Community needs assessments leading to better outcomes: ACA requirement fortifying health
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* Lindsey Wahowiak

Since the Affordable Care Act first mandated them, nonprofit hospitals have been required to carry out community health needs assessments every three years, identifying and addressing areas of public health concern.

Such assessments have not only helped to pinpoint where community health can get better, they also have the potential to build stronger relationships and foster the kind of cross-sector collaboration public health has been working toward.

But to make the most of the assessments’ potential, hospitals need to work closely with public health and get buy-in from people and organizations not typically represented at the health care table, experts say.

When the ACA was passed in 2010, it included four new federal mandates for tax-exempt hospitals. Three surrounded billing and financial assistance eligibility policies for people served by a hospital. But one was to conduct a community health needs assessment every three years and adopt a strategy to implement changes to address those needs. In 2014, the U.S. Internal Revenue Service published final rules guiding hospitals on what is required of an assessment, including how hospitals must document how they are addressing needs, a description of needs that are not being addressed and reasons why they are not. APHA supported the rules as they were being developed.

The goal of the assessments is to move hospitals away from just treating the sick, and toward addressing population health and prevention, said Brad Gibbens, MPA, deputy director of the Center for Rural Health at the University of North Dakota, which has helped to write and evaluate assessments performed across the state. Community health needs assessments are meant to help achieve the ACA’s goals of improved care and improved health at a lower cost. But they may be intimidating to hospital staff, who by the nature of their jobs do not work in the big picture the way public health workers might.

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/47/4/1.4/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/47/4/1.4/F1)

Workers hired from local neighborhoods tend plants in the Bon Secours Community Works hoop house in Baltimore. Neighborhood cleanup efforts were part of local community health needs assessments. Job programs also address local unemployment.

Photos courtesy Bon Secours Community Works

Gibbens said he was once told by a hospital’s CEO, “We never used to care much about poverty, but now we have to.”

“That’s the shift in health care,” Gibbens told *The Nation’s Health.* “It’s recognizing things like income, poverty, education — all of those determinants have an impact on a person and their ability to get well and be well.”

The question is how to properly assess a community’s health needs. Gibbens said the hospitals he works with start by getting community input. In the most ideal situations, a community team is convened, with representatives from economic development, city or county government, the faith community, business community and local health department. They discuss, but they also can disseminate surveys, which will have far better reach at weekend services, in grocery bags and in students’ take-home packs for parents than they would if shared by the hospital alone, he said.

Face-to-face interviews with select people from the community are also encouraged, as are forums or focus groups to dig into what the community wants.

The Nelson-Griggs District Health Unit, one of 28 local health departments in North Dakota, was part of local assessment from the onset, said Julie Ferry, MS, RN, the unit’s administrator. Ferry said she served on the planning committee, and offered names of people in the community who could be key stakeholders in the assessment process. The unit distributed surveys to residents who used its services, and also shared them with schools and social services organizations “to obtain input from all residents, not just the clients we serve,” she said.

Working with community members and leaning on public health is the ideal for starting and completing a community health needs assessment, Gibbens said. But he noted that in some places, health departments are just asked for data, without getting their input — meaning insight and experience can be missed.

## Cooperation key to assessments’ success

In some communities, hospitals and public health have been working together for years, even decades. In Baltimore, Bon Secours Community Works has served as the public health and services wing of the Bon Secours Health System on the west side of the city. There, public health advocates focus on a few key ZIP codes to address social determinants of health. Because of this, the hospital had a strong relationship already with a team of public health experts on the ground.

Tatiana Y. Warren, PhD, business intelligence specialist with Bon Secours Community Works, said having that history of working in the neighborhood made the assessment process easier and more robust. Even with that experience, the results of the survey and community forums portion of the process surprised the assessment team. More than unemployment or crime, residents said the two biggest problems they faced were rats and trash. Those were problems that were simple to address, Warren said, but also offered an opportunity to address social determinants of health: Bon Secours Community Works now hires eight community members every six months to gain job training in landscaping and neighborhood beautification.

“It’s filling the community needs in terms of addressing the rats and trash,” Warren told *The Nation’s Health.* “But it’s also filling the needs of the social determinants of health problem. It definitely tackles some of the things that came out of the report.”

![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/47/4/1.4/F2.medium.gif)

[Figure2](http://www.thenationshealth.org/content/47/4/1.4/F2)

Residents enjoy a back-to-school open house at Bon Secours Community Works in Baltimore. The event highlighted the partnership between hospitals and public health.

Bon Secours’ hospital and Community Works serve as an example of how working together makes implementing the solutions to address assessment findings easy and thorough. And in the current political climate, when public health and prevention funding is on the chopping block — or in many communities, already too low — building these partnerships is more important than ever, advocates said.

Back in North Dakota’s Nelson-Griggs District Health Unit, engaging more community stakeholders in public health means expanding resource opportunities. With fewer than three full-time staffers to serve two counties, Ferry said every dollar and every potential partner can make a difference. When she and the local hospital administrator met to discuss the results of their community health needs assessment, Ferry said, that opened the door for a long-term partnership that benefits the unit, the hospital and community members.

“We need to look at our services as part of a continuum of care that serves the whole community,” she said. “Limited staff resources will be the biggest barrier in looking at new opportunities in our respective service areas. All entities, not just health care providers, can benefit from partnership, but we need to look at our entire community, not just the clients we serve. The turf issues need to be set aside as there aren’t the resources to sustain new initiatives.”

Another reason for public health leaders to help lead the assessments: accreditation. According to research published in the March/April issue of the *Journal of Public Health Management and Practice*, completing a community health assessment is a prerequisite for local health departments seeking accreditation from the Public Health Accreditation Board. Between that prerequisite and the IRS’ requirements for tax-exempt hospitals, the study said, collaboration is making these assessments more efficient and better overall, “thus building a strong foundation for continued collaboration to improve community health.”

As communities work to address the needs found in their assessments, and begin the next round, they can address health issues, and improve their delivery of care — and perhaps ensure their own future.

In North Dakota, that means bringing universities, hospitals, public health, businesses and more together to create recruitment efforts to bring health providers to the community, and make communities more attractive for young professionals to stay for the long term.

“It’s a really bad joke, but a common comment is we’re one bad accident (away) from having a provider shortage,” Gibbens said. “We recommend a committee. It’s the same type of thinking (as the community health needs assessments teams). It’s putting some of the responsibility on the community.”

To learn more, visit [http://bit.ly/chnas](http://bit.ly/chnas).

*   Copyright The Nation’s Health, American Public Health Association