How to Create, Conduct Community Health Needs Assessments

Healthcare organizations working toward addressing the social determinants of health are using community health needs assessments (CHNAs) to determine the best path forward. From uncovering community health and social woes to identifying viable community partnerships, CHNAs are crucial for managing the root causes of public health issues.

According to the CDC, a CHNA “refers to a state, tribal, local, or territorial health assessment that identifies key health needs and issues through systematic, comprehensive data collection and analysis.”

CHNAs were created to help healthcare organizations uncover the health and social ills of a specific community, giving those organizations the tools to address the problems.

In 2010, the Affordable Care Act (ACA) revised the criteria for tax-exempt, non-profit hospitals, calling on all non-profit entities to complete a CHNA and submit it to the IRS. Those organizations are also required to publicly post their CHNA results.

All non-profit hospitals are required to submit a CHNA, regardless of hospital affiliation, according to Mary Ann Cooney, the Chief of Medical Systems Transformation at the Association of State and Territorial Health Officials (ASTHO). Cooney is a seasoned expert on CHNAs, and noted that all nonprofit organizations within the same region or hospital system must complete an assessment.

However, CHNAs have many deeper purposes, Cooney said in an interview with PatientEngagementHIT.com.

“Community health needs assessments are not conducted solely for the purpose of meeting the IRS regulations,” Cooney explained. “The true reason for conducting them is to demonstrate the needs within the community that a hospital then prepares some of its programs around.”

For example, if a hospital uncovers a significant homeless population within the community, the organization should work on hospital and community partnerships that would meet that need. These programs might include clinic vans or collaborations with health departments to offer free clinic days. Solutions will largely depend on the specific needs of the community.

There is not a standard form that hospitals must full out for the CHNA. Making the CHNA prescriptive would likely require the government to fund the initiative, Cooney posited. Instead, organizations deploying a CHNA will need to develop their own assessment questions and parameters.

Organizations are not entirely alone in this effort. Those entities serving a similar region are free to collaborate on CHNA development, so long as they submit their own separate results to the IRS.

Additionally, many industry bodies serve as thought leaders in the area. The CDC has several resources to help hospitals develop CHNA measures.

The CDC suggests most hospitals look at community health resources, patient access to care, health-related factors (i.e. smoking and drinking habits), the social determinants of health, health service utilization, health status (i.e. mortality rates or rates of chronic illness), and community demographics.

CHNAs must link back to specific hospital services and programs that organization leaders can develop to meet community needs, Cooney said. Hospitals can deploy their own programming, such as free or subsidized maternity care for socioeconomically underprivileged pregnant women, for example.

Hospitals can also use these assessments to inform future community partnerships, such as ones with housing departments to chip away at a high homelessness rate.

These opportunities are causing more healthcare professionals to embrace CHNAs, Cooney noted. When first implemented via the ACA, many leaders were frustrated with needing to report more data. Now that the healthcare industry is focusing on value-based care and addressing the social determinants of health, experts see CHNAs as a huge improvement opportunity.

“Now healthcare professionals see CHNAs as a real guiding tool to conduct the programs that they have that are most meaningful to the community,” Cooney explained. “Especially now in the environment where quality payments are being made and Medicare has put forth regulations about quality and access and pricing being very efficient.”

At Kaiser Permanente, for example, organization leaders use CHNAs to help guide their community health practices, according to Pam Schwartz, MHP, Senior Director of Community Impact and Learning for the health system.

Schwartz has helped lead CHNA development and rollout in the 42 Kaiser hospitals and service areas across the country. Through that experience, she has learned that the CHNA is not just a form to submit to the IRS.

“For us at Kaiser Permanente it was more than just a compliance exercise,” Schwartz said in a separate interview with PatientEngagementHIT.com. “It helps us understand the health of our communities and it helps us prioritize how we can allocate resources to addressing the health needs. So ultimately it directs us toward the root causes of health and incorporates the wisdom of communities into the process.”

Kaiser started deploying the CHNA slightly prior to when the ACA regulations rolled out in 2010. The organization used population health indicators to determine health needs and the root causes of health.

Once the ACA mandated CHNAs for non-profit hospitals like Kaiser Permanente, Schwartz and her team were prepared to meet those requirements while working to improve the health of their communities.

Kaiser built a dedicated space to store and analyze key data. The data platform allowed Kaiser to organize results by service area so it could easily look quantitatively at its communities. This data structure also allowed the organization to look at both health outcomes data and social health data.

“The idea was for us to be able to understand more quickly what was going on in our communities,” Schwartz stated. “We supplemented these data with local data and primary data. A part of the regulations asked hospitals to also talk to folks (i.e. collect primary data) to really understand the data and at times identify additional needs.”

Creating and carrying out a CHNA has not always been an easy task, Schwartz conceded. Social and community health needs run deep, so tackling them is often a daunting and intimidating undertaking.

“These health needs are big and they’re complex and one hospital or hospital system can’t address them alone,” Schwartz asserted. “You really have to figure out how to partner with other people, other organizations, the business leaders, the health departments, and so on.”

Kaiser Permanente began to tackle this large project by approaching the challenge methodically. The organization set out to determine which health needs its hospital services could feasibly address and then proceeded accordingly.

For example, if one of the Kaiser hospitals found that obesity was an emerging health issue, the hospital worked to determine how its services could meet that need. What were the resources that the hospital had or were good at that could help address the need?

That methodical approach also helped with more downstream, social issues, Schwartz explained. If economic insecurity emerged as an issue, the hospital could leverage its position at a community jobs creator and hire locally and within the community.

The hurdle of meeting social needs increases when put to scale, Schwartz explained.

“It was challenging in a large service area to know how to design a community engagement strategy and identify who can best represent the needs and inform our planning on how we can best respond,” Schwartz pointed out.

In these cases, Kaiser hospitals needed to work outside of their facility, Schwartz said. Whether a hospital is tackling a problem in a rural, 2,500-person service area or in an urban setting with hundreds of thousands of residents, hospitals need to become a community partner.

“We really had to think about how to move beyond the walls of healthcare and how we can get our own health system to think about health in these ways because these are new areas for us,” Schwartz recalled. “We’ve really started to think more carefully about how we can become part of the solution by addressing things such as housing, transportation, violence, or jobs.”

Underpinning all of the challenge solutions is the idea of building community partnerships. Working with other regional stakeholders is critical throughout the entire CHNA process, including during development, conducting the assessment, and creation of care plans.

“The idea is to understand the health needs and how best to address them,” Schwartz advised. “We engage community partners as we’re assessing the needs, but then we also engage them again as we’re planning our responses so we could really understand the complexity that’s going on in our communities and really think about the best way to address them informed by community input.”

For example, a lone hospital can likely determine that access to health services is a community problem. However, partnering with the community can help the hospital learn whether those barriers derive from lack of transportation, lack of services, lack of patient finances, etc.

Kaiser Permanente is known to partner with health departments, hospitals, universities, and other community-based organizations. Going forward, healthcare organizations must expand the community partnership process.

“There’s more work to be done moving forward about how to partner better with health departments and other organizations,” Schwartz stated. “It is definitely the wave of the future, doing this in partnership and combining assets towards addressing the health needs because nobody can do it alone.”

These efforts are just beginning and are creating a lot of excitement throughout the healthcare industry, Schwartz said.

Industry professionals are beginning to recognize how effective CHNAs and resulting community partnerships are in forging the path toward value-based care.

“It’s becoming clear that we need to think big and we need to get comfortable moving upstream from healthcare. How can we take on things like economic security, housing, transportation, food insecurity, jobs, or even the climate?” Schwartz posed.

“CHNAs open a window to prevention and to social needs in a way that is critical to value-based care,” Schwartz added. “It shows the integration between clinical work like health outcomes and community barriers to health like transportation, housing and food insecurity, including informing how you can address people with complex health needs.”

From there, healthcare organizations can look inward to determine which resources they already have – or can feasibly obtain – that can support those community needs. Going forward, Schwartz sees the healthcare industry continuing to be energized by that opportunity.

“The most exciting things about the CHNA are really thinking about how organizations can leverage their assets towards addressing health needs or community health,” Schwartz concluded. “When you start thinking about what your organization can do and what your organization can do in partnership with others, it’s a whole new day for what’s possible. It allows you to really think about making a difference in these really complex, big health needs.”