What Is a Community Health Needs Assessment?

November 29, 2023 - A community health needs assessment (CHNA), sometimes called a community health assessment, is foundational for nonprofit healthcare organizations and a vital tool for hospitals and health systems working to improve population and public health.

Completion of a CHNA every three years is a condition of maintaining 501(r)(3) status as a charitable hospital organization per the Internal Revenue Service (IRS). Said otherwise, nonprofit healthcare organizations must complete a CHNA every three years to maintain their tax-exempt status.

According to the IRS, a CHNA must account for the views and interests of the community that is served by the hospital as well as public health experts. The results of the CHNA must be publicly reported.

Beyond those stipulations, the IRS gives hospitals and health systems latitude in conducting a CHNA, with the intent for hospitals to tailor their assessments to their community’s specific goals and priorities.

In fact, that’s the sole purpose of a CHA, according to the American Hospital Association Community Health Improvement network (ACHI).

“The CHA allows hospitals, stakeholder organizations and community members to collaboratively identify and prioritize community health needs; assessing strengths and weaknesses should be part of this process,” ACHI says on its website reviewing the beginning states of CHA development.

“It is a tool for leveraging hospital and community assets to meet those needs. CHA findings illuminate the path for partners to implement strategies that measurably improve community health. A successful CHA collaboration helps both hospitals and communities reach their individual and shared goals.”

While it can be beneficial for hospitals to tailor their CHAs based on the resources they have available and the goals they have in mind, it can be hard for them to begin designing and implementing their assessments with such free reign. Below, PatientEngagementHIT compiles the advice of leading organizations that have provided guidance for hospitals conducting an assessment of community health needs.

Planning the CHNA

The IRS drills down the process for completing a CHA to five points:

1. Define the community it serves.
2. Assess the health needs of that community.
3. In assessing the community’s health needs, solicit and take into account input received from persons who represent the broad interests of that community, including those with special knowledge of or expertise in public health.
4. Document the CHNA in a written report (CHNA report) that is adopted for the hospital facility by an authorized body of the hospital facility.
5. Make the CHNA report widely available to the public.

Most healthcare industry trade groups recommend hospitals and health systems begin with a planning stage that accounts for the organization’s population health goals, the community’s public health goals, and the resources available to all for achieving those goals. In doing so, hospitals can better tailor the questions asked during the assessment to ultimately design realistic interventions.

Hospitals might also consider reviewing prior CHNAs to determine what worked well to replicate effective processes and modify outdated ones, ACHI recommends on its website.

Next, hospitals should contact the community-based organizations (CBOs) they plan to partner with in order to complete the community health assessment. CBOs are important because they provide a different perspective on community needs and goals. They can also be integral partners when hospitals reach the surveying stage; CBOs are often charged with recruiting community members to provide input on CHNA surveys and in focus groups.

This is a good time for hospitals to also consider their own teams in completing the community health assessment. Population and public health staff members, plus community health workers, are usually instrumental in developing and rolling out the CHNA.

Completing the Community Health Assessment

Before hospitals can gather data for their community health needs assessments, they must first develop a community profile. This includes key demographic information and insights into leading social determinants of health affecting the population. According to ACHI, hospitals might consider the following demographic data:

• Age (e.g., children and youth, adults, older adults)
• Race and ethnicity
• Income level
• Education level
• Insurance status
• Language preference
• Disability status
• Veteran status
• Sexual orientation
• Gender identity

That information may come from hospital data sources, like SDOH screenings, or more public data sets like the CDC PLACES and Social Vulnerability Index. USDA data could be helpful for tracking food security as a social determinant of health, ACHI offered as another example, or HUD for housing security.

Once hospitals have mapped their population and demographics, they should begin gathering community health needs data. Hospitals will usually employ multiple avenues for doing so, including traditional surveying, focus groups, stakeholder interviews, town hall meetings, and a review of data characteristics.

Honoring the expertise of CBOs, which can help connect hospitals with the community members integral to the CHNA, will be key. CBOs are familiar with the community leaders who can provide insights for the assessment and have developed the trust levels necessary for those leaders to participate in the CHNA.

Although healthcare organizations will develop talking points and areas for exploration with CBOs, there are some resources that provide frameworks for the data aggregation portion of the CHNA. AHA, the Catholic Health Association, plus the National Association of County and City Health Officials and CDC, all provide frameworks for designing and gathering data for a CHA. Organizations may consider using these frameworks as a launchpad for their own CHA strategies.

Community Health Improvement Plan

Integral to the CHNA is the community health improvement plan (CHIP) that germinates from it.

“A community health improvement plan (or CHIP) is a long-term, systematic effort to address public health problems based on the results of community health assessment activities and the community health improvement process,” per the CDC. “A plan is typically updated every three to five years.”

In essence, the CHIP is informed by the insights the CHNA uncovers. According to ACHI, hospitals should focus on three to six community health priorities as part of their action plans. Priorities should be based on the urgency of the issues, the community’s ability to act on the problem, the resources available to solve the problem, and the extent to which the issue is the root of other downstream problems.

From there, organizations can engage in typical change management tasks. This includes compiling a team to carry out an intervention, identifying the end goal for the intervention, and flagging any key metrics for assessing progress. Budget, time investment, and overall return on investment should be part of this conversation.

Interventions need to be complemented by efforts to track progress, ACHI added.

Notably, the whole of the CHNA and CHIP need to be grounded in an effort to advance health equity, ACHI asserted.

What’s more, hospitals and health systems need to consider how they will communicate CHNA results. An August 2021 JAMA Network Open study found that only about six in 10 hospitals publicly report their CHNA results, despite public reporting being a key stipulation from the IRS for tax-exempt status.

ACHI recommended organizations publish a report of their findings online, ensuring all data is clearly communicated. This allows external stakeholders to engage with the findings and help contribute to future improvement. Accessibility is key, ACHI added, noting that reports should leverage plain language, images, and bold headers to make sure laypeople can engage with the report.

CHNA Efficacy

Despite being a requirement for tax-exempt status per the IRS, the extent to which hospitals and health systems use CHNAs to reinvest in their communities has been the root of public debate.

The American Hospital Association says that hospitals are instrumental in investing in their communities, with one June 2022 report showing that nonprofit hospitals offered more than $110 billion in community benefits in fiscal year 2019, exceeding the value of their federal tax exemption by nearly nine times.

“For the past two and a half years, our nation has seen firsthand how America’s hospitals and health systems have cared for their patients and provided essential services to their communities in times of an unprecedented public health crisis,” Rick Pollack, president and chief executive officer of AHA, said in a statement.

“In addition to providing critical care, hospitals and health systems of all sizes, types, and locations deliver a wide range of tailored benefits, activities, services, programs, and research to meet the varied health needs of those they serve. Today’s analysis shows that advancing health in their communities remains the North Star for America’s hospitals and health systems.” 

But separate reports tell a different story. In April 2023, the Lown Institute, a Massachusetts-based think tank, found that nonprofit hospitals received more in tax breaks than they spent on charity care in 2020. The report found a combined fair share deficit of $14.2 billion.

These investments do not necessarily indicate that CHNAs are ineffective, nor that hospitals do not complete them. However, reinvestment in the community is the next step following a CHNA and is the intended use of the tax breaks afforded as a nonprofit hospital.