Community Health Assessment and Community Health Improvement Planning
Community health assessment (CHA) and community health improvement planning (CHIP) are typically carried out by, or on behalf of, communities composed of community agencies, organizations, and lay community members. The purpose of CHAs and CHIPs is to examine community health status and health trends; prioritize health issues; and identify, implement, and evaluate intervention strategies, programs, or policies to improve priority health issues.1 Federal and state policies, such as the Internal Revenue Service (IRS) Community Health Needs Assessments (CHNAs) for Charitable Hospitals requirements2 and Colorado's Public Health Act (SB 08-194),3 and state, local, tribal, and territorial health department accreditation have led to an increase in community assessment and planning efforts in recent years.
There are different models to guide CHA and CHIP, many with overlapping components, which may lead to confusion in choosing an approach. Moreover, various organizations and agencies, such as health departments, nonprofit hospitals, United Way organizations, Federally Qualified Health Centers (FQHCs), and Community Action Agencies, may complete assessments and independent plans with slightly different parameters and for different purposes, including state and federal regulations, accreditation, funding, and reporting. These competing approaches may lead to unnecessary duplication and present barriers to the collaboration in and alignment of assessment and planning across multiple agencies and organizations. The evolution of these models/approaches has influenced purpose, parameters, applications, and further model development. Several of the models discussed have multiple versions reflecting this historical development. This history is briefly described elsewhere in this issue.4
With such variability in assessment and planning currently in place in many communities, it may be useful to examine the components of these different assessment and planning models. Specifically, there is need to examine the more widely used approaches to identify potential areas for coordination of assessment and planning; to maximize cross-sector collaboration, shared use of limited resources, and collective impacts; and to identify critical components that improve community health. The purpose of this article is to examine and align components of CHA and CHIP models and requirements and identify components critical for community health improvement.
Identifying Assessment and Planning Models
In this article, the authors identified 18 assessment and planning models, frameworks, and requirements through searches of peer-reviewed and gray literature and online searches for policy and accreditation requirements. We identified and grouped similar components into 11 categories, as depicted in the Supplemental Digital Content Table (available at http://links.lww.com/JPHMP/A321). We understand not all 18 models were created specifically to guide applied CHA and CHIP and others are infrequent in their use. Thus, we included all models in the Figure, the Supplemental Digital Content Table (available at http://links.lww.com/JPHMP/A321), and the overview, but focus on the 7 models and requirements most commonly used by health departments, health systems, and hospitals, as well as one community model used in the United States and internationally.2,10,12–15,19–21,23 In this article, we provide an overview of similar components across these models and requirements, opportunities for alignment, and elements critical for improving community health.
Overview of Assessment and Planning Models
Several of the models we identified were created for and are primarily used by governmental public health agencies. One of the earlier models, Planned Approach To Community Health (PATCH), was used predominantly by state and local health agencies in collaboration with communities for assessing health needs and implementing health education and health promotion interventions.5,6 PATCH was largely informed by the PRECEDE (predisposing, reinforcing, and enabling constructs in educational/environment diagnosis and evaluation) phases of the PRECEDE-PROCEED model. PATCH and other models informed the creation of the PROCEED (policy, regulatory, and organizational constructs in educational and environmental development) phases.7 Although seldom used anymore, APEX-PH (Assessment Protocol for Excellence in Public Health) was the foundation for local health department assessment and planning,8–10 on which PACE-EH (Protocol for Assessing Community Excellence in Environmental Health)10,11 and MAPP (Mobilizing for Action through Planning and Partnerships) were developed.10,12 More recently, the Public Health Accreditation Board13 standards and the Association of State and Territorial Health Officials14,15 guides provide direction for state, local, tribal, and territorial health department accreditation and development of state health assessment and state health improvement plans, respectively. Some of these public health planning models are more prescriptive in their approach, by providing more in-depth diagnostic steps,7,10–12 whereas others provide a more general framework for assessment and planning.5,6 Other models used primarily by the community and public health sector include the Community Health Improvement Process,16 the County Health Rankings & Roadmaps to Health Action Cycle,17 and the Healthy People 2020 MAP-IT (Mobilize Assess Plan Implement Track)18 model.
Several models are geared toward hospitals and health care systems. The Partnership Approach was developed as a comprehensive community health status assessment to assist communities, largely through hospitals and health systems, in community health development theory-based community health improvement initiatives.19 The IRS requires nonprofit hospitals to conduct a CHNA and complete an implementation strategy to address health priorities, every 3 years, to document and justify eligibility for tax-exempt status.2 The Catholic Health Association Assessing & Addressing Community Health Needs20 and the Association for Community Health Improvement (ACHI) Community Health Assessment Process21 provide hospitals with guidance in completing hospital-led assessment and planning requirements. Finally, FQHCs are required to assess the health and service needs of their selected target population every 5 years.22
Models, such as the World Health Organization's Healthy Cities/Healthy Communities, reflect a more comprehensive and holistic view of health, which includes education, income, peace, housing, equity, social justice, a stable ecosystem, and sustainable resources.23 With an emphasis on a cross-sector approach, the Centers for Disease Control and Prevention's CHANGE (Community Health Assessment aNd Group Evaluation) model includes and assesses the community-at-large, community organizations, hospitals and clinics, schools, and work sites.24 Finally, the Israel et al25 Community-Based Participatory Research model guides community-based research, with an emphasis on establishing, strengthening, and maintaining relationships between researchers, community partners, and community members, as well as involving communities throughout the research process.
Common Components Across Assessment and Planning Models
We identified 11 similar assessment and planning components across models. These included preplanning; partnership development; developing vision and scope; collecting, analyzing, and interpreting data; identifying community assets; identifying priorities; developing and implementing an intervention plan; developing and implementing an evaluation plan; communicating and receiving feedback on the assessment findings and/or the plan; planning for sustainability; and celebrating success.
Important aspects of preplanning primarily entail identifying and organizing resources prior to commencement of the assessment and planning activities. During this phase, planners garner internal leadership and staff support, assess community and organizational capacity to carry out the assessment and planning process, identify and obtain necessary resources, identify community organizations or members for engagement and collaboration, and determine the assessment and planning approach.10,12,19–21
Development of partnerships is part of all models; however, who is involved and the extent to which they are involved vary. Models recommend or require engagement of a broad-based community stakeholders from a variety of sectors, including hospitals, health departments, clinics, and formal and informal community leadership.10,12,13,19,23 Models also include the engagement of diverse stakeholders reflective of the larger community demographics,13,19,20,23 as well as medically underserved, low-income, minority, and high-risk populations.2,13,19
The extent to which community stakeholders and community members are involved also varies. A typology often used for assessing community participation is Arnstein's26 Ladder of Participation, in which lower rungs are nonparticipatory, middle rungs are more symbolic and tokenistic, and higher rungs are participatory with citizens sharing or holding much of the power. Several assessment and planning models entail active, participatory, productive, and meaningful participation representative of the higher participatory ladder rungs10,12,13,19,20 and recommend extensive participation early in and throughout the assessment and planning processes.19,20,23 Depending on how participatory activities are implemented, some models may be reflective of the lower participatory rungs of the ladder, such as developing an advisory committee or team or consulting with community stakeholders on community needs.2,21
There are several steps in which community participation can occur: prior to commencement of assessment and planning, during the assessment and planning processes, and postassessment and planning activities. Most steps are included in at least one of the models:
- Preassessment and planning activities included developing the overall plan (ie, involvement in decisions about the purpose and approach, and definition of community),19,20 identifying and recruiting additional community partners to engage,19,20 and identifying existing data sources and reviewing and contributing to the development of measurement tools/questions.13,19,20
- Activities that occur within the assessment and planning processes, for which community stakeholders can be engaged, included providing data or information on issues2,13,19,20; identifying community health resources or assets19,20; assisting in data collection, analysis, and/or interpretation13,19; participating in the process to prioritize health needs2,13,19,20; verifying selected priority needs after they have been identified19–21; planning programs or policies to address priorities10,12–15,19,20; implementing programs or policies to address priorities10,12,13,19,20,23; and evaluating programs or policies.2,10,12–15,21
- Postassessment and planning activities occur after these processes are completed. Community participation can occur by helping disseminate reports and receiving and providing feedback on completed reports.2,13,19,20
While all assessment and planning models included partnership development, few models encouraged true collaboration across multiple sectors. By true collaboration, we mean stakeholders coordinate and combine resources10,12,19 and identify accountable parties (individuals or organizations) with responsibility for implementing strategies together,13,19 not simply sharing information or inviting participation.
Vision and scope
While not as common, another early step in the process was developing the purpose, vision, and scope of the assessment and planning processes. This step includes defining the community of interest (ie, geographic, special population), visioning, and establishing expectations for the processes.2,10,12,14,15,19–21,23
Data collection, analysis, and interpretation
Data collection and analysis are at the heart of assessment and planning. All models included collecting and analyzing data, although there are variations in the types of data, methods used, and prescriptiveness of the approach. Specific data types, beyond morbidity, mortality, and other health outcomes, may include indicators for demographics,13,19,20 functional health status or health-related quality of life,10,12,19,23 public health systems,10,12,13 socioeconomics,13,19 culture,19 political and historical context,19 environment,2,13–15 and behavior.13,19,20
Several models specifically included collecting and analyzing primary and secondary data,19–21 as well as qualitative and quantitative data.13,19 Other recommendations included analyzing data in subgroups by race, ethnicity, and neighborhood to identify disparities,2,19,20 collecting multiple health conditions from multiple sources,13 using standardized data collection instruments for comparison across place and time,13 and assessing the quality and reliability of the data.13,21 Beyond collecting data on community problems or issues, many models also included identifying community resources or assets that could be utilized to address health issues.2,10,12,13,19,21,23
Models included establishing priorities as part of the assessment process. This included reviewing data to identify priorities, based on preidentified criteria such as importance, changeability, measurability, feasibility, political and economic support, and/or impact.2,10,12,19,21 While some models encouraged using a collaborative process to select priorities,13,19,20 other models appear to include simply verifying or validating priorities with the community after initial, internal priority selection.2,21
Develop and implement intervention plan
Developing and implementing an intervention plan were a part of all models, which included identifying a range of strategies to address health priorities,10,12,13,19,20 considering barriers and community contextual factors,10,12,19 developing concrete actions,10,12 coordinating the plan with partners,10,12,13,23 and formally adopting the plan.2,10,12 Additional recommendations included developing and implementing public health policy, programs, or interventions that are community-focused,19,23 are evidence-based,13,20 address root causes,19,20 and are reflective of multiple levels of the social-ecological model that address upstream drivers and underlying determinants of health.10,12,19,23
Develop and implement evaluation plan
Developing and implementing an evaluation plan are another common and important components of assessment and planning. Model components for evaluation plans typically included monitoring program or policy performance and assessing health outcomes.2,10,12–15,21 Evaluation plans included developing goals, objectives, evaluation questions, indicators, and evaluation methods10,12–15 that evaluate the process,10,12–15,21 as well as outcomes or impact of actions.2,13
Communicate and receive feedback
Models often included communicating the assessment findings2,13–15,19–21 and disseminating the written intervention plan,2,13–15,19,20 providing an opportunity for community stakeholders to review drafts and contribute feedback on the assessment,2,13,19,20 and incorporating feedback from partners in the assessment and plan.2,13 Although rare, it might also include continuing dialogue and feedback loops, with the community, throughout the process.21
Sustain and celebrate
While not as common in assessment and planning models, components such as planning for long-term sustainability and celebrating successes were included in some. This included sustaining assessment and planning efforts by maintaining partnership,19 establishing new systems to maintain gains,23 and updating and sustaining the intervention plan.20 Underlying some models are the principles of community health development; that is, these assessment and planning models have dual goals of (1) improving the health of the community and (2) building local capacity to more effectively carry out those interventions.19 Few models included celebrating benchmarks and showcasing accomplishments.10,12,23 Assessment and planning are long processes; reaching benchmarks and improving health outcomes take years. Thus, celebrating shorter-term successes can help maintain high levels of enthusiasm and interest and acknowledge hard work and achievements.27
We found several commonalities across assessment and planning models and requirements. Broadly, these included preplanning; partnership development; developing vision and scope; collecting, analyzing, and interpreting data; identifying community assets; identifying priorities; developing and implementing an intervention plan; developing and implementing an evaluation plan; communicating and receiving feedback on the assessment findings and/or the plan; planning for sustainability; and celebrating success. The 2 most common assessment and planning processes are carried out by nonprofit hospitals, as required by the IRS,2 and health departments, for state and community health improvement14,15 and accreditation.13 While the purpose, parameters, timelines, and reporting requirements of these processes are different, there are opportunities for hospitals and health departments to collaborate and align efforts and, more importantly, improve community health. Frequently, components critical for community health improvement are facilitated through cross-sector collaboration and broad stakeholder engagement.
First, community assessment and planning should be treated as a shared responsibility across multiple sectors, including health care, public health, social services, housing, transportation, law enforcement, education, planning and zoning, community-based organizations and associations, and others. Models that emphasize multisector collaboration will bring together wide-ranging stakeholder groups to address broader determinants of health, plan toward a common goal, and combine financial, personnel, and other community resources. Hospitals and health departments can ensure broad-based community involvement and support, including formal and informal community leaders.
Beyond cross-sector collaboration, several models we examined engaged diverse community members in the process, who are reflective of the larger community demographics as well as medically underserved, low-income, minority, and high-risk populations. Broader community participation can provide differing perspectives,28 particularly the perspectives of the ultimate beneficiaries of programs and policies,29 emphasize locally relevant issues and approaches to addressing health issues,30,31 and build capacity for future collaboration and problem solving.28,30,32–34 Hospitals and health departments should aim for the higher rungs of Arnstein's26 Ladder of Participation, by engaging community stakeholders and community members in meaningful and participatory engagement throughout the assessment and planning processes, rather than an exclusively consultative role.
Hospitals and health departments should ensure the scope of the assessment and plan includes the broader community and not simply the hospital patient or health department client population. Most assessments and plans identify their priority population using geographic boundaries (ie, city, county, state). For ease of aligning funding streams and regulations, Jacobson and Teutsch35 recommend defining community using geopolitical boundaries.
Data are at the heart of assessment and planning efforts and should be used to guide decisions, but there are frequently data gaps and limitations encountered in these processes. It is important to consider health inequities by race, ethnicity, socioeconomic status, geography, and gender, but stratified secondary data may not be available at the county or community level. Thus, collecting primary data may be necessary. While health departments may not have the financial resources to conduct a random sample household survey, they (or academic institutions) likely have the expertise, which provides another opportunity for collaboration. Past studies found that hospitals often hire outside consultants to conduct CHNAs36,37; this is work that could be completed by collaborating, and even contracting, with health departments or academic institutions.
Occasionally, prioritization of the top health issues may be conducted by a small group internal to the organization conducting the assessment. Furthermore, hospitals or health departments may intentionally select priorities they alone can address for fear of being held accountable for expected changes and health improvements. For example, health departments may resist adopting mental health as a priority when mental health falls under the auspices of another governmental agencies. Hospitals may avoid adopting physical environmental improvements to increase physical activity. However, if prioritization and future planning are conducted across multiple sectors, actions and resulting changes should be a shared responsibility among stakeholders and occur, in part, outside hospital and health department walls. Ideally, the prioritization process should be transparent and inclusive, with final priorities identified through community forums, steering committees, or other multisector groups.
To improve community health, programs or policies selected for implementation should be based on existing evidence of effectiveness; reflect multiple levels of the social-ecological model; address underlying determinants of health, including socioeconomic, environmental, behavioral, and medical factors; and be appropriate for the community of interest. Planning tools, such as Theory of Change and Logic Models, can facilitate the planning process by ensuring underlying determinants are considered, through use of backward mapping strategies that begins with outcomes and lead to interventions, and by identifying assumptions and external factors.38,39 In addition, a Health in All Policies approach can be used to consider health across all sectors and in all policy decisions.40 Plans to evaluate programs or policies should monitor performance, short-, intermediate-, and long-term outcomes, as well as impact. Furthermore, evaluation plans should be developed concurrently to the program and should not be an afterthought.
Finally, throughout the assessment and planning processes, there should be a continuous cycle of sharing information with stakeholders, receiving information from stakeholders, and incorporating their feedback into the assessment and planning processes. This continuous process of community engagement, information dissemination, and feedback loops can help facilitate colearning and shared decision-making, develop new skills and abilities, strengthen relationships, build the capacity of the community and organizations involved, and create sustainability.41
This article is limited by the authors' knowledge of existing assessment and planning models and requirements, as well as more detailed description of model components. We assessed models based on requirements and recommendations. This is not to say these components are not voluntarily included in some assessment and planning processes, although they are not required. Several models were not included in this article, based on relevance to applied assessment and planning and space limitations. In addition, several states have developed CHA/CHIP models based on models included in this article, which we did not include.
Implications for Policy & Practice
* While there is no ideal or recommended assessment and planning model to use, this article provides an overview of different models, similarities and differences, and important considerations in conducting CHAs and developing CHIPs. This is of particular importance when considering the alignment of hospital and health department assessment and planning processes to avoid duplication of efforts, improve cross-sector collaboration, and implement intervention and evaluation plans that improve community health outcomes. Despite differences in purpose and reporting requirements, the basic components of hospital and health department assessment and planning are largely the same. Several examples of successful hospital and health department collaborations exist.42–44
* With the Affordable Care Act facing possible repeal or replacement, it is unknown whether the IRS requirements for nonprofit hospitals to conduct CHNA will remain. However, there will continue to be an expectation for nonprofit hospitals to provide community benefit to justify their tax-exempt status at the federal and/or state level, which could include the continuing assessment of and planning for community health improvement. A standardized approach to assessment and planning may not be appropriate, but federal and state policy requirements for hospitals could be revised or implemented to better facilitate alignment, collaboration, and potential for improved health outcomes.45–47
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community health assessment; community health improvement planning; community health needs assessment; health departments; implementation strategies; nonprofit hospitals