of technical assistance in the procurement process.

Over the past year, many lessons have been learned and LBDHHS is pursuing opportunities to adapt and scale the Framework through discussions with legislative allies, philanthropic partners, and city leadership.  Plans are being developed to further spread and scale the Framework as a tool to prioritize equity in budgeting decisions across the Health Department, other CLB Departments, as well as regional and statewide partners.  Partnerships with philanthropic entities and community benefit funds are being developed to increase investments in Health Equity Community Projects and to sustain the technical assistance provided to community-based organizations.  Together, these strategies create synergy and support future implementation and impact of the Framework on addressing health inequities across Long Beach.

Visit https://www.longbeach.gov/health/ to view the LBDHHS' website.

¹See the Framework here:  https://longbeach.gov/globalassets/health/media-library/documents/lb_healthequityinfographic_092122-2--1---1-

²More on the Long Beach Recovery Act here: https://www.longbeach.gov/recovery/

³Read more about the City of Long Beach's Racial Equity and Reconciliation Initiative here:  

https://www.longbeach.gov/health/healthy-living/office-of-equity/reconciliation

The City of Long Beach (CLB) is a diverse community of about 465,000 people.  The diversity is reflected in the community's race and ethnicity, income, sexual orientation, ability level, age, access to health care, healthy lifestyle supports, housing status, and health outcomes.  Local data has shown that life expectancy differs by as much as 17 years at the neighborhood level across the city.  The COVID-19 pandemic exacerbated pre-existing health disparities.  During the height of the pandemic, there was an over-representation of COVID-19 hospitalizations and deaths among those living in poverty and overcrowded conditions, among Black, Latino, and Native Hawaiian/Pacific Islanders, and those who were unvaccinated.  Nearly two-thirds of those hospitalized also had comorbid conditions such as diabetes and/or hypertension.  In short, where you live in Long Beach and your racial identity created the context within which you experienced the pandemic.

Data from local case rates and hospitalizations were regularly shared through a public dashboard, a daily reminder of the disproportionate devastation the virus was causing.  In May of 2020, tensions were heightened in the wake of the murder of George Floyd.  In response to community unrest and advocacy against police violence inflicted on Black people, the Mayor of Long Beach dedicated $1 million toward Black Health Equity.  At the same time, community stakeholders advocated for greater investment in Latino community members, who were also experiencing high rates of COVID-19 cases and deaths. 

With the Mayor's funding announcement and emergency support through the CARES Act in 2020-2021, LBDHHS quickly sought to address the most urgent community needs.  Programs prioritized populations hardest hit by COVID‐19, including older adults, people with underlying health conditions, people experiencing homelessness or living in overcrowded housing, and Black, Indigenous, Latino, Cambodian, Filipino, and Pacific Islander residents.

In March 2021, the City adopted the Long Beach Recovery Act (LBRA), a plan to fund economic and public health initiatives and support residents and businesses critically impacted by the pandemic.  The LBRA included funding awarded through the American Rescue Plan Act and other grant funds coming into the City, including a large grant received from the Centers for Disease Control (CDC) dedicated to addressing health disparities stemming from COVID-19.

Many lessons were learned from the process of distributing CARES Act funds.  LBDHHS intentionally sought to distribute the second round of funds in a way that would address health disparities while minimizing tension and competition between community groups.  A need was identified for a unifying framework by which teams across divisions and bureaus within LBDHHS could approach LBRA and CDC investments.  Given the history and context within Long Beach, LBDHHS centered the voices of those most impacted by health inequities in the development process. The goal was also to create a durable model that could be used for a variety of community conditions and to ensure investments were aligned with existing planning documents, including the LBDHHS Strategic Plan, Community Health Assessment, and City of Long Beach's Racial Equity and Reconciliation Report.  The resulting Health Equity Investment Framework (Framework https://longbeach.gov/globalassets/health/media-library/documents/lb_healthequityinfographic_092122-2--1---1-) needed to be flexible enough to achieve relevant short-term and long-term population health outcomes, while also sturdy enough to withstand accountability to key funders and city leadership.

In late 2021, LBDHHS hired a third party to lead and manage a series of discussions intended to assist city staff in developing the Framework.  This consultant interviewed key city staff to gather background information on the history of equity funding in Long Beach, issues raised by community members regarding difficulty accessing resources, as well as what could be improved in city processes.  This information was critical in understanding the history and context for the LBRA Equity Fund dispersion to community-based organizations.  City staff were then guided through a series of meetings over a period of five weeks.  The goals of these convenings were to establish a common language and to explore existing models. These models included targeted universalism, the social-ecological model, and the upstream model of public health intervention.  Contributing factors such as the social determinants of health, which are included in the Healthy People 2023 priorities, were also taken into consideration.

The Framework was grounded in the following core set of principles:  Investments must be community driven, data informed, equity focused, community centered, intentional, and research informed.  LBDHHS then examined its COVID-19 data on cases, hospitalizations, and vaccinations as well as the California Healthy Places Index (HPI) to better understand the root causes and contributing factors that put some groups at higher risk for being hospitalized due to COVID-19. The HPI (healthyplacesindex.org), a powerful tool developed by the Public Health Alliance of Southern California, identifies local factors that predict life expectancy and compares community conditions such as housing, transportation, and education across the State.  In Long Beach, the primary contributing factors to the disproportionate burden from COVID-19 hospitalizations included underlying health conditions such as diabetes and hypertension, race and ethnicity—as a proxy for racism and white supremacy—neighborhood and other social conditions, and COVID-19 vaccination status.

COVID-19 hospitalizations resulted in many negative outcomes, particularly among communities of color who are low income and have less access to resources. These outcomes include food insecurity, poorer mental health, trauma, violence (including domestic violence), income loss, exacerbation of chronic illness, grief, and isolation.

Together, the understanding of root cause contributing factors and outcomes of COVID-19 hospitalization informed the development of a menu of program categories and interventions to improve short- and/or long-term health and life outcomes.  This menu demonstrated the linkages between upstream factors and downstream outcomes for community stakeholders, funders, and political leaders.

Next, City staff convened a group of community constituents to review and provide input on an initial draft of the Framework.  This advisory committee was supportive of the Framework and suggested areas for collaboration across agencies to enhance the funding to community-based organizations.  They likewise underscored the importance of focusing on collective processes at a neighborhood level to build capacity.  LBDHHS then engaged a graphic designer to depict the Framework in a visual format to be shared with stakeholder groups and organizations applying for LBRA funds. 

From there, a Request for Proposal (RFP) was announced.  Rolling out the Framework required careful review of LBDHHS' procurement processes.  The application process was simplified, and technical assistance was provided with the goal of increasing access to city funding for community organizations, particularly those who were less established.  The RFP asked applicants to specify populations of focus using HPI Quartile 1 (highest need) tracts, race/ethnicity, and any additional intersectional identities or experiences that would further prioritize the community of focus. The additional intersectional identities or experiences included age, sexual orientation, previous experience of domestic violence or incarceration. 

Rather than prescriptively defining the funding scope, LBDHHS created an open opportunity for community organizations to propose projects that aligned with the menu and strategies identified in the Framework.  The CLB's procurement team refers to this as a "problem-focused" approach.  Evaluation criteria were established to ensure funding decisions aligned with the Framework's principles and prioritized geographic regions and racial/ethnic groups identified in the COVID-19 hospitalization data.  It was important that in addition to supporting the work of delivering services, investments were also made to build the capacity of people, neighborhoods, and community organizations.  In this way, though LBDHHS was distributing emergency” funds, these investments not only supported short-term recovery but also sought to address root causes of inequity across the city.

The goals of the Health Equity Investment Framework (Framework) include 1) creating a tool that aligns investments with existing strategic plans and needs assessments, and 2) improving short and long-term population health and life outcomes.  There are three associated sub-goals: i.) creating a framework that would be adaptable to a variety of community or health conditions, ii.) increasing access to funding for organizations who are centered in communities and best equipped to carry forward transformative work in neighborhoods, and iii.) reducing health inequities through strategic investments in contributing factors and impacts of health disparities.

Development of the Framework included several levels of engagement with internal and external stakeholders.  Internal stakeholders included leadership from within LBDHHS, as well as members of the CLB leadership team, including the Deputy City Manager, the Special Deputy City Manager for Recovery, the Health Equity Officer, and Financial Management's Purchasing Division.  LBDHHS also convened an ad-hoc Advisory Committee of community leaders to review the Framework.  These leaders included members of the Long Beach Unified School District's Board of Education, local philanthropic partners, and representatives from higher education institutions. 

Qualitative data stemming from conversations with community members, community-based organizations, as well as the Black Health Equity Collaborative and Mi Vida Cuenta Latino Health Initiative were included to center voices of those most impacted by COVID-19 in the prioritization of strategies. Community members, leaders, and organizational stakeholders shared which aspects of investment were most critical for different neighborhoods or communities.  They also influenced the understanding of the how” to invest in different strategy areas such as economic resiliency, violence prevention, and mental health.

Prior to releasing the RFP, LBDHHS hosted two virtual community meetings to introduce the Framework, provide notice of upcoming LBRA funding opportunities, and connect organizations to available technical assistance.  Members of LBDHHS' Racial and Health Equity Team were key organizers in outreach for these convenings and supported engagement from community partners who serve diverse populations in Long Beach.  These meetings were translated into Spanish, Khmer, and Tagalog.  The second convening provided an overview of the various forms of technical assistance available to community organizations.  Partners from the CLB's Economic Development Department presented on support for businesses, including the BizCare Program.  The CLB's Financial Management Department shared about services available to help organizations respond to an open solicitation and navigate the bidding platform.  These particular resources are available to all businesses; however, smaller nonprofit organizations are often not aware of their availability.   

LBDHHS hired a consultant to provide technical assistance in two phases.  The first phase focused on providing assistance with the RFP process and the second phase focused on supporting organizations in their ability to be contract ready.  These areas included program design, data management, program evaluation, budgeting, and financial management.  In alignment with the Framework's goal to build the capacity of smaller and newer organizations, LBDHHS identified eight organizations during the proposal evaluation process to engage in tailored organizational development and technical assistance opportunities.  Organizations awarded these contracts participated in group trainings and received individual consultancy services to prepare them for being considered for implementation of their proposed project.

Eligibility and evaluation criteria were designed to ensure the City was investing in organizations that had the capacity to write and manage grants and offer needed services, while also building the capacity of organizations that may not have a history of working with the City, thus building a stronger context-specific network of providers to support racial and health equity.  An additional goal of the technical assistance was to support relationship- and trust-building across organizations working in the same neighborhoods.

Due to this intentional focus on robust community engagement, LBDHHS received an overwhelming response to the RFP, with a total of 94 projects submitted by 63 organizations. The total requested amount was just over $19,900,000 with an average budget of $212,000 per proposed project.

The work of developing the Framework, crafting the RFP, and making awards to local community organizations spanned across just over 12 months and included the contributions of more than 20 LBDHHS staff members.

There are no start-up costs associated with applying the Framework, but the underlying assumption is that there are resources available to direct toward addressing a health condition of interest and providing technical assistance services.  Because of limited internal capacity to provide technical assistance and the potential conflict of interest, LBDHHS hired an external partner to provide services over a period of 12 months at a cost of $280,000.

To date, LBDHHS has applied the Framework in the development of one Request for Proposal (RFP) opportunity for community partners.  Aspects of the Framework's core tenants in simplifying procurements, using data to identify priority populations, and increasing access to funding through technical assistance have also been applied to other funding opportunities. The evaluation and plans outlined below include early findings from these efforts as well as plans for future measurement.

Central to the evaluation of the Framework are the two primary goals: 1) creating a tool which aligns investments with existing planning documents and 2) improving short and long-term population health and life outcomes in the city. The evaluation plan is therefore divided into two areas:

1.      Connectedness of the Framework to LBDHHS' strategic plan.

2.      Efficacy of the Framework as a tool to improve health outcomes.

Goal #1 Evidence of connectedness to LBDHHS' strategic plans and assessments.

LBDHHS holds a strategic vision that Everyone within our diverse communities is safe, healthy, and has the resources to thrive.” Established pillars toward achieving this vision include building a strong internal infrastructure, building a healthier population, and fostering equity.

There is close alignment between the equity objectives of the 2021-2026 LBDHHS Strategic Plan (https://www.longbeach.gov/globalassets/health/media-library/documents/planning-and-research/plans/strategic-plan/2021-2026-dhhs-strategic-plan) and the goals and outcomes achieved thus far with the development and application of the Framework.  The creation of the Framework meets several of the department's equity objectives including objective 1.1 to Utilize an equity lens in planning and implementing programs, policies and practices, and to effectively design health and race equity initiatives,” and objective 3.1 to Utilize disaggregated data to inform and influence all new and expanded policies or programs.”

The investment strategies likewise connect to strategic objectives related to decreasing chronic diseases, including objective 5.3 which seeks to Reduce the incidence of chronic diseases (asthma, hypertension, cardiovascular disease, and diabetes) among Black residents in Long Beach.”  Objective 16.1 of the strategic plan is to Prevent and reduce mental illness and trauma in communities with the highest rates.”  The Framework identifies mental health supports and trauma-informed responses as a category for investment.  This funding category received significant response, with 21 projects proposed by community partners to address the current community need.  Use of the Framework both allowed LBDHHS to direct significant investment toward achieving this objective and made it easier for organizations best suited to drive this work to access the funding. 

Through a methodical, data-driven, and community-centered process, the Framework guided LBDHHS to achieve objective 13.1 to Further build collaborative partnerships and mobilize resources to promote health, equity and safety.” This is also a component in evaluating the effectiveness of the Framework as a tool to address health inequities.  Initial process metrics and future evaluation plans are outlined below.

Further evidence of the Framework's connectedness within the work of the organization and City of Long Beach include alignment with goal four of the Racial Equity and Reconciliation Initiative: Improve health and wellness in the city by eliminating social and economic disparities in the communities most impacted by racism.”

A second evaluation component in determining connectedness of the Framework to the department's work is ensuring that it is translatable and durable for use with other conditions.  This objective will be realized as teams throughout the department and across other City Departments begin using the Framework to set budget priorities and outline investment strategies.  The first two areas for which the department has further explored application of the Framework are the Advancing Peace program and Early Childhood Education (ECE) efforts.

Initial results from application of the Framework to the advancing peace efforts offered insights into the potential of grounding the Framework in a positive, asset-based approach.  Instead of centering on an adverse condition like incidence of violence, in this application, the condition” is advancing peace.  The Framework then identifies the root elements necessary to support safety and to promote peace for community residents as well as the impacts of increased peace on short- and long-term health and life outcomes.

The department's ECE leaders have also started to apply the Framework to guide investment strategies and create synergy with community partners to achieve population level improvements.  Team members have received training on the Framework and discussed how its application will be useful in collaborating with the CLB's public school representatives and ECE providers to organize and identify investment strategies for multi-stakeholder, place-based resiliency projects.  The Framework has laid the foundation for translating the analysis of forthcoming data related to the developmental skills of CLB kindergartners into ECE investments.  In this case, the Framework will be used to define investment strategies and priorities using school readiness as the condition” of focus.  

After learning of its success in application to COVID-19 hospitalizations and the related Health Equity Community Projects RFP, team members across LBDHHS are eager to apply the Framework to their work.  Plans are in place for a phased roll-out across the department, including utilization of the Framework as a tool for improving organizational infrastructure to support equity.  Over the next year, focus will be placed on providing training to management and supervisory staff, providing example materials, templates, and early process outcome data for use and replication.  LBDHHS's Collective Impact Bureau will continue to engage the Racial and Health Equity Team to oversee ongoing institutionalization of the Framework.  Finally, LBDHHS is looking to apply the Framework not only in consideration of funding to external community groups, but, working together with the City's Office of Equity, as a model for prioritizing budget decisions locally and across the region.

Goal #2 Efficacy at achieving its goals in improving health outcomes:

There are two categories by which LBDHHS is interested in evaluating the Framework's effectiveness at improving health outcomes and reducing inequities. Through application of the Framework in 2022, initial data have been collected and reviewed to understand impact.  Future plans to dive deeper and monitor consistency have additionally been outlined.

As mentioned, the Framework was utilized in the design of the Health Equity Community Projects RFP in 2022.  Several of the strategies identified through the Framework application related to other existing programs under the LBRA.  This included investments in Economic Inclusion and Resiliency, Nutrition Security, and Health Education and Outreach.  As these were already identified and separate program investments, LBDHHS sought to share the Framework with program teams across the department and City who were engaged in these efforts to inform their work.  This included sharing data and community input, encouraging greater provision of technical assistance, discussing neighborhood prioritization based on the HPI Quartile 1, and sharing the anticipated scope of investments within the Health Equity Community Projects RFP.

Most notably, the information from the Framework's application also informed the design of investments in a Promotora/Community Health Champion program.  Although the scope of work expectations and objectives were more specific in this case, LBDHHS replicated efforts to add technical assistance services for the RFP application process, simplify the RFP template, narrow the priority population based on the HPI Quartile 1 neighborhoods, and conduct greater outreach to organizations best suited to conduct these services. Results from this RFP and the Health Equity Community Projects RFP are discussed in the sections below.

The first objective in evaluating progress toward Goal 2 is to increase access to funding for organizations who are centered in communities, historically excluded from City procurements, and best equipped to carry forward transformative work in neighborhoods.  This objective will be achieved by increasing new partnerships, increasing access to technical assistance, and designing funding opportunities that are relevant to the work of local organizations.  Initial results from application to the Health Equity Community Projects (HECP) and the Promotora/Community Health Champions (P/CHC) RFPs are summarized below.

For the HECP RFP there were 114 prospective bidders who downloaded the RFP materials from the City's procurement platform and 63 submissions.  This equates to 55% conversion from prospective to actual bidder, with the city-wide historical average being closer to 10%.  Twenty percent of proposers in response to the RFP had never applied to the City before and 93 project designs were submitted by these 63 organizations.

Twenty-seven organizations sought technical assistance from a contracted provider and 37% of those had never applied to the city for funding before.  Even more, at least 55% of those organizations were small community-based organizations with up to a maximum of just five paid staff.  Of the 29 contracts awarded, 6 organizations had not previously contracted with the City (or 20.6% of awards) and 13 organizations receiving contracts had engaged with the technical assistance provider (44.8% of awards).

For the P/CHC RFP, there were 25 prospective bidders who downloaded the RFP and this resulted in 13 organizations or 52% of prospective bidders following through and submitting a proposal.  Thirteen organizations sought technical assistance from a contracted provider.  Of the 6 contracts awarded through this RFP, 1 organization had not previously contracted with the City (or 16.7% of awards).

As LBDHHS scales the Framework, continued evaluation goals include the following:

Strategy 1 (short term): Ensure robust technical assistance.  90% of organizations who are connected with a technical assistance provider through the Health Equity Community Projects RFP report the trainings as having a positive impact in organizational development and that it will help them apply to future grants.

Strategy 2 (long term): LBDHHS will increase new partnerships, with 10% of awards going to new organizations per funding opportunity crafted using the Framework.

Strategy 3 (long term): LBDHHS will maintain greater than 20% conversion percentage from prospective bidder to proposal submission for funding opportunities designed using the Framework.

The second objective in evaluating progress toward Goal 2 is to reduce health inequities through strategic investments in contributing factors and outcomes of the condition of focus. This objective will be achieved by ensuring that work is happening in neighborhoods with greatest need, and that the menu of services or programs categories offered have a positive health impact for those most affected by inequities.

Initial results observed from implementation through the Health Equity Community Projects RFP demonstrated that funding from the RFP was nearly equally awarded to projects across the three geographic regions prioritized.  Twenty-one projects were awarded through the RFP in the amount of $3 million and these equity-driven projects align explicitly with the investment strategy areas outlined with application of the Framework to COVID-19 hospitalizations.

Continued evaluation plans to measure progress include the following:

Strategy 1 (short term): Demographic data on program beneficiaries through vendor final reports in December 2024 will indicate that greater than 75% of beneficiaries live in central, west, or north Long Beach zip codes.

Strategy 2 (short term): Demographic data on program beneficiaries through vendor final reports in December 2024 will indicate that greater than 75% of beneficiaries identify as persons of color or other prioritized identity (LGBTQIA, older adults, low-income, etc.)

Strategy 3 (short term): Data from vendor final reports in December 2024 will indicate positive impact on health as measured through reporting metrics such as increased understanding of health information, increased access to resources, and improved perception of health or interest in engaging in health promoting behaviors.

Strategy 4 (long term): Health inequities in the City of Long Beach are reduced and LBDHHS is reaching goals outlined within strategic plans.

Sustainability of the Health Equity Investment Framework (Framework) was considered in five important ways.  First, during the development phase, the goal was to create a framework that would be durable and translatable to conditions outside of COVID-19 hospitalizations.  As discussed in the results section, the Framework is being applied across programs in the Health Department (Advancing Peace and School Readiness) and across City Departments to help others organize investments with a focus on equity and to strategize ways to have the greatest impact.  It was also shared during a workshop at the annual meeting of the members of the statewide collaborative, CHEAC (County Health Executives Association of California) as well as with the Southern California Public Health Alliance leadership team.  During the workshops, attendees were given the opportunity to apply the Framework to their local jurisdictions and conditions of interest.

Second, LBDHHS approached the Framework as an important tool in the process of building the local infrastructure of community organizations, especially those that began operating during the most intense phases of the COVID-19 pandemic.  LBDHHS wanted to honor and acknowledge their role in addressing the underlying contributing factors and impacts of COVID-19 hospitalization, especially in those groups most disproportionately represented in the data.  The vision is that LBDHHS will continue to play a coordinating and connecting role, but that community organizations will have the strength and agility to carry out their work and be able to draw down funding to sustain and grow their services.  The goal is to be able to continue to uplift and support the work going on in the community, especially by lowering the barrier to applying for funding.  Going forward, LBDHHS is committed to providing tailored, on-the-ground outreach driven by the Racial and Health Equity Team.    

Third, a clear need for more funding to the community organizations themselves was identified.  Nineteen million dollars was requested for funding activities, yet the available funds to distribute totaled three million.  Given the unprecedented funding requests and the success in reaching so many community organizations, discussions with local health plans, philanthropic groups such as the California Endowment, First 5 Los Angeles and others are underway.  LBDHHS is likewise in conversation with state representatives around making this Framework a model for how local health departments invest in community organizations and at the same time map the impact back to long-term population health outcomes.  Statewide financial support of local health jurisdictions as a backbone will be critical to the spread and scale needed to move the needle on long-term health outcomes.

Fourth, the Framework's success would naturally be measured by its narrowing scope over time as contributing factors and/or impacts are addressed.  By its nature, the sustainability of the Framework is tied to data trends and noting which areas are making progress and what issues need more attention.  This flexibility and adaptability are essential to being able to address long-term population health outcomes that may not be realized for generations. 

Fifth, and arguably the most important, the sustainability of the Framework is deeply tied to its role in building community trust.  The success in this area is connected to LBDHHS' commitment to hiring a Racial and Health Equity Team, with four coordinators working across the largest race/ethnicity groups (Black, Latino, Cambodian, Filipino) and one coordinator dedicated to working across multi-cultural spaces to conduct outreach and strengthen relationships and communication between communities and the CLB.

In summary, sustainability was thoughtfully baked into the tool's design and implementation.  LBDHHS was careful to create a durable tool that would help focus the city team on where the investments would have the most impact and at the same time make the process of accessing funding more possible than ever for community-based organizations. 

In the coming year, LBDHHS will begin to spread the Framework across the department, doing trainings for supervisors and encouraging use to help achieve the equity goals and objectives of LBDHHS' strategic plan.  Key leadership will continue to pitch the Framework and the findings to different audiences outside of the department to help draw down funding and engage in conversations around partnerships for impact.  In this way, the Framework will help to center the lived experience of community members, uplift the work of community organizations, support the local infrastructure, bring funding to areas of need and improvement, build community trust, and ultimately move the needle on improving critical population health outcomes.  

There were numerous lessons learned throughout the process of developing and launching the use of the Framework.  First, regarding community engagement, it is important to realize that if you are not hearing anything from community organizations, you may not be asking, or you may not be reaching the organizations best suited to carry out the work.  Another important lesson learned through this process is that community organizations appreciated and needed the technical assistance to be able to successfully complete the RFP.  Data showed that nearly two thirds of the organizations that applied for technical assistance had fewer than 5 staff members and a little over a third had never applied to the city for funding.  Of the 63 organizations that ended up applying, 20 percent had never applied to the city before and almost half had never received a contract/funding from the city.

As far as funding, LBDHHS learned that the need was far higher than anticipated.  LBDHHS ultimately received requests for 93 projects submitted by 63 organizations.  The total request was $19.6 million, while the budget for the Healthy Equity Community Projects RFP was only $3 million.

Focusing on neighborhood level investments was a critical lesson learned after the CARES Act funding experience.  Early in the process of engaging the community on the best way to use the LBRA and CDC funding, it became clear that if LBDHHS just looked at funding across each race/ethnic group, this would lead to divisiveness and ultimately create more harm.  By focusing on neighborhood level impacts, LBDHHS could address individual inequities by race/ethnicity while also addressing capacity challenges and resource needs across communities and neighborhoods with intersecting identities.

Finally, launching the Framework required significant partnership and a foundational commitment to equity at all levels of the CLB.  The Framework for Reconciliation, a city-developed document with clear goals and objectives was central to the rollout LBDDHS' new approach to making investments in the community.  Having equity-trained staff in central procurement, the city attorney's office and across the LBDHHS was critical to taking the idea of the RFP and turning it into a reality.  LBDHHS' Framework is a model for taking equity work from the planning stage and turning it into actionable, purposeful, and impactful activities to improve health and life outcomes.