Community Health Needs Assessment Research Articles

Joint Community Health Needs Assessments as a Path for Coordinating Community-Wide Health Improvement Efforts Between Hospitals and Local Health Departments.

To examine the association between hospital-local health department (LHD) collaboration around community health needs assessments (CHNAs) and hospital investment in community health. We combined 2015 National Association of County and City Health Officials (NACCHO) Forces of Change, 2013 NACCHO Profile, and 2014-2015 Area Health Resource File data to identify a sample of LHDs (n = 439) across the United States. We included data on hospitals' community benefit from their 2014 tax filings (Internal Revenue Service Form 990, Schedule H). We used bivariate and multivariate regression analyses to examine LHDs' involvement in hospitals' CHNAs and implementation strategies and the relationship with hospital investment in community health. The LHDs that collaborated with hospitals around CHNAs were significantly more likely to be involved in joint implementation planning activities than were those that did not. Importantly, LHD involvement in hospitals' implementation strategies was associated with greater hospital investment in community health improvement initiatives. Joint CHNAs may improve coordination of community-wide health improvement efforts between hospitals and LHDs and encourage hospital investment in community health improvement activities. Public Health Implications. Policies that strengthen LHD-hospital collaboration around the CHNA may enhance hospital investments in community health.

Conducting Community Health Needs Assessments in the Local Public Health Department: A Comparison of Random Digit Dialing and the Community Assessment for Public Health Emergency Response

Community health needs assessments (CHNAs) are now required by the Affordable Care Act (ACA) for nonprofit hospitals and the Public Health Accreditation Board (PHAB) for local health departments that seek accreditation. Currently, various primary data collection methods exist that meet the ACA and PHAB requirements. To compare 2 CHNA data collection methods implemented in the same geographical area from a local health department perspective. Two community surveys, one door-to-door and one telephone, in the 76706 zip code area of McLennan County, Texas. Adult survey respondents (Community Assessment for Public Health Emergency Response [CASPER]: N = 184; random digit dialing [RDD]: N = 133) of the 76706 zip code in McLennan County, Texas. Survey response rates, sociodemographic characteristics of survey respondents, and self-reported health behaviors from both community survey types. The CASPER survey had a contact rate of 36.0% and a cooperation rate of 60.5%, compared with a 10.1% response rate for the RDD survey. CASPER respondents were younger (26.6% aged 18-24 years), had lower education attainment (17.4% less than high school), and had a higher proportion of Hispanics (24.5%) than RDD respondents (4.6%, 10.5%, and 17.3%, respectively). CASPER respondents were less likely to report being overweight or obese (56.5%), to report days where no fruit or vegetables were consumed (7.1%), and to report days where no walking activity was conducted (9.8%) than RDD respondents (70.2%, 27.8%, and 21.8%, respectively). The CASPER survey cost less to conduct ($13 500) than the RDD survey ($100 000) and was logistically easier for the local health department to conduct using internally available resources. Local health departments use various data collection methods to conduct CHNAs for their populations and require varying levels of commitment and resources. RDD and CASPER can be used to meet ACA and PHAB requirements, collecting valuable health needs estimates and offer various strengths and weaknesses. PHAB and ACA requirements can be met using the CASPER or RDD survey to conduct CHNAs. However, local health departments may consider the CASPER survey a viable alternative to the RDD survey when time and resources are limited. The CASPER survey offers flexibility and efficiency and requires limited equipment and training.

Trialing the Community-Based Collaborative Action Research Framework: Supporting Rural Health Through a Community Health Needs Assessment.

To describe the application of the Community-Based Collaborative Action Research (CBCAR) framework to uplift rural community voices while conducting a community health needs assessment (CHNA) by formulating a partnership between a critical access hospital, public health agency, school of nursing, and community members to improve societal health of this rural community. This prospective explorative study used the CBCAR framework in the design, collection, and analysis of the data. The framework phases include: Partnership, dialogue, pattern recognition, dialogue on meaning of pattern, insight into action, and reflecting on evolving pattern. Hospital and public health agency leaders learned how to use the CBCAR framework when conducting a CHNA to meet Affordable Care Act federal requirements. Closing the community engagement gap helped ensure all voices were heard, maximized intellectual capital, synergized efforts, improved communication by establishing trust, aligned resources with initiatives, and diminished power struggles regarding rural health. The CBCAR framework facilitated community engagement and promoted critical dialogue where community voices were heard. A sustainable community-based collaborative was formed. The project increased the critical access hospital's capacity to conduct a CHNA. The collaborative's decision-making capacity was challenged and ultimately strengthened as efforts continue to be made to address rural health.

Health Disparities Educational Initiative for Residents.

The Wayne State University Graduate Medical Education (GME) Office and Ascension Crittenton Hospital developed an educational initiative to increase resident awareness of health disparities and local community health priorities. The Plan-Do-Study-Act (PDSA) rapid-cycle performance improvement framework was used for implementation and evaluation. During the first PDSA cycle, residents attended 5 didactic sessions. During the second PDSA cycle, residents participated in a problem-based learning (PBL) case. The following data were collected: evaluations of the didactic sessions and case, the number of appointments for diabetes self-management and education (DSME) referred by faculty and residents, and responses to questions on the annual GME surveys related to resident understanding of health disparities and the hospital's community health needs assessment (CHNA). Eighty-eight percent of residents defined health disparities at least partially correctly in both project years. The percentage of residents who knew how to access their hospital's CHNA increased from 25% to 29% year over year. Residents rated PBL more effective in achieving learning objectives than didactics, but the difference was not statistically significant. Six appointments for DSME were referred by program faculty and residents in the 2-month period immediately before the didactic sessions, and 6 referrals were made in a 2-month period between the didactic sessions and the PBL case. In the 2-month period immediately following the PBL case, 9 appointments for DSME were referred by residents and program faculty. Residents have a good understanding of health disparities, although many may not recognize disparities that exist in their local community. PBL was more effective than didactics for resident education about local health disparities, CHNA, and DSME. Aligning GME and hospital leadership in a common vision for disparities education, as well as community engagement, is critical to successful outcomes.

The Magnitude of a Community's Health Needs and Nonprofit Hospitals' Progress in Meeting Those Needs: Are We Faced With a Paradox?

Although most nonprofit hospitals are required to conduct periodic community health needs assessments (CHNAs), such assessments arguably are most critical for communities with substantial health needs. The objective of this study was to describe differences in progress in conducting CHNAs between hospitals located in communities with the greatest compared with the fewest health needs. We used data on CHNA activity from the 2013 tax filings of 1331 US hospitals combined with data on community health needs from the County Health Rankings. We used bivariate and multivariate analyses to examine differences in hospitals' progress in implementing comprehensive CHNAs using 4 activities: (1) strategies to address identified needs, (2) participation in developing community-wide plans, (3) including CHNA into a hospital's operational plan, and (4) developing a budget to address identified needs. We compared progress in communities with the greatest and the fewest health needs using a comprehensive indicator comprising a community's socioeconomic factors, health behaviors, access to medical care, and physical environment. In 2013, nonprofit hospitals serving communities with the greatest health needs conducted an average of 2.5 of the 4 CHNA activities, whereas hospitals serving communities with the fewest health needs conducted an average of 2.7 activities. Multivariate analysis, however, showed a negative but not significant relationship between the magnitude of a community's health needs and a hospital's progress in implementing comprehensive CHNAs. Hospitals serving communities with the greatest health needs face high demand for free and reduced-cost care, which may limit their ability to invest more of their community benefit dollars in initiatives aimed at improving the health of the community.

Defining “Community” in Community Health Evaluation

This article examines the theoretical basis of the community as it is evoked in health evaluation. In particular, we examine how hospitals carrying out Community Health Needs Assessments (CHNAs) define communities as well as the implications for these definitions for how to study and engage community problems. We present qualitative findings from a sample of Appalachian nonprofit hospitals, who we asked to describe their approach to defining the community in their most recent Internal Revenue Service–mandated CHNA. Drawing upon a theoretical debate in the history of evaluation research, the authors argue that the contemporary community cannot be circumscribed merely by geographic boundaries, nor can it be identified easily with a bounded group of clearly demarcated individuals. Instead, following the tenets of community-based health research, the authors argue for a richer, more dynamic conceptualization of the community in evaluation research in which definitions arise from community bodies themselves.

Using a Gender‐Responsive Approach to Generate Policy, Systems, and Environmental Changes to Improve Women's Health

Community coalitions have proven to be an effective mechanism for identifying and addressing social determinants of health. This project mobilized the Inkster Partnership for a Healthier Community (IPHC) coalition, bringing together diverse organizations, and community residents in Inkster, MI to collaboratively develop a strategic plan to address health inequities revealed in a community health needs assessment (CHNA). The coalition designed a multi‐faceted, gender‐responsive approach designed to increase social connectedness as a means to improve health and foster well‐being among women in the community. The approach included three core strategies: (i) providing health literacy mentoring, (ii) using community health workers (CHWs) and lay health educators to increase opportunities for access to and use of community health resources and self‐management programs, and (iii) publicizing targeted health messages intended to positively influence gender norms related to women's health. Emphasis was also placed on instituting policy systems and environmental (PSE) changes to promote sustainable community health improvements. Initial implementation outcomes indicate that a gender‐responsive approach to community health improvement initiatives is a promising model for how coalitions can purposefully adapt and evolve to incorporate gender‐based considerations into programmatic and PSE change efforts that equitably benefit all residents.

Increased Public Accountability for Hospital Nonprofit Status: Potential Impacts on Residency Positions.

The Institute of Medicine recently called for greater graduate medical education (GME) accountability for meeting the workforce needs of the nation. The Affordable Care Act expanded community health needs assessment (CHNA) requirements for nonprofit and tax-exempt hospitals to include community assessment, intervention, and evaluation every 3 years but did not specify details about workforce. Texas receives relatively little federal GME funding but has used Medicaid waivers to support GME expansion. The objective of this article was to examine Texas CHNAs and regional health partnership (RHP) plans to determine to what extent they identify community workforce need or include targeted GME changes or expansion since the enactment of the Affordable Care Act and the revised Internal Revenue Service requirements for CHNAs. Texas hospitals (n = 61) received federal GME dollars during the study period. Most of these hospitals completed a CHNA; nearly all hospitals receiving federal GME dollars but not mandated to complete a CHNA participated in similar state-based RHP plans. The 20 RHPs included assessments and intervention proposals under a 1115 Medicaid waiver. Every CHNA and RHP was reviewed for any mention of GME-related needs or interventions. The latest available CHNAs and RHPs were reviewed in 2015. All CHNA and RHP plans were dated 2011 to 2015. Of the 38 hospital CHNAs, 26 identified a workforce need in primary care, 34 in mental health, and 17 in subspecialty care. A total of 36 CHNAs included implementation plans, of which 3 planned to address the primary care workforce need through an increase in GME funding, 1 planned to do so for psychiatry training, and 1 for subspecialty training. Of the 20 RHPs, 18 identified workforce needs in primary care, 20 in mental health, and 15 in subspecialty training. Five RHPs proposed to increase GME funding for primary care, 3 for psychiatry, and 1 for subspecialty care. Hospital CHNAs and other regional health assessments could be potentially strategic mechanisms to assess community needs as well as GME accountability in light of community needs and to guide GME expansion more strategically. Internal Revenue Service guidance regarding CHNAs could include workforce needs assessment and intervention requirements. Preference for future Medicaid or Medicare GME funding expansion could potentially favor states that use CHNAs or RHPs to identify workforce needs and track outcomes of related interventions.

What Challenges Do Nonprofit Hospitals Face in Taking on Community Health Needs Assessments? A Qualitative Study From Appalachian Ohio.

The purpose of this study is to understand the experiences of Appalachian hospitals in undertaking Community Health Needs Assessments (CHNAs). Of particular interest is whether new requirements to undertake regular evaluation and public health programming pose challenges for rural, Appalachian hospitals. Using a sample of nonprofit hospitals in Appalachian Ohio, we conducted in-depth qualitative interviews with hospital administrators overseeing community benefit activities and external consultants hired to complete assessments. Following a grounded theory approach, we coded interviews to ascertain major themes. Our findings suggest that there are several challenges faced by nonprofit hospitals that may relate to their status as rural hospitals. In particular, we found that these hospitals struggle to hire staff to oversee CHNAs, often lack the material resources to address needs identified in reports, and seek more concrete guidelines from the IRS on carrying out these new activities in their communities. The results from these interviews suggest that there is significant support for new CHNA activities in Appalachian Ohio, but challenges remain to translate these efforts into improved health outcomes in this region. Because rural Appalachia, in particular, faces significant health disparities and a relative lack of health care providers, there is a potential for hospitals to take on an important role in public and preventive health if initial challenges are addressed.

Exploring the Link Between Completion of Accreditation Prerequisites and Local Health Departments' Decision to Collaborate With Tax-Exempt Hospitals Around the Community Health Assessment.

Community health assessments (CHAs) are a core function of local health departments (LHDs). Recently, completing a CHA has become a prerequisite for LHDs seeking accreditation by the Public Health Accreditation Board (PHAB). Similarly, under the Affordable Care Act, nonprofit hospitals are required to conduct periodic community health needs assessments (CHNAs). Opportunities thus exist for LHDs and hospitals to jointly complete CHAs/CHNAs. This study examined existing LHD-hospital collaborations around CHAs/CHNAs, focusing specifically on the relationship between LHDs' level of engagement with PHAB accreditation activities and their collaboration with hospitals around CHAs/CHNAs. Data came from the 2013 NACCHO (National Association of County & City Health Officials) Profile Study and the Area Health Resource File. Complete data were available for 1332 LHDs that participated in the 2013 NACCHO Profile Study. Logistic regression explored the relationship between LHDs' completion of accreditation prerequisites, in particular completion of a CHA, community health improvement plan, and strategic plan, and their involvement in collaborations with tax-exempt hospitals around CHAs/CHNAs. LHDs that collaborated with tax-exempt hospitals on CHAs/CHNAs were larger, more likely to be locally governed, and more likely to have a local board of health. Bivariate analysis showed that CHA/CHNA-related collaboration with hospitals was significantly correlated (P < .01) with an LHD's completion of accreditation prerequisites. In multivariate regression analysis, completion of all 3 PHAB accreditation prerequisites significantly increased the odds of LHDs collaborating with hospitals when controlling for other LHD and community-level characteristics. PHAB accreditation prerequisites together with IRS requirements for hospitals foster potential for collaboration around CHAs/CHNAs. Joint completion of CHAs/CHNAs not only allows partners to complete the assessment more efficiently but has also been shown to produce higher-quality assessments, thus building a strong foundation for continued collaboration to improve community health.

Abstract A67: Addressing rural disparities: Community outreach to assess the need for cancer prevention, screening, and access to treatment in rural Utah

Abstract Background/Purpose The purpose of this study is to collect community health needs assessment data specific to rural Utah as part of designing tailored prevention and education programs. Cancer prevention, screening, and access to treatment in Rural Utah presents a unique set of challenges. Utah is a large state with vast and sparsely populated areas. More than 96% of the state is defined as either rural (&amp;lt;100 persons/sq. mile) or frontier (&amp;lt;7 persons/sq. mile). In Utah, these populations contend with great distances from academic health care centers, lack of ready access to care, and lack of education and available reliable health information; resulting in poor cancer health outcomes, lower cancer screening rates, and higher rates of tobacco use. Since 1999, Community Outreach and Prevention Education (COPE) at Huntsman Cancer Institute (HCI) has successfully disseminated information about cancer prevention to &amp;gt;1 million people. With funding from the National Cancer Institute, HCI has expanded COPE efforts to address known cancer disparities in 4 identified Utah health districts via a Community Health Educator (CHE). The first phase of the three-year grant is underway. Data collection methods, and findings will be described. Methods The COPE program expansion targets Tooele, Tri-County, Central, and Southeastern Utah health districts. Each have poor rankings in cancer mortality, early detection, and health behaviors, with limited contact from HCI's research, clinical, and education programs. The 3 phases of expansion include: • Year 1: partnership building, community health needs assessment (CHNA) • Year 2: evidence-based intervention strategies, program implementation • Year 3: program evaluation, sustainability During year 1, knowledge, beliefs, intentions, and behaviors related to cancer prevention and screening were collected via stakeholder interviews, focus groups with community members, short surveys, and follow-up e-mail/telephone questionnaires. The CDCynergy Lite planning model and theory of planned behavior guided the CHNA instruments. Results/Findings Rural data and outcomes from community members and key stakeholders will be shared. Discussion The results of the CHNA will contribute to evidence-based intervention strategies and will be used to implement tailored and culturally appropriate programs to improve these needs and evaluate effectiveness. Results/findings from year 1 also provide opportunities for HCI researchers and other community organizations to expand their work in the targeted districts. Citation Format: Jennyffer Morales, Ana Maria Lopez, Garrett Harding, Jeff Yancy, Donna Branson. Addressing rural disparities: Community outreach to assess the need for cancer prevention, screening, and access to treatment in rural Utah. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A67.

Putting the Community back into Community Health Needs Assessments: Maximizing Partnerships Via Community-Based Participatory Research.

The community health needs assessment (CHNA) mandate of the Patient Protection and Affordable Care Act (ACA) has the potential to make significant and sustainable change in the health of communities. However, to date many hospital-led assessments have used traditional, top-down data collection approaches that overemphasize individualized community member deficits and underutilize collaboration across sectors. The purpose of this paper is to present the principles of community-based participatory research (CBPR) as a framework for conducting CHNAs in a way that mitigates the potential for harm, waste, and misrepresentation of community assets and needs that characterizes many existing CHNA processes, illustrating the power of applying CBPR partnerships to this process. CBPR is a framework to engage community members directly in research design, the collection and analysis of data, and the creation of action plans that address research findings. Key principles include collaborative involvement, establishment of empowering processes, and long-term commitment. A case example of an innovative community partnership demonstrates the power and challenges of taking a CBPR approach to the CHNA process. CBPR has incredible potential to be incorporated into ACA-mandated hospital CHNAs, leading to increased impact and shared power with community members.

The Progress of US Hospitals in Addressing Community Health Needs

To identify how US tax-exempt hospitals are progressing in regard to community health needs assessment (CHNA) implementation following the Patient Protection and Affordable Care Act. We analyzed data on more than 1500 tax-exempt hospitals in 2013 to assess patterns in CHNA implementation and to determine whether a hospital's institutional and community characteristics are associated with greater progress. Our findings show wide variation among hospitals in CHNA implementation. Hospitals operating as part of a health system as well as hospitals participating in a Medicare accountable care organization showed greater progress in CHNA implementation whereas hospitals serving a greater proportion of uninsured showed less progress. We also found that hospitals reporting the highest level of CHNA implementation progress spent more on community health improvement. Hospitals widely embraced the regulations to perform a CHNA. Less is known about how hospitals are moving forward to improve population health through the implementation of programs to meet identified community needs.

Local Health Departments' Involvement in Hospitals' Implementation Plans

Background: More than half of all local health departments (LHDs) in the U.S. are involved in collaborations with nonprofit hospitals on a community health needs assessment (CHNA), yet little is known about the role that LHDs play in hospitals’ implementation plans. Purpose: This study aims to explore the current state of hospital–LHD collaborations around the implementation plan using data from a survey of LHDs across the country. Methods: The study sample included 457 LHDs that completed both the 2015 Forces of Change survey and the 2013 Profile survey conducted by the National Association of County and City Health Officials. Univariate and bivariate analyses were used to compare LHDs involved in hospitals’ implementation plans to LHDs not involved in such activities. All analyses were conducted in 2016. Results: Of the 457 sample LHDs, 62% were involved in at least one activity associated with hospitals’ implementation plans. These LHDs were larger, had greater budgets, and were more likely to be locally governed. In addition, almost all of these LHDs reported that they also collaborated with hospitals around the CHNA. Implications: There is evidence of substantial involvement of LHDs in hospitals’ implementation plans. Importantly, joint CHNAs appear to pave the path for hospital–LHD collaboration in this area. Since LHDs that collaborate with hospitals on their implementation plans tended to be better resourced, policymakers may want to find ways to ensure that smaller LHDs have the necessary human and fiscal resources to be engaged in joint community health needs assessment and improvement planning activities.

A Mixed-Methods Approach to Understanding Community Participation in Community Health Needs Assessments.

Nonprofit hospitals are exempt from paying taxes. To maintain this status, they must provide benefit to the community they serve. In an attempt to improve accountability to these communities and the federal government, the Patient Protection and Affordable Care Act of 2010 includes a provision that requires all nonprofit hospitals to conduct a community health needs assessment (CHNA) and implement strategies to address identified health priorities every 3 years. This Act's provision, operationalized by a regulation developed and enforced by the Internal Revenue Service, mandates the involvement of public health agencies and other community stakeholders in the completion of the CHNA. To better understand community participation in nonprofit hospital-directed community health assessment and health improvement planning activities. Using a 2-phased, mixed-methods study design, we (1) conducted content analysis of 95 CHNA/implementation plan reports and (2) interviewed hospital and health system key informants, consultants, and community stakeholders involved in CHNA and planning processes. Community participation was assessed in terms of types of stakeholders involved and the depth of their involvement. Our findings suggest that many hospitals engaged and involved community stakeholders in certain aspects of the assessment process, but very few engaged a broad array of community stakeholder and community members in meaningful participation throughout the CHNA and health improvement planning process. Vast improvements in community participation and collaborative assessment and planning can be made in future CHNAs. On the basis of the findings, recommendations are made for further research. Practice implications include expanding community engagement and participation by stakeholder and activity type and using a common community health improvement model that better aligns hospital CHNA processes and implementation strategies with other organizations and agencies.

The Hospital Community Benefit Program: Implications for Food and Nutrition Professionals.

This article briefly explains the food and nutrition implications of the new standards, tax penalties and reporting requirements for non-profit hospitals and healthcare systems to maintain a tax-exempt or charitable status under section 501(c)(3) of the Federal Internal Revenue Code set forth in The Patient Protection and Affordable Care Act (P.L. 111-148, Sec. 9007). The newly created 501(r) of the Internal Revenue Code requires, beginning with the first tax year on or after March 23, 2012, that such hospitals demonstrate community benefit by conducting a community health needs assessment (CHNA) at least once every three years and annually file information by means of a Schedule H (Form 990) regarding progress towards addressing identified needs. As hospitals conduct their CHNA and work further and collaboratively with community stakeholders on developing and monitoring their proposed action plans, the breadth and depth of food and nutrition activities occurring as a result of the Affordable Care Act Hospital Community Benefit Program will likely increase. The CHNA requirement, along with other emerging initiatives focused on improving the food environments and nutrition-related activities of hospitals and healthcare systems offer fruitful opportunities for food and nutrition professionals to partner on innovative ways to leverage hospital infrastructure and capacity to influence those residing, working or visiting the hospital campus, as well as the surrounding community.

The Power of Community Voices for Enhancing Community Health Needs Assessments.

As required by the Affordable Care Act, Community Health Needs Assessments (CHNAs) are formalized processes nonprofit hospitals must perform at least every 3 years. CHNAs are designed to help hospitals better tailor health services to the needs of local residents. However, CHNAs most often use quantitative, population-level data, and rarely incorporate the actual voices of local community members. This is particularly a problem for meeting the needs of residents who are also racial or ethnic minorities. This article discusses one model for integrating residents' voices into the CHNA process. In this model, we videotaped interviews with community members and then coded and analyzed interview data to identify underlying themes. We created a short video aimed at starting conversations about community members' concerns. In addition to demonstrating how other nonprofit hospitals may use qualitative data in the CHNA process, this article illustrates how adding qualitative data may change how we think about health promotion. We find that community members requested that health care providers view culture as a health resource, foster community connections, and be present in the community.

Leveraging University-Community Partnerships in Rural Georgia: A Community Health Needs Assessment Template for Hospitals

Background: Under the Affordable Care Act, nonprofit hospitals are required to conduct a Community Health Needs Assessment (CHNA) every three years. Using recommendations proposed by Georgia Watch, students and faculty members from the University of Georgia (UGA) conducted a CHNA for a hospital in a rural county in Georgia. The purpose of the CHNA was to identify community health problems and needs, as well as community assets and resources. The aim of this report is to describe the process for conducting the CHNA, the findings, and the lessons learned.

Community Health Needs Assessment: Potential for Population Health Improvement.

Derived from various health care policies and initiatives, the concept of population health has been newly adopted by health care and medicine. In particular, it has been suggested that the Patient Protection and Affordable Care Act provision that requires nonprofit hospitals to conduct a community health needs assessment (CHNA) and implement strategies to address health priorities has the potential to improve population health. A mixed methods study design was used to examine the potential for population health improvements to occur through the Internal Revenue Service (IRS)-mandated nonprofit hospital CHNA and planning processes. Methods involved a 2-phased approach composed of (1) content analysis of 95 CHNA/implementation strategies reports and (2) interviews with key informants, consultants, and community stakeholders involved in CHNA and planning processes. Although this is a great opportunity for the nonprofit hospital assessment and planning processes to influence population health outcomes, the findings from the first 3-year assessment and planning cycle (2011-2013) suggest this is unlikely. As nonprofit hospitals begin the second 3-year assessment and planning cycle, this article offers recommendations to increase the potential for nonprofit hospitals to improve population health. These recommendations include clarifying the purpose of IRS CHNA regulations, engaging community stakeholders in collaborative assessment and planning, understanding disease etiology and identifying and addressing broader determinants of health, adopting a public health assessment and planning model, and emphasizing population health improvement. (Population Health Management 2016;19:178-186).

Opportunities for Prevention: Assessing Where Low-Income Patients Seek Care for Preventable Coronary Artery Disease.

The Affordable Care Act has many aspects that are aimed at improving health care for all Americans, including mandated insurance coverage for individuals, as well as required community health needs assessments (CHNAs), and reporting of investments in community benefit by nonprofit hospitals in order to maintain tax exemptions. Although millions of Americans have gained access to health insurance, many--often the most vulnerable--remain uninsured, and will continue to depend on hospital community benefits for care. Understanding where patients go for care can assist hospitals and communities to develop their CHNA and implementation plans in order to focus resources where the need for prevention is greatest. This study evaluated patient care-seeking behavior among patients with coronary artery disease (CAD) in Florida in 2008--analyzed in 2013--to assess whether low-income patients accessed specific safety net hospitals for treatment or received care from hospitals that were geographically closer to their residence. This study found evidence that low-income patients went to hospitals that treated more low-income patients, regardless of where they lived. The findings demonstrate that hospitals-especially public safety net hospitals with a tradition of treating low-income patients suffering from CAD-should focus prevention activities where low-income patients reside.