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Healthy Monadnock: A Homegrown Community Health Improvement Journey

This story was originally published in the 100 Million Healthier Lives Change Library and is brought to you through partnership with 100 Million Healthier Lives and the Institute for Healthcare Improvement.

Who Are We & What Are We Doing?

Healthy Monadnock (HM) started in 2007 as a community engagement initiative with a bold mission to become the healthiest community in the nation by the year 2020. Located in the southwestern-most corner of New Hampshire serving 108,000 rural residents in 33 municipalities presents unique challenges; yet, HM surprises many outsiders with the comprehensive community health improvement efforts in the region.


What Have We Been Up To?

HM had BIG goals, yet community members and stakeholders were up for the challenge. We selected HM goals, strategies, 27 health indicators, had the Cheshire Medical Center's Center for Population Health (CPH) serving as the backbone of the initiative, and knew that we had a lot of awesome work going on in the community to achieve our audacious health  and wellness goals. We even had foresight to create a leadership council to look at the Social Determinants of Health, the environments which people live, learn, work and play before others in the state of NH were. However, we were not intentional about how the work in our communities was actually impacting all of the perfect plans we laid... and we were not sure how to get there. 

In 2015, our region created yet another perfect plan - our first Community Health Improvement Plan (CHIP). Modeling our plan after our State plan, we identified a number of priority areas that were mostly negative health outcomes or behaviors, such as tobacco use, obesity, and substance misuse. However, this CHIP did not exactly coincide with our community-made HM plan...

We knew that there was still much to learn about community health improvement, so we were eager to do the best that we could for our community. 

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So... Then What Happened?

The most serendipitous opportunity to join the SCALE initiative- Spreading Community Accelerators through Learning and Evaluation - an initiative within  the Institute for Healthcare Improvement's (IHI) 100 Million Healthier Lives initiative. The idea behind SCALE is simple - develop a core set of skills for successful community health improvement using bright spots (aka rock star communities) across the nation and spread that knowledge nationwide.

Tell Me What Those Special Core Skills Are!


The idea is that five core skills will lead to key behavior and process shifts which then lead to a culture of health. The Community of Solutions skills that were developed are: Leading from Within to grow oneself as a leader, Leading Together to work well in teams, Leading for and with Equity to always find those who aren't thriving, Leading for Outcomes to keep evaluation at the forefront of our minds, and Leading for Sustainability to sustain the change.


"Strive for continuous improvement instead of perfection." — Kim Collins

Sounds Great... But How Did You Use the COS Skills?

Using our SCALE knowledge, experience, and insights we created a workgroup model to move the work of our CHIP from planning to implementation. 

With each workgroup we provided education and technical assistance around the COS skills - working to determine which of the skills and tools would be most beneficial to them and their partners at their stage of readiness. Some workgroups gravitated to Leading from Within and regularly begin their meetings with a Habit of the Heart activity. We created action planning guiding principles that called out specifically involving voices of lived experience throughout the planning process. Other groups were ready to measure what matters, and moved forward with Leading for Outcomes by measuring data over time and letting go of measurements that were not helping to answer “Who is not thriving?” or “Whose lives are better because we are here?” 

Living Wage Campaign

In 2016, we launched our Living Wage Monadnock campaign where we envision a Monadnock Region where every employee in every sector earns a living wage for their work - optimizing their income, education, and social potential and resulting in stronger economic development, improved health outcomes, and reduced health care costs for the region. We utilized voices of lived experience and community champions to help co-design this work. A bright spot is that we had 7 local businesses committed to being early adopters and paying their full time staff a living wage by 2020. A challenge (or, fail-forward) is that without one person leading the change and holding people accountable the momentum stops. It is a fine line we walk as backbone staff to determine where our roles begin and end to support community driving initiatives.

In the Monadnock Region, 29% of households make less than $25,000 per year, or $12/hr.


Monadnock Region Per Capita Income 2010 to 2016

Farmer's Market Project

In 2018, we started a data driven process we selected one town, Hinsdale, to work with to co-design a food access project. We held many one-on-one interviews with town residents to gather information on what was most important to them. They were proud of their farmers market (asset) and wanted to increase access and utilization to their community. We found that purchasing an EBT machine for their market would allow community members on SNAP to purchase goods at the farmers market, as well as utilize Granite State Market Match - which would allow for each dollar they spent on produce to be matched. 


The EBT machine project had many setbacks. Though we were successful in procuring the machine and training folks how to use it, we did not market the option in a robust way due to uncertainties in obtaining the machine. Moving into the 2019 season we have the materials ready to go to try again! #failforward


Beautiful spread of fresh produce from a Hinsdale Farmers Market vendor

Vouchers for Veterans

Vouchers for Veterans table at Hinsdale, NH Farmers Market

Our Vouchers for Veterans program was a much larger success. We were able to be up and running with our program for 5 Sundays in September. We provided $20 vouchers once a week to all Veterans, and the only restrictions were that the vouchers had to be used at the Hinsdale farmers market during the month of September. This included prepared foods and other items like bread and eggs which can be excluded with other food supplement programs. We received testimonials from many veterans in their own handwriting about the impact this program had on them and their families. 

"Thank you for your support of vets. This gave me veggies I would not buy." - Michael, Chesterfield, NH

"I think this was a great idea - it helps the veterans with food and social events in my town." - USCG Veteran Staley, Hinsdale, NH


Vouchers for Veterans Utilization in 2018 at Hinsdale Farmers Market

Teaching COS Skills

In 2018, we began holding many Community Health Improvement and Leadership Academies (CHILAs) to intentionally share the Community of Solution (COS) skills with partners and community members in our region - as well as in the wider community of New Hampshire. 

April 2017 Community Health Improvement & Leadership Academy (affectionately known as CHILA) in Concord, NH

In April 2018, we held our first NH CHILA to launch the idea to ~40 NH partners, and three communities committed to being part of this journey. In September 2018, we held our second NH CHILA with those three communities to continue teaching and deepening their understanding of the COS skills, as well as to begin mapping out their individual journeys. 

Since September 2018, we also began spreading the COS skills to our local Greater Monadnock Regional partners with mini-CHILAs. Each of the 5 COS skills has its own 2.5hr session every-other month to make learning easier to digest.

In all CHILAs, an average of 70% of attendees have indicated that they have gained "Quite a bit or More" Knowledge from the content, as well as finding the information and tools presented as "Quite a bit or More" applicable in their jobs according to session Rapid Feedback Form results.

Key HM Initiative Shifts

In 2017, a transition in leadership at the backbone organization (CPH) allowed us to revisit our utilization of COS Skills and began more deeply incorporating SCALE learnings into our community. During this time we had a positive shift in leaders adopting Community of Solution skills and tools. Further, the Leadership Council for a Healthy Monadnock (LCHM) took ownership of their role in guiding the HM initiative in 2019. The LCHM has embraced the idea of distributed leadership, with committees and workgroups made up of people who want to work together strategically to make big changes in regional outcomes (see figure below).


Monadnock Region Strategic Evaluation & Action Plan

Healthy Monadnock has had a mindset shift since 2015. In lieu of the old competitive nature to be the healthiest in the nation, the community has shifted to more of an equitable approach of simply asking: “Who is not thriving?” 

Our efforts working alongside communities and people that are most impacted by negative health outcomes has changed the way that we see and deliver programs, policies, and environmental changes in our region. We are grateful for the skills that we learned and applied through the SCALE initiative - and admit that we would not be where we are today without them. This is just one small piece of the journey for us  (Healthy Monadnock), and we look forward to many more years of equitable and meaningful community health improvement efforts.