Before the Patient Protection and Affordable Care Act (ACA) took effect, tax-exempt hospitals spent little on community health improvement and, instead, focused their community benefit around patient care and services, especially to the uninsured.1,2 The ACA requires nonprofit hospitals to conduct a Community Health Needs Assessment (CHNA) every 3 years. CHNAs provide a basis for implementation strategies (most often in the form of a plan) that guide priorities for activities and spending around community benefit, with an express intention of improving population health.3 Both CHNAs and the resulting implementation strategies are expected to be made widely available to the public and demonstrate nonprofit hospitals' commitments to community benefit.2
As part of the CHNA process, regulations require “community input” as to the significant health needs of the population served by the hospital (living in the service area of the hospital, although not necessarily patients).4 Community input, as well as the process as a whole, is not well-defined by these regulations,5 so CHNAs have incorporated a wide range of methods in soliciting opinions from the public including focus groups, community surveys, and community events.5,6 Community involvement in the process also varies considerably, from very minimal to very in-depth participation by the public.7 Community input is designed to complement or provide additional information and context to the work of a leadership committee or team that guides the overall CHNA process.
Prior work in public health has demonstrated the general importance of gathering community input as part of needs assessments.8,9 Often this input is framed around the idea of garnering community buy-in to public health interventions and other programs designed to target significant health issues. Little work has been done to understand the impact of community input on needs assessment outcomes, however, not on how institutions use community input to craft implementation strategies. In fact, some research has noted the limited depth of public input in some cases and noted that such input can be marginalized and have smaller impacts on outcomes than intended.8
This article describes the CHNA process in 3 nonprofit hospitals and examines how community input helped shape the priorities chosen by the hospitals and ultimately the implementation strategies used to address significant health needs in those 3 communities. Specifically, we compare priority setting of the leadership team before public input and explore how the final CHNA product reflects the inclusion of community concerns. The makeup of the leadership teams for these projects followed similar existing models and included representatives from local public health, primary care, academics, and other groups providing health-related services in the communities.10
The authors conducted 3 CHNAs for separate nonprofit hospitals in 2016. The hospitals sit in 3 varied geographic settings. Community 1 sits in a metropolitan statistical area (most urban of the 3), community 2 sits in a micropolitan statistical area, and community 3 sits in an outside rural setting. The process we adopted included a series of 3 meetings with leadership teams, 1 community-wide meeting, a community-wide survey, and the development of an implementation plan. Leadership team meetings were held for the following purposes (listed chronologically):
1. To define the community served by each hospital, review existing health data (County Health Rankings, BRFSS data, etc), and Census data (demographics) and to identify the greatest health needs in the community based on the leadership team knowledge. Specifically, the leadership teams were individually asked to identify the 3 most important health issues in the community served by the hospital.
2. To review initial findings from the community survey (see later) and determine whether more specific sampling would be needed to target specific underrepresented groups in the community based on comparisons between demographic information provided by the respondents and Census data.
3. To synthesize initially identified community health needs with community survey results and prioritize significant health needs to target in each hospital's implementation strategy.
This process was adapted from prior CHNA work in the state of South Carolina, detailed in the LiveWell Kershaw 2013 Community Health Needs Assessment Report.11 This process involves the creation of a leadership team comprising nonprofit hospital administrators, providers, and staff and including outside community members as relevant. The leadership team works with a coordination team to create the CHNA and implementation reports. The creation of the CHNA includes assessments around community themes and strengths, community health status, forces of change, and capacity of the local public health system. Finally, the resulting implementation report is delivered to nonprofit hospital administration that decides what implementation resources are available and the feasibility of implementing the recommended strategies. All this feedback is incorporated into a report. The authors of this article served as the coordination and primary writing team for the West Virginia CHNAs described later.
The community survey was designed to solicit input from the populations comprising each hospital's geographic service area. In 2 cases, the hospitals chose to focus on the county in which the hospital was located as the “community served.” In one other case, the hospital chose to focus on 2 counties (the second county as not served by a hospital of its own and thus residents primarily used the hospital in the first county). Surveys were advertised and distributed through a number of methods, both on paper and via an online portal. There was no intentional effort to create a representative sample of all residents of the community. Instead, the survey was broadly disseminated in an effort to reach the most people, with special attention given to soliciting input from populations that had potentially unique needs (for instance, surveys were disseminated in the waiting room of primary care centers and free clinics and were administered in person in more rural parts of counties).
The survey instrument included a number of questions related to community health needs. Most pertinent to this research, the survey asked residents, “In the following list, what do you think are the 3 most important health problems or health issues in your county?” Thirty-five options were offered (adapted from the South Carolina model) and participants were asked to select 3 or write in an “other” answer. The full question and potential responses can be found in Supplemental Digital Content Appendix I (available at: http://links.lww.com/JPHMP/A320). Additional survey questions looked at demographics and geographic location of the respondent within the area served.
After significant health needs are identified by the leadership team, existing secondary health data, and the community as described by the process earlier, the coordination team presents a summary of all findings to the leadership team. At that point, the leadership team has a discussion of all input to date and selects priority areas to focus on using a prioritization matrix system that asks each leadership team member to rank pressing issues based on all input. The final selection of community health needs becomes the basis of the CHNA report.
Using the CHNA report, the leadership team next recommends 1 or more strategies to address the health needs. Ultimately, hospital administration reviews the final suggestions and, based on factors such as resources and competing priorities, selects the final implementation steps. The entire process can slightly vary from site to site. Often, the amount of participation that hospital administrators have in the leadership team can vary and impact how much change takes place from leadership team recommendations to the final CHNA implementation plan. The results later describe only priorities as identified by the CHNAs and do not explore the activities outlined in the implementation plans.
Tables 1 to 3 describe priorities identified by the leadership team, priorities identified through the community survey, and the finalized priorities (as selected by the leadership team) in each community. Bold priorities in the final column of these tables indicate the influence of public input into the finalized priorities. The survey findings indicate that community participation was essential in shaping the final priority list for all 3 nonprofit hospitals.
From the results, it is evident that community input provided several issues that the leadership teams did not generate on their own. These issues provided both a deeper understanding of substantial health needs in the communities served by nonprofit hospitals and providing some direction on how to target significant needs. It is evident from the tables that the leadership team chose in later prioritization meetings specific strategies to focus on and, in some cases, decided resources or other limitations prevented the hospital from directly addressing some identified health needs. We briefly describe the prioritization process in each community and how input from the population served to enrich and strengthen the CHNAs.
Community 1 had considerable overlap between leadership team priorities and those identified by the public survey. Upon review of the responses, the leadership team thought it was important to include mental health with substance abuse and to add a priority around injury control and prevention. These areas were identified as substantial needs by the community but not by the leadership team. Sexually transmitted diseases and infection were selected because of recent historical experience of 2 leadership team members who serve in agencies that address health needs of low-income populations—an issue that may not have been reflected in health data (because of temporal lag) and viewed largely as a secondary effect of intravenous drug use on risky sexual behaviors and potential engagement in risky behaviors in exchange for drugs.
Community 2 also found substantial overlap between community priorities and leadership team priorities. The number one issue identified by both was drug and alcohol abuse. The leadership team, however, decided that hospital resources would best be prioritized elsewhere due to limited expertise and capacity to influence that issue at the hospital level. On that note, it saw obesity and diabetes and a very significant problem in the community and began to explore ways to tackle the issue. The community survey asked a number of questions around larger community perceptions, and it was clear that access to health and wellness activities was lacking in the community (>65% of community members indicated it to be a problem). With that in mind, the hospital decided to directly work to enhance opportunities for health and wellness to help with prevention and management of obesity and diabetes.
Again, there was considerable overlap between the leadership team and community input. Unlike the leadership team, however, the community indicated cancer as a major health issue in the community. Survey results also spurred the leadership team to broaden its definition of obesity as a health problem to include diabetes, heart disease, and other chronic conditions. The final priorities of this hospital addressed both cancer and other chronic diseases in its implementation strategies.
It is also crucial to discuss the importance and value of community involvement in the process from another angle. It is highlighted here the importance of outside input in the priority setting area, but community involvement in the agenda setting stage may lend itself to stronger collaboration between the hospital and community as implementation begins. Because the needs addressed by the CHNA have been identified as self-important by the community, they are likely more receptive to working on solutions to these issues. Future research should investigate these linkages and outputs.
The results presented earlier also reflect initial leadership team and community priorities in inconsistent and varied ways. In some cases, issues that are highly ranked may drop out of the final prioritization or lower-ranked issues may rise to the top. This inconsistency is difficult to explain by the coordination team. Future CHNA work may need to find approaches that allow leadership teams to more consistently rank issues for final reports and provide guidance for the importance of community input. At the same time, this flexibility may allow leadership teams to think outside of populist thinking and consider specific needs of special populations such as minorities, individuals with low income and special health conditions, etc. Perhaps, more important than standardizing the final prioritization is developing a method for capturing how and why issues move up or down in the rankings.
This article demonstrates the importance of community input in nonprofit hospital CHNA processes. While leadership team members had important contributions to identifying the most pressing needs in their communities, community input both provided additional health needs that were not identified by the leadership team and provided potential avenues to address significant health needs (such as increasing health and wellness opportunities to help prevention and management of chronic disease). Community input became central to the final version of the CHNA plan and was directly involved in shaping implementation strategies. Changes resulting from this input ranged from adding completely new priorities (such as cancer or injury control and prevention) to refining needs identified by the leadership team (adding other chronic disease to obesity) to identifying strategies by which to address identified health needs (focusing on a lack of access to health and wellness activities). While community input has long been considered integral to public health interventions and efforts, the data here demonstrate its importance in the community benefit process under the ACA. As reforms to the ACA are considered, it will be important that policy makers and other stakeholders continue to understand and prioritize the importance of community input into the process by recognizing the unique role and contribution it can provide.
Implications for Policy & Practice
* Community participation is key in identifying unique health needs and should always be incorporated into the CHNA process.
* CHNAs without adequate public input may not translate into implementation plans that accurately address pressing health concerns.
* As reforms are considered to the ACA, it will be important to emphasize the importance of community input in identifying ways nonprofit hospitals contribute community benefit.
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community benefit; community health needs assessment