Community-centered framework coordinates population health strategy for chronic disease and substance use disorderNew community framework helps coordinate care for chronic diseases and HIV

Public health agencies routinely conduct community health assessments, yet many jurisdictions continue to face challenges translating population health data into coordinated action that addresses structural determinants of health, health equity, and public health infrastructure needs. These challenges became increasingly visible during the COVID-19 pandemic and highlight the need for community-centered approaches that align public health, healthcare systems, and community partnerships across sectors. This Policy and Practice Review presents a community-centered framework for translating local population health data into coordinated, equity-oriented population health strategy. Using Shelby County, Tennessee, a large urban county in the southern United States, as an illustrative case, the analysis synthesizes publicly available datasets, community health needs assessments, and institutional reports to align local priorities, governance structures, and cross-sector operational strategies within a unified implementation approach. The framework organizes population health priorities into five domains: chronic disease prevention, maternal and child health equity, HIV and sexual health, behavioral health and substance use, and violence prevention and community safety. Across domains, the framework emphasizes shared measurement, data integration, community partnerships, trust, and cross-sector accountability as foundational components of sustainable population health improvement. Although not an implementation evaluation, this review offers a practical approach for jurisdictions seeking to strengthen public health infrastructure, operationalize equity-centered decision-making, and move from fragmented programs toward coordinated population health action responsive to evolving community needs.