A Community Health Needs Assessment Environment Scan
101 Pages Posted: 4 Nov 2018
Date Written: October 13, 2018
Among the many provisions of the Affordable Care Act (ACA) that aim to improve population health, one stands out as having the potential for bridging the efforts of the healthcare delivery sector, public health agencies, and other community organizations to improve population health outcomes. Under IRS §501(r) regulations, non-profit hospitals are required to work with health departments and other community organizations to conduct a Community Health Needs Assessment (CHNA) at least every three years and adopt an implementation strategy (IS) describing how identified needs will be addressed. These regulations have the potential to refocus some of the “community benefits” that hospitals are required to spend (estimated at $62 billion in 2011) towards improving population health. Taken together with other provisions in the ACA intended to encourage the healthcare delivery sector to be accountable for health outcomes in defined populations, as well as the increasing prominence of population health and performance management in the healthcare delivery sector, the new CHNA requirements – and especially their implementation strategies – have the potential to refocus healthcare providers’ attention “upstream” to address the social and behavioral determinants of health. Indeed, the CHNA requirements of the ACA and related initiatives offer an extraordinary promise for advancing a culture of health through multi-sector collaboration to build health partnerships.
However, although some hospitals and communities have adopted promising approaches to meeting the IRS requirements, CHNA and other community health improvement processes vary markedly in how they define the community served, in how they receive input from community members, in the methods they use to set priorities, in the degree of collaboration among hospitals and other organizations, and in they measure performance. Community stakeholders often do not understand how to engage hospitals as partners. And hospitals often lack the staffing and competencies to engage in and sustain partnerships. Consequently, the IRS CHNA regulations so far do not seem to have transformed the healthcare delivery sector to the degree that they might have.
To understand why the IRS regulations have not yet realized their promise, and to identify models that can help them do so, this environmental scan was designed to summarize the forces of change in the U.S. healthcare delivery system and other factors that affect population health and the context in which hospitals operate. This scan is conducted as part of a project supported by the Robert Wood Johnson Foundation to assess the impact of the CHNA requirements on improving population health in communities.
To understand the context in which CHNAs are being conducted, we begin by examining changes in the healthcare delivery system, showing how hospitals, and healthcare more generally, are transitioning from a system in which they were reimbursed based on the volume of services they provided, to one based on the value of the results they produce. As a result, healthcare delivery systems are increasingly being held accountable for improving health outcomes, which they realize they cannot do without collaboration with other entities in the communities they serve.
Section 3 discusses a series of parallel developments all based on the growing understanding that improving population health outcomes requires the engagement and collaboration of the healthcare delivery system and public health agencies, and indeed many other entities in the community. These developments create incentives for hospitals and other healthcare organizations to collaborate with multiple public and private organizations in the communities they serve. From this perspective, a community health improvement process provides the potential to leverage and coordinate the strengths and resources of both the healthcare and public health systems as well as many public and private sector agencies and organizations to create healthier communities (Kuehnert, 2012). Indeed, if implemented as intended, a coordinated community health improvement process can help communities achieve the five conditions that Kania and Kramer (2011) in their groundbreaking work on “collective impact” conclude are necessary for large-scale social change: a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and backbone support organizations.
Section 4 describes the IRS community benefit and CHNA regulations and the plethora of guidance, CHNA models, data, and other resources that have been developed to help hospitals implement the IRS regulations. These include models and other guidance for conducting community health assessments and developing implementation strategies for hospitals and local health departments. Also included are small-area data resources and web-portals providing access to evidence about effective community-based interventions.
Section 5 describes activities undertaken by individual states – in some cases pre-dating the IRS regulations – that facilitate hospitals’ community health improvement processes in the ACA era. These include delivery system reforms, prevention strategies, community benefit regulations, CHNA mandates, data resources, and other activities intended to foster collaboration between healthcare, public health, and other community organizations.
There have been no comprehensive assessments of the impact of either CHNAs per se or the ACA-mandated IRS regulations, but Section 6 summarizes the studies, mostly state-based, of community health improvement processes that have been published to date. Consistent with the results from the Public Health Institute analysis described above, the results of these studies demonstrate considerable variability in how CHNAs are done, and how seriously they are taken by hospital and other decision-makers.
The paper concludes with a discussion of some open questions regarding approaches to conducting CHNAs and developing implementation strategies. In particular, we address: the definition of the community served by hospitals, methods for priority setting, collaboration among hospitals and with other organizations, expectations about collaboration among hospitals and with other organizations in implementation, as well as evaluation and performance measurement.
Keywords: Community Health Needs Assessment, CHNA, Community Benefits, Community Health Improvement Process, Population Health
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