ONE SIZE DOES NOT FIT ALL: UNDERSTANDING THE CHALLENGES AND
USEFULNESS OF THE COMMUNITY HEALTH NEEDS ASSESSMENT
by
Liana Marielle Verzella
B.S. Health Management Systems, Duquesne University, 2012
Submitted to the Graduate Faculty of
Health Policy and Management
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Health Administration
University of Pittsburgh
2014
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Liana Marielle Verzella
on
April 14, 2014
and approved by
Essay Advisor:
Nicholas Castle, MHA, PhD
______________________________________
Professor
Department of Health Policy and Management
Graduate School of Public Health
University of Pittsburgh
Essay Reader:
Brenda Cassidy, DNP, MSN,CPNP-PC
Assistant Professor
School of Nursing
University of Pittsburgh
______________________________________
Essay Reader:
Pamela Schanwald, RN, MSHA
CEO
______________________________________
The Children’s Home of Pittsburgh & Lemieux Family Center
(If you have an extra reader, add their info; you can adjust the spacing on this page to fit it.)
ii
Copyright © by Liana Verzella
2014
iii
Nicholas Castle, MHA, PhD
ONE SIZE DOES NOT FIT ALL: UNDERSTANDING THE CHALLENGES AND
USEFULNESS OF THE COMMUNITY HEALTH NEEDS ASSESSMENT
Liana M. Verzella, MHA
University of Pittsburgh, 2014
ABSTRACT
The passing of the Patient Protection and Affordable Care Act and The Health Care Education
Affordability Reconciliation Act of 2010 created new requirements and responsibilities for taxexempt hospitals, one of them being a community health needs assessment. In July of 2011, the
IRS further clarified the requirements of the needs assessments and mandated that hospitals
report their findings on the Schedule H of the Form 990. Although this process was created to
help heath care systems best care for the needs of their communities’, these new expectations
have put a strain on many healthcare organizations, especially those not positioned to meet the
needs identified in their assessments. The community health needs assessment, or CHNA, seeks
to understand the needs, health status, and behaviors of the community served by a hospital, yet
it does not take into account the myriad and diversity of the tax-exempt healthcare organizations
that make up today’s market. Is it realistic to assume that all healthcare systems can meet the
same requirements, whether it is a 10-bed specialty hospital, or multi hospital, integrated
healthcare system? In a time of healthcare reform, resource scarcity and economic instability, the
CHNA adds another layer of complication for many healthcare organizations, yet it can also be a
beneficial and resourceful asset. This piece takes a look into the usefulness and challenges of the
CHNA, and the idea that it may not be a “one size fits all” process, as the IRS had originally
iv
anticipated. As healthcare is transitioning from acute episodic care to population based care, the
CHNA will play a large role in the success of healthcare organizations achieving this goal. The
CHNA will become a useful tool in the planning and implementation of population and
community-based programs, and while improving the public health sector to help shape the
future of healthcare.
v
TABLE OF CONTENTS
PREFACE.................................................................................................................................VIII
1.0 INTRODUCTION................................................................................................................ 1
2.0 COMMUNITY HEALTH NEEDS ASSESSMENT: 101………………………………..3
2.1.1 Background……………………………………………………….............3
2.1.2 Reporting Requirements and Guidelines……………………………….5
2.1.3 ACA and Policy Implications…………………………………………...6
3.0 EXAMPLES OF CHNA PROCESS HEALTH NEEDS ASSESSMENT....................... 7
3.1 The Children's Home of Pittsburgh ............................................................................ 7
3.1.1 Background……………………………………………………………….7
3.1.2 Methods and Processes…………………………………………………...8
3.1.3 Outcomes………………………………………………………………...10
3.2 West Penn Allegheny Health System ........................................................................ 12
3.2.1 Background……………………………………………………………...12
3.2.2 Methods and Processes.…………………………………………………13
3.2.3 Outcomes………………………………………………………………...13
4.0 USEFULNESS OF A CHNA ............................................................................................. 15
5.0 CHALLENGES ................................................................................................................... 16
6.0 FINANCIAL IMPLICATIONS........................................................................................ 19
7.0 EFFECT ON PUBLIC HEALTH ..................................................................................... 20
Appendix A: Interview with Deborah Thompson.................................................................... 22
Appendix B: Interview with Mark LaRosa ............................................................................. 24
Appendix C: Interview with Kim Phillips ............................................................................... 26
Appendix D: The Children's Home: Initiative Selection Document ...................................... 27
Appendix E: The Children's Home: Pediatric First Aid Class Survey ................................. 28
Appendix F: The Children's Home: Baby Ready Pets Survey ............................................... 29
BIBLIOGRAPHY ....................................................................................................................... 30
vi
LIST OF FIGURES
Figure 1: The 6 steps of the CHNA process………………………………………………………5
Figure 2: The Timeline for the CHNA Process at The Children’s Home of Pittsburgh…………..9
Figure 3: Outcomes of the Baby Ready Pets Class at The Children’s Home of Pittsburgh……..11
Figure 4: Outcomes of the Pediatric First Safety Class at The Children’s Home of Pittsburgh…12
Figure 5: Top 10 Community Health Issues Identified by WPAHS…………………………….14
vii
PREFACE
The work in this essay is a product of my residency at The Children’s Home of Pittsburgh from
January 2013 to January 2014. This essay is a collaboration of my work in completing and
implementing a Community Health Needs Assessment for The Children’s Home of Pittsburgh,
primary data from CHNA’s conducted in the market, and scholarly research. I would like to
thank the management team at The Children’s Home of Pittsburgh, especially Pam Schanwald,
for giving me the opportunity to complete the CHNA for the organization and for all of the
guidance and mentorship during my residency. I would also like to extend many thanks to Dr.
Nicholas Castle, Mark LaRosa, Kim Phillips, and Deb Thompson for your advice, tips, and
assistance throughout this process.
viii
1.0 INTRODUCTION
In the healthcare sector, there has been much debate over the difference between the
actions of nonprofit hospitals and for profit hospitals. Since 1969, nonprofit hospitals have been
tax- exempt based off of their charitable nature and community benefit; however, there is a
“growing concern that nonprofit hospitals are providing insufficient benefits to their
communities in return for their tax-exempt status” (Principe et al. 2012). In response to the
criticisms and controversy surrounding these organizations, federal mandates have forced
hospitals to assess their charitable contributions. Since 2009, the Internal Revenue Service has
required tax-exempt hospitals to complete a revised Schedule H and Form 990 which asks the
organization to “Describe how the organization assesses the health care needs of the
communities it serves” and report the value of community benefit that the hospital provides
(Bilton, 21). This may have been the first “version” of a community needs health assessment, but
with the enactment of the Affordable Care Act in March of 2010, a new requirement took effect
that required all tax-exempt hospitals to complete a community health needs assessment every
three years starting in 2012.
Throughout the history of healthcare, non-profit hospitals have been a vital player in
maintaining the health of our populations, in addition to providing community support. Hospitals
that fall into Section 501(c)(3) of the Internal Revenue Code, defined as a charitable organization
that provides healthcare to those who would otherwise be unable to afford it, have been given tax
exemptions. The goal was to ideally, “Give nonprofit hospitals incentives to provide additional
1
benefits to their communities beyond providing health care service in exchange for
reimbursement” (Rubin, Singh & Jacobson, 2013). In recent years, policymakers have
questioned the adequacy and amount of actual benefit that these now almost 3,000 hospitals
provide to the community, which has led to more stringent and thorough assessments of their
tax-exempt status (http://www.aha.org). While hospitals have historically been seen as charitable
organizations providing services to the poor, the evolution of the healthcare sector and influence
of corporate business and financial incentives has shifted the focus of many organizations.
The new community health needs assessment, or CHNA, is a “written document that
describes the community served by the hospital and identifies the health needs of the
community” (Rubin, Singh & Jacobson, 2013). Generally, the CHNA is a process used to
identify the needs of a community and prioritize them, based on collecting and analyzing data,
using internal and external resources, and gathering input from the community (Bilton, 23). One
component of the CHNA requires hospitals to develop an implementation strategy to address the
identified needs found in the assessment, along with actionable and measurable outcomes. This
process “seeks to understand and document health status, behaviors, and needs in the
community” using data collected by the hospital in addition to population indicators (Bilton, 22).
According to an article in the American Journal of Public Health, the CHNA has “the potential to
affect both the level and composition of community benefits as well as their concentration at
hospitals in areas or markets with the most need for free or subsidized care” (Principe et al.
2012). These CHNA’s are not only intended to improve the health of the organization’s
community, but also to help with the transition to population based healthcare across the country.
Although the federal government has revised and imposed these new requirements for
nonprofit organizations, there are still many questions left unanswered. The Association for
2
Community Health Improvement created universal guidelines to complete the CHNA process,
but there are still many hurdles that hospitals must overcome to satisfy the requirements. Some
say that many factors were overlooked when formulating the new demands, such as financial
burdens, the usefulness of the outcomes, diversity among healthcare organizations, the overall
affect on public health.
2.0 COMMUNITY HEALTH NEEDS ASSESSMENT 101
2.1.1 Background
Section 501(c)(3) of the Internal Revenue Code requires that every tax-exempt hospital
must conduct a CHNA at least one time every three years, and must “adopt an implementation
strategy to meet the community health needs identified through the CHNA” (Federal Register,
2013). The IRS demands that each hospital define their community, although that definition is
flexible and vague. The IRS expects a hospital to use its geographic location to determine the
community it serves, but in some cases, “the definition might also take into account target
populations served or specialized functions” (Federal Register, 2013). When completing a
CHNA, hospitals also have to follow the proposed regulations that state which persons must be
involved in the process. Organizations must get input from persons that represent the broad
interests of the community and have knowledge of public health. The regulations require that
input must come from “at least one governmental health department, members of the minority
populations in the community or who represent the community and any written comments
received on the hospital’s most recently conducted CHNA” (Federal Register, 2013). Along with
this input, an organization must also collect demographic and statistical data on their community.
The CHNA process is accomplished by collecting both qualitative and quantitative data
in collaboration with input from community stakeholders and organization leaders and managers.
3
Although the CHNA is unique to each organization, the Association for Community Health
Improvement, a group of the American Hospital Association, created a guide to help hospitals
through their CHNA process. The ACHI (INSERT CITATION) established a six-step
framework outlining the needs assessment process according to best practices, as follows:
Step One: Establishing the Assessment Infrastructure
The first step in any assessment is to identify all available resources, including staff, finances,
and infrastructure. In this step, hospitals can look at the possibility of partnering with external
organizations to provide extra resources and support.
Step Two: Defining the Purpose and Scope
Each hospital or healthcare system must define the geographic area and population of their
community. This includes looking at primary, secondary and tertiary service areas, and
examining the range of topics that will be assessed.
Step Three: Collective and Analyzing Date
Data collection sets the foundation for any assessment, especially the CHNA. Using a mix of
existing data, internal operational data, demographics, healthcare indicators, and collected
statistics, this step is crucial for organizations to create a baseline for their assessment.
Step Four: Selecting Priorities
It is the responsibility of the key stakeholders and those identified to prioritize the needs that
have been identified at this point. Needs should be based on the data collected, and prioritized
according to the organization’s resources and ability to meet those needs.
Step Five: Documenting and Communicating Results
A CHNA must be documented in a summary or report explaining the process and methods used
to complete the assessment, including data collection, identification of needs, strategic plan, and
outcome measurement. The report or summary must be made available to the public through the
organization’s website and marketing efforts.
Step Six: Planning for Action and Monitoring Progress
Part of the ACA requirement is that hospitals that complete a CHNA must create and adopt an
implementation plan. Many hospitals use this as an opportunity to re align their strategic plan
and incorporate the results of the CHNA into their strategic goals. Hospitals must demonstrate
their implementation strategy and how they intend to not only meet the identified needs, but how
they will track and evaluate outcomes.
4
Step 1
Establish Assessment Framework and Resources
Step 2
Define Purpose and Scope
Step 3
Collect and Analyze Data
Step 4
Prioritize Needs
Step 5
Disseminate Results
Step 6
Monitor and Evaluate Actions
Figure 1: The 6 Steps of the CHNA Process
(Source: Adapted from Association for Health Improvement)
2.1.2 Reporting Requirements and Guidelines
In addition to organizing and completing the CHNA, hospital organizations must also
document their process and create a report made available to the public. That report must
describe the data used in the assessment, methods of collecting and analyzing the data, and
identify any collaborations used during the process. The report must include:





A definition of the community served by the hospital and a how the community was
determined
A description of the process and methods used to conduct the CHNA
A description of how the hospital used the input received
A prioritized description of the health needs identified
A description of the potential measures and resources identified to address the needs
(Federal Register, 2013)
Supplemental to the CHNA report, a hospital organization must include their
implementation strategy in their Form 990 to report to the IRS. The IRS amended this
5
requirement to allow hospitals to send a narrative summary description of its process and
implementation strategy, and required that it be updated only every three years. The
implementation strategy must state how the hospital plans to address the needs of the community
that were identified in the assessment, or reasons why the hospital does not intend to address the
needs. (Federal Register, 2013). Every hospital must make their CHNA report available to the
public through their web site, including their implementation strategy. The hospital must also
make public their updates on of the actions they have taken to address the needs identified in
their report. Lastly, the organization must send the IRS a copy of its audited financial statements
for the taxable year and disclose the amount of excise tax that was imposed if they failed to meet
the requirements under section 501(r)(3) (Federal Register, 2013).
2.1.3 ACA and Policy Implications
The Affordable Care Act places a large amount of responsibility on the tax-exempt
hospitals to not only complete a CHNA, but also to follow a strict set of guidelines that were
created by the federal government. Along with conducting a CHNA every three years, and
creating an implementation strategy, every assessment must have representation from a broad
interest in the community and must be made available to the public. While the CHNA was
created with the purpose to help the organization efficiently and effectively provide healthcare to
its community, there are also punitive damages if the requirements are not met. Any hospital that
fails to meet the ACA’s requirements regarding the CHNA will face a $50,000 excise tax and
may face the loss of their tax-exemption status (Federal Register, 2013). The policy implications
of the CHNA provision of the ACA are an important factor in the amount of hospital
expenditures on community benefits. With the continuation of ACA implementation, the
6
individual health insurance mandate, and the push toward community health, “the need for
hospital based charity care should decline substantially (Young et al., 2013). The new policies
are intended to place more accountability and transparency regarding a hospital’s community
benefit activities and outcomes, while providing incentives and support for these nonprofit
hospitals.
3.0 EXAMPLES OF COMMUNITY HEALTH NEEDS ASSESSEMENTS
The ACA regulations require that a hospital must assess the health needs of its
community through a CHNA by identifying needs, prioritizing those needs, and identifying
potential measures and resources available to meet those needs. After clarification, it was
determined that a CHNA only needs to recognize the most significant heath needs, and that “a
hospital facility may determine whether a health need is significant based on all of the facts and
circumstances present in the community it serves” (Federal Register, 2013). As each hospital and
hospital system is unique and diverse, each CHNA process will be unique and altered to
accommodate the organization’s resources and capacity.
3.1 THE CHILDREN’S HOME OF PITTSBURGH
3.1.1. Background
The Children’s Home of Pittsburgh is a medium sized non-profit Pediatric Specialty
Hospital located in Southwestern Pennsylvania. Established in 1893, the purpose of The
Children’s Home is to promote the health and well-being of infants and children through their
three programs, adoption, Child’s Way® daycare and their Pediatric Specialty Hospital. Their
mission is to serve the medically fragile population from birth to age 18 in the greater Allegheny
7
County, and they achieve this by providing acute care for infants and children transitioning from
the hospital to the home (http://www.childrenshomepgh.org/lemieux-family-center).
3.1.2. Methods and Processes
Like every other 501c3 hospital, The Children’s Home had to complete a CHNA to
qualify for their tax-exempt status. A CHNA was started in January of 2013 for the first time
through a collaboration of management team members, community stakeholders, and
consultants.
The Children’s Home based their CHNA on the following factors:
 Improve access to healthcare
 Enhance the health of the community
 Advance medical or health care knowledge
 Relieve or reduce the burden of government or other community effort
The Children’s Home chose to use the consulting group, Parente Bearde, to help them complete
the CHNA process for fiscal year 2012. Because this was the first time that the organization was
completing a CHNA, the organization used a variety of methods and resources, both internally
and externally.
The strategic CHNA plan was as follows:
1. Establish a Community Needs Committee– consultants, staff/board leaders, clinicians,
2. Review the CHNA strategic plan with the committee and revise the scope of work,
project plan, timeline and responsibilities
3. Define “community” for purposes of the CHNA
4. Obtain community input on what the needs are of the community
5. Brainstorm and prioritize the community needs that fit with our mission
6. Establish initiatives and programs that will meet the needs of the community
7. Approve initiatives and develop implementation strategy to address needs
8. Adopt implementation strategy of initiative
9. Implement programs by June 30, 2013 and track the progress
10. Make information readily available to organization and community.
11. Establish communication protocol to ensure transparency
12. Determine how best to present needs and implementation strategy through Form 990
reporting.
8
In order to truly get a sense of the community’s needs, The Children’s Home created a
Community Needs Committee that was comprised of stakeholders from diverse backgrounds,
such as internal staff, Pittsburgh Public schools, The University of Pittsburgh School of Nursing,
and Children’s Hospital of Pittsburgh of UPMC. The committee was tasked with developing
policies for improving the health of communities served and ensuring that a dialogue was
initiated and maintained with appropriate community stakeholders. The overarching goals of the
CHNA were to:
 Understand our communities’ health care needs.
 Develop roadmap to direct resources where services are most needed and impact is most
beneficial.
 Collaborate with community partners where together we can make a positive impact.
 Improve the health of our communities – achieve measurable results.
CHNA Timeline
February 8
Mid February
End of February
March
April 1
April 25
May
June 30
Review and Selection on Initiatives
Complete Research on Initiatives
Implementation Plan Outline
Send Information to Committee for feedback
Prepare Documentation for Submission
CHNA Report and Form 990 Finalized and Presented to BOD
Submit 990 Form and Report to IRS
Initiatives Must be Fully Implemented
Figure 2: Timeline of the CHNA Process for The Children’s Home of Pittsburgh
(Source: The Children’s Home of Pittsburgh’s CHNA Documentation)
The committee was tasked with prioritizing the healthcare needs of the community defined by
The Children’s Home. Three questions were used to prioritize the needs:
1.How important is the problem to our community?
9
2.What is the likelihood of being able to make a measurable impact on the problem?
3.Does the hospital have the ability to address this problem?
The committee used a survey created internally to rank the prioritized needs and vote on which
issues to focus on and create a strategic plan for.
3.1.3. Outcomes
After reviewing the strategic plan of the organization, the committee brainstormed on
which community needs were a priority and how The Children’s Home could best meet those
needs through a roundtable discussion. Using a list of predetermined needs based on
demographic and geographic statistics, committee members brainstormed which needs were
reasonable for The Children’s Home to take on. The committee discussed the importance of each
topic and what resources that were available to meet each need, and how well each fit with the
mission of the organization. Among the topics were childhood obesity, teen pregnancy,
homelessness, injury prevention, and pediatric safety, to name a few. It was decided through the
use of a brief survey that the safety and education of patients, their families, and the neighboring
communities was a top priority. Based on the guidance and recommendations from the
committee members, it was decided on unanimously to implement two new pediatric safety
educational programs. Stemming from numerous requests and questions by patient families, the
committee suggested collaborating with a local animal shelter by holding a pet safety course for
families bringing new infants home. Using an already established program, Baby Ready Pets, the
organization was able to easily create an implementation strategy for the program. The course,
taught by two paramedics, was altered for The Children’s Home, and included pet safety
information for medically fragile children, in addition to the original material taught in the
course. Using the expertise and opinions of the committee, it was agreed upon that a much
10
needed program was a pediatric first aid class for parents and family member who care for
infants and children. The first aid class was taught by a registered nurse on the committee with
ties to the community, and provided basic education to ensure the safety of a child. Staying true
to the mission of the children’s home, it was decided that the organization would offer a pediatric
first aid class to the community at no cost, using resources that were already on hand and support
from internal staff. The educational programs were offered to the community throughout the year
and were evaluated by management to see the effectiveness of the classes. By the end of the
year, the Baby Ready Pets class served over 12 couples and there were over 30 participants in the
pediatric safety class, whose satisfaction results are below.
Figure 3: Outcome of the Baby Ready Pets Class at The Children’s Home of Pittsburgh
11
Figure 4: Outcome of the Pediatric First Safety Class at The Children’s Home of Pittsburgh
WEST PENN ALLEGHENY HEALTH SYSTEM
3.2.1. Background
The purpose of the West Penn Allegheny Health System, WPAHS, is to improve the
health of the people in Western Pennsylvania, and their mission is to “practice medicine, educate
and conduct research as an integrated team of physicians, nurses and support professionals who
are committed to improving the health of [their] patients” (www.wpahs.org). To accomplish this,
the organization completed a community health needs assessment to understand the needs of the
patients and communities they serve. Their CHNA process included the use of steering
committees, development and implementation strategies, and qualitative and quantitative data
collection.
12
3.2.2. Methods and Processes
The WPAHS utilized a local planning and research firm, Strategy Solutions, Inc., to help
them complete their CHNA for 2012-2013. Using a steering committee that was made up of
community leaders, public health experts, board members, and internal leaders, the organization
came up with a process that would examine the needs of their community. They defined their
community by geographic location, specifically, at the counties that make up the primary service
area for the WPAHS. Their process examined:










Demographics
Access to Quality Healthcare
Chronic Disease
Health Environment
Healthy Mothers, Babies and Children
Infectious Diseases
Mental Health and Substance Abuse
Physical Activity and Nutrition
Tobacco Use
Injury
Primary data was collected through community focus groups and in-depth stakeholder
interviews. WPAHS collected quantitative data from demographic and socioeconomic data
through state and federal databases and statistic data sets.
3.2.3. Outcomes
Data collected from the focus group participants through the use of an electronic polling
system indicated top ten community health concerns. These health issues were also confirmed
and explored by the stakeholders identified after being interviewed. The quantitative research
results provided information on WPAHS’s service area in comparison to state and national data
in the areas of: access, chronic disease, environment, infectious disease, mental health, nutrition,
tobacco use, public health, and other health indicators.
13
Figure 5: Top 10 Community Health Issues Identified by WPAHS
(Source: Reprinted with Permission from WPAHS CHNA Executive Summary)
Through a collaboration of the steering committee, the hospital system, and the Suburban Health
Foundation board, the data was analyzed and prioritized based on:
1.
2.
3.
4.
The accountable entity
The magnitude of the problem
The impact on other health outcomes
The capacity to implement solutions
Based on the greatest needs related to the hospitals mission, capabilities and resources, the
WPAHS decided upon implementing strategies to address the needs of the following conditions:





Heart disease
Pneumonia
Multiple chronic conditions/medications among Medicare patients
Diabetes and associated co-morbidities
Breast, lung and colon cancer
14
The needs identified were met through the use of community education, outreach and health
screenings, physician and EMS outreach and training, and programs to help patients with the
continuum of care (www.wpahs.org).
4.0 USEFULNESS OF A CHNA
Over the past few years, there has been a plethora of research and literature that explain
the usefulness of needs assessments. An article in Nursing Standard journal states that a needs
assessment is “a systematic method for reviewing the health issues facing a population, leading
to the agreed priorities and resource allocation that will improve health and reduce
inequalities’”(Holt & Jack, 2008). The article continues to explain that by completing a health
needs assessment, hospitals will benefit from stronger community involvement, improved team
and partnership working, professional development, and an overall better use of resources (Holt
& Jack, 2008). According to a Trustee Executive Briefing from Health Forum by Michael Bilton,
there are many benefits associated with the CHNA, including:




Planning and targeting community health services
Raising awareness of key health issues
Benchmarking and monitoring health status improvements
Regional health improvement collaboration (Bilton, 24).
It is evident that the outcomes of the CHNA can be used in a variety of ways, and can help an
organization align it’s strategic goals with the future of healthcare. Vice President of Planning
and Business Development for The West Penn Hospital in Southwestern Pennsylvania, Mark
LaRosa, stated that the CHNA process “provides an overall understanding of the diverse trends
in the community and market, and helps define the scope of those trends” (LaRosa). He
continued to explain that the CHNA is a useful tool for population health and the growing trends
15
toward innovative delivery systems, such as Accountable Care Organizations. The assessment
not only helps the organization implement positive and useful programs, but it also creates health
awareness to the community at a low cost.
According to the Association for Community Health Improvement, a Community Health
Needs Assessment helps an organization to:




Review the community’s health status and unmet needs;
Collect information to target community benefit and outreach programs;
Meet the requirements mandated by the Patient Protection and Affordable Care
Act for not-for-profit hospitals; and
Create or strengthen partnerships among community organizations with shared
accountability for the population’s health. (http://www.assesstoolkit.org/)
The CHNA may be a strenuous process; however, the overall benefit and charitable intentions
outweigh the challenges that hospitals must overcome, and helps to stress the importance of
community involvement in a hospital’s decision-making process.
5.0 CHALLENGES
The ACA’s requirements of the CHNA have gone through a series of revisions due to the
lack of consistency and confusion surrounding the vagueness of the demands. Hospitals must
figure out their role in the community and how they complete their CHNA all within compliance
with the regulations. Regardless of the type, size, or availability of resources, every 501(c)(3)
hospital must complete a CHNA, and herein lies the main problem. A 400 bed multi hospital
integrated health system must follow the same requirements as a 20 bed specialty hospital,
knowing that they have different spans of resources and capabilities to meet the communities’
needs. This challenge, along with the complexity of working with population and outcome based
data, hinder healthcare organizations from successfully completing their CHNA.
16
Deborah Thompson, CEO of Get Strategy Solutions, commented on the CHNA process after her
extensive experience helping healthcare organizations complete their process. A challenge, she
noted, is that the outcome of the CHNA can vary and depends on who the organization took their
lead from and who they looked to for guidance, whether that be consultants, strategic advisors,
accountants, or their financial management. Many organizations look to their financial
departments to drive their CHNA decisions, which may end up being financially biased and may
steer the organization away from best practices.
Mark LaRosa states that although he has seen the benefits of the CHNA, there are a
myriad of challenges that he faces when completing the process. He commented that the CHNA
is a very difficult process, which includes “tying the community’s needs into the organization’s
strategic business initiatives. Collecting data and using key stakeholders in the community tells
you about your needs, but it doesn’t tell you how to prioritize the critical issues, or how they are
suppose to fit into your business plan” (LaRosa). He continues to explain that the assessment
may reveal needs that are not within your organization’s scope, so you must choose the issues
that you know you will have the resources to cover. In essence, the needs identified in the CHNA
do not always fit within the core strengths of the organization, making it challenging successfully
carry out. Another challenge is determining the scope of the service area to complete the CHNA
on. Two organizations in the same geographic are tend to have different “communities,”
resulting in different outcomes. In essence, the organization defines their community, which
creates a challenge when it comes to continuity.
Although many hospitals are having issues completing the assessment, the CHNA can be
even more challenging and time consuming for smaller, niche hospitals, such as The Children’s
Home of Pittsburgh. The Children’s Home of Pittsburgh, a 16-bed specialty Pediatric hospital,
17
completed its first CHNA in 2013. The Chief Financial Officer, Kimberly Phillips, commented
that “this was a very hectic and overwhelming process for us…It is hard for small institutions,
like ourselves, to complete the assessment without the input and resources needed” (Phillips).
Challenges arise not only with resource allocation and financial obligations in these types of
organizations, but also with manpower and staffing to support the CHNA process.
A common challenge found across the industry is the underlying purpose of the CHNA.
Many of the needs that arise from the assessment are socioeconomic problems in which hospitals
do not have the resources to deal with. Mr. LaRosa commented that many of the needs they find
have to deal with access to healthcare, such as transportation issues. The hospital is then faced
with the burden of knowing this is a need in the community, but possibly not having the
resources to fix it. The question then arises as to who is responsible for ensuring this need for
access to care, and who will pay for it? Does it fall on the hospital itself, or does the local, state
and federal government have a responsibility to meet those needs?
It seems that the CHNA process was created as though all hospital organizations are the
same, with comparable populations, service lines, resources, and operational capacity. This
“blanket statement” has led to the continued frustration and confusion among hospitals that are
attempting to successfully complete a CHNA. From the lack of clarification on the definition of
“community,” to the vagueness of the requirements and outcome measures, the CHNA has many
systematic flaws in trying to incorporate an outcome based, population approach to healthcare
(Rubin, Singh & Jacobson, 2013).
18
6.0 FINANCIAL IMPLICATIONS
As noted in much literature, the CHNA has an effect on the financial operations of many
healthcare organizations. The New England Journal of Medicine published an article that
concluded that “tax exempt hospitals spent 7.5% of their operating expenses on community
benefits during fiscal year 2009” (Young et al., 2013). While it may have been originally
overlooked, healthcare organizations may be affected financially by the CHNA, depending on
the capacity of the organization. These hospital systems have much at stake when completing a
CHNA, as they may face losing their tax-exempt status if they fail to meet the set requirements
(Mondaq Business Briefing, 2013).
Deborah Thomas explained that the CHNA process is going to drive hospital planning
and evaluation of clinical programs and their reimbursement systems. She stated that “bundled
payments are going to be a large influence on healthcare systems, and the CHNA will drive that
and have an impact on what services should be offered and bundled. It will help organizations
strategize and streamline services so that new interventions are based on the need of the
community” (Thomas). Coming from a strategic planning point of view, Mark LaRosa described
that the CHNA allows a hospital to offer beneficial programs to the community that are
impactful and low cost. He added that the process and follow through of the programs “take
resources away from other operations. It adds another layer of responsibility to the organization”
(LaRosa).
As Chief Financial Oficer for a Pediatric specialty hospital, Kim Phillips rationalized that
while the CHNA process and effort to improve transparency is valuable, this was implemented at
a time when reimbursements are being cut, and healthcare organizations are being held at a
19
higher standard of giving free services, mentioning that “This creates more strain on
organizations, and forces resource allocation and the potential of cutting programs” (Phillips).
Most of the initiatives and programs that result from a CHNA are not revenue generating,
and since many organizations already have strategies set in place to address the communities
needs prior to the CHNA, the process has a negative financial impact (LaRosa). The information
collected from these primary sources is consistent with the literature, concluding that there are
financial implications for a hospital organization completing a CHNA.
7.0 EFFECT ON PUBLIC HEALTH
The transition from individual to population healthcare is not only present in today’s
healthcare sector, but will be for years to come. The CHNA both directly and indirectly affects
the healthcare industry, particularly in public health. With the influence of community input
from the CHNA, hospital organizations can improve awareness and health status in their
communities and help to align with the mission of public health. An article from the Federal
Register notes that hospital facilities should take into account input from healthcare consumers,
local school districts, community health centers, and representatives from the workforce,
indicating that “broad input from the community can increase the likelihood of well-targeted
initiatives that address the needs of communities and improve the health of residents” (Federal
Register, 2013).
Literature from the American Public Health Association explains the complexity of
population health outcomes and states that, “Given that many factors influence population health
and do so in complex ways, no single entity can be held accountable for health outcomes”
(Rubin, Singh & Jacobson, 2013). The Public Health sector has many challenges to tackle, as
20
more responsibility will be placed on local and state health departments. With the opportunity to
collaborate with hospital organizations, public health departments can have the availability of
more resources to help with their efforts in improving the health status of the population.
In a piece of literature written by Michael Stoto of Academy Health, Stoto mentions that “
‘Population Health’ is a more modern version of ‘Public Health,’ which itself maybe be a goal of
improving the health of the public…”(qtd. in Stoto,4). In Stoto’s piece, he indicates that the new
CHNA requirement “has the potential to leverage the strengths and resources of both the health
care and public health systems to create healthier communities (qtd. in Stoto,4). Although
originally intended for tax-exemption purposes, the CHNA may have greater public health
benefits than envisioned, which will ultimately help to improve the overall health in the United
States.
21
APPENDIX A
Interview with Deborah Thompson
Get Strategy
February 17, 2014
What resources do you recommend to use for the CHNA process:
o ACHI Website
How has implementation of CHNA differ for different hospitals?
o “Quality is in they eye of the beholder”- Organizations use different methods of data
collection based on their resources and restrictions. AHA has “best practices”- does the
organization follow them, or chose to take a different path? The ACHI website has a
“toolkit” that all hospitals can use, but the guidelines were created in 2007, before the IRS
passed the CHNA rule. If you followed the approach, you would be conducting a CHNA
according to “best practices” but that is ideal, not all organizations did this.
o Another factor was who the organization took their lead from and who they depended on
(their consultants, strategic advisors, accountants, internal management) Many
organizations, such as TCH, looked to the financial department to take lead of the CHNA
and drive decisions, which would be financially based and may have lead the organization
away from “best practices”
What are your thoughts on the 1st year? Will there be changes?
o IRS guidelines are changing. Proposed in April 2013, and suppose to pass in October 2013,
but was delayed due to the sequestration. The first round, in 2011, every 501c3 hospital had
to do its own assessment. The new guidelines will allow for collaborative efforts between
hospitals to conduct 1 CHNA, but each must have its own implementation plan and personal
evaluation component. Evaluation was lacking the 1st time around, and the new guidelines
will make it mandatory for organizations to evaluate their plans.
What are the drawbacks for small non-profit hospitals like TCH?
o Because we are so specialized, it would benefit us to collaborate from a resource perspective
o Two ways to make the assessment:
1. Prioritize needs first, and then make a plan (TCH/UPMC)
2. Collect data, prioritize needs, and make a plan (best practices)
o The new guidelines will allow for either method to be used
What is the impact of the CHNA for hospitals like TCH?
o It is going to drive hospital planning and evaluation of clinical programs. In 2016- bundled
payments are going to be a large influence on healthcare systems, and the CHNA will drive
that and have a big impact on what services should be offered and bundled, and will help
organizations strategize and streamline services so that new
interventions/programs/products/services are based on the need of the community.
22
o Evaluation improvement- many hospitals are behind the curve with this type of evaluation,
but are already using evaluation for quality, satisfaction, etc.
 Look and see where there is excess capacity, how much capacity is there to meet that
demand you find between you and your competitors
What financial implications does the CHNA have on hospitals and healthcare as a whole?
 The organization has to spend money on resources to complete the CHNA (ex: Deb
Thomas)
 Because there are usually other methods and initiatives already being done to meet
communities needs before the assessment is completed, the net impact has a negative
financial impact
23
APPENDIX B
Interview with Mark LaRosa
Vice President, Planning and Business Development, West Penn Hospital
March 7, 2014
What are your thoughts on your process?
 The positives are that is provides an overall understanding of the diverse trends in the
community and in the market and the scope of those trends.
 The negative aspect is that it is a very difficult process. You have to tie the community’s
needs into the organization’s strategic business initiatives. The combination of 1. Market
data and 2. Using key stakeholders in the community tell you about your communities
needs, but it doesn’t tell you how to prioritize the critical issues or how they can fit into
your business plan
 The assessment may reveal issues that are not within your scope, so you have to choose
issues that you know you have the resources to cover
What are the drawbacks of the process for healthcare organizations?
 You have to make sure all of the allocations are covered based on the service area- or is it
biased on what you want?
 The scope of the services area is defined by the organization (ex: two organizations in the
same geographic are can have different “communities”
 Many of the needs that arise are socioeconomic issues which hospitals don’t have the
resources to fix (disparities, safety and security, transportation) Look at other
underdeveloped countries compared to our country.
 Should there be a CHNA for the state government or police force? This might solve more
of the socioeconomic problems in the community and region
 Once you identify the needs within a CHNA, most have issues around access. Who pays
for that access? Who is responsible for that access?
What is the impact of the CHNA for hospitals?
Negative
 You have to look at what percent of the CHNA’s have made a change in the strategic
direction of an organization- very little percentage
 Not a revenue producing process
 May be a duplicative process to efforts that are already being made in the community
Positives
 Useful tool for population health and the trends toward ACO’s
 Helps organizations implement positive programs
 Creates more health awareness to the community at a low cost
24

Ex: WPH CHNA confirmed that the notions that diabetes and weight issues are
rampant in the community and their strategic initiatives were timely and important
What are the biggest challenges for your organization when completing the CHNA?
 The needs identified do not always fit within the core strengths of the organization
 It doesn’t provide you with a process to meet that need
 The process is even harder for niche healthcare organizations
 How do you make this a useful tool for your organization?
o Involve clinicians and staff in the assessment- give them surveys/interview
o Complete a medical staff development plan
 Look and see where there is excess capacity, how much capacity is there to meet that
demand you find between you and your competitors
What financial implications does the CHNA have on hospitals and healthcare as a whole?
 The organization has to spend money on resources to complete the CHNA (ex: Deb
Thomas)
 Because there are usually other methods and initiatives already being done to meet
communities needs before the assessment is completed, the net impact has a negative
financial impact
Tips and Recommendation:
 CHNA: Is it one size fits all?
 Challenges and Usefulness of the CHNA
 Disconnect between organizations
 Priorities are “self prioritized”
 Common issues
 Common components:
o Population
o Health status of population
o Health indicators
o Market Share
o Utilization Rates
o Competition
o Maps/Access to care
o Our inventory of services
 *How much capacity is there that we can meet compared to our competitors?
25
APPENDIX C
Interview with Kim Phillips
Chief Financial Officer, The Children’s Home of Pittsburgh
January 27, 2014
What are your thoughts on your CHNA process done for the first time?
 It is a very hectic and overwhelming process. There were limited guidelines to follow and it was
“very hard for a small institution like ourselves without the input and resources needed to
complete the CHNA.” It was hard to find and use the resources along the way
What changes do you think will be made?
 I don’t think there will be many changes made to our process the next time around. We chose
people on our committee who were in touch with our community and based on their
prospective, we figured out what the needs were. We have very limited resources, and it would
be hard to complete the process in another way. A new change in the regulations is the
possibility of partnering or collaborating with another 501c3 hospital, which may be beneficial
to us.
What are the drawbacks for small non profit hospitals, such as The Children’s Home?
 It is harder to implement programs because of the resources needed to successfully have the
programs needed. Although our bureaucracy is smaller than some larger healthcare systems,
and our processes may be implemented quicker, we don’t have enough hours or manpower for
the additional needs.
What financial implications does the CHNA have on your hospital?
 It allows us to offer some beneficial programs to the community that are impactful and low cost.
Because of our size and scope, there are limited options that we can do, but the outcome of the
process is that we can add to the programs we already offer to meet the needs of the
community in the sense of pediatric care and education. The process and follow through of the
programs “take resources away from our other operations. It adds another layer of
responsibility to the organization.”
 Transparency is valuable, at a time when reimbursements are being cut, and healthcare
organizations are held at a standard of giving free services. This creates
more strain on us, forces resource allocation and the potential of cutting programs.
What comments do you have on the future of the CHNA?
 How many times can the same process be done? Confusion of once the communities’ needs are
met, taking your ability to meets those needs into consideration, what is the next step?
26
APPENDIX D
The Children’s Home of Pittsburgh: Initiative Selection Document
Community Needs Committee: Initiative Selection
Criteria:






Will it be cost effective?
Is it sustainable?
Do we have the resources to implement it?
Do we have the man hours to fulfill the program?
Does the initiative fit with the mission?
Will it benefit the community?
Obesity
Adolescent Risky Behavior
Dental Care
Child Abuse
Infant Mortality
Diabetes
Support for LGBT Community
Homelessness
Environmental Toxins
Teen Pregnancy
Asthma
Access to care
Pediatric Safety and Education
27
APPENDIX E
The Children’s Home: Pediatric First Aid Class Survey
presented by Gail Ratliff Woomer, MN, RN, IBCLC
Please assist in the evaluation of the class you attended at The Children’s Home and Lemieux Family Center for future
planning. Thank you!
Please use the following rating scale to evaluate the objectives by circling the
corresponding number below.
Strongly Agree = 4
Agree = 3
Disagree = 2
Strongly Disagree = 1
The trainer(s) were successful in teaching the information during the class
4
3
2
1
I understand the different interventions and practices taught in Pediatric First Aid
4
3
2
1
My knowledge of Pediatric First Aid improved because of the training program
4
3
2
1
I feel competent treating a child with the First Aid skills taught in the class
4
3
2
1
I changed my behavior / used the skill or knowledge after the training
4
3
2
1
The teaching strategies used by the trainer was appropriateness (i.e., lecture, Power Point slides)
4
3
2
1
Which topic of the class was the most important to you?
Would you recommend the class to your friends?
Yes
No
May we share this evaluation with the instructor?
Yes
No
28
APPENDIX F
The Children’s Home: Baby Ready Pets Survey
presented by Animal Friends
Please assist in the evaluation of the class you attended at The Children’s Home and Lemieux Family Center for future
planning. Thank you!
Please use the following rating scale to evaluate the objectives by circling the
corresponding number below.
Strongly Agree = 4
Agree = 3
Disagree = 2
Strongly Disagree = 1
The trainer(s) were successful in teaching the information during the class
4
3
2
1
I understand the different interventions and practices taught during the class
4
3
2
1
My knowledge of animal and child safety improved because of the training program
4
3
2
1
I feel safer and having my child around my pet after participating in the class
4
3
2
1
I changed my behavior / used the techniques with my animal(s) after the class
4
3
2
1
The teaching strategies used by the trainer was appropriateness (i.e., lecture, Power Point slides)
4
3
2
1
Which topic of the class was the most important to you?
Would you recommend the class to your friends?
Yes
No
May we share this evaluation with the instructor?
Yes
No
29
BIBLIOGRAPHY
1. "ACHI's Community Health Assessment Toolkit." Hospital Connect. Association for
Community Health Improvement, n.d. Web. 4 Mar. 2014.
<http://www.assesstoolkit.org/>.
2. Barnett, Kevin, DrPH. "Best Practices for Community Health Needs Assessment and
Implementation Strategy Development: A Review of Scientific Methods, Current
Practices, and Future Potential." Report of Proceedings from a Public Forum and
Interviews of Experts. The Centers for Disease Control and Prevention. Atlanta, Georgia.
11 July 2011. http://www.phi.org/ uploads/ application/files/dz9vh55o 3bb2x56lcr
zyel83fwfu3mvu24oqqvn 5z6qaeiw2u4.pdf
3. Bilton, Michael. "Community Health Needs Assessment." Trustee 64.9 (2011): 2124. Business Source Complete. Web. 14 Mar. 2014
http://search.ebscohost.com.pitt.idm.oclc.org/login.aspx?direct=true&db=bth&AN=6718
3043&site=ehost-live
4. "Community Health Needs Assessments." West Penn Allegheny Health System.
Allegheny Health Network, Web. 10 Feb. 2014. <http://www.wpahs.org/communityhealth-needs-assessments>.
5. "Community Health Needs Assessment (CHNA)." Community Commons. N.p., n.d. Web. 14
Jan. 2014. <http://assessment.communitycommons.org/CHNA/>.
6. "Community Health Needs Assessments for Charitable Hospitals." Federal Register 5
Apr. 2013. Academic OneFile. Web. 14 Mar. 2014.
7. "Fast Facts on US Hospitals." American Hospital Association. Web. 8 Jan. 2014.
<http://www.aha.org/research/rc/stat-studies/fast-facts.shtml>.
8. Holt, Maxine, and Kirsten Jack. "Community profiling as part of a health needs
assessment." Nursing Standard 22.18 (2008): 51+. Academic OneFile. Web. 14 Mar.
2014. http%3A%2F%2Fgo.galegroup.com%2Fps%2Fi.do%3Fid
%3DGALE%257CA174059911%26v%3D2.1%26u%3Du itt_main%26
it%3Dr%26p%3DAONE%26sw%3Dw%26asid%3Db178b1c9a1ca7874fb64cc8f2c8d29
1f
9. "IRS Issues Community Health Needs Assessment Proposal For Charitable
Hospitals." Mondaq Business Briefing 16 Apr. 2013. General OneFile. Web. 14 Mar.
2014. http://go.galegroup.com.pitt.idm.oclc.org/ ps/i.do?id=GALE%7
CA326493643&v=2.1&u=upitt_main&it=r&p=ITOF&sw=w&asid=e206ee40349ebc96e
9a0abef50786fbf
10. Jarris, Paul E,M.D., M.B.A., Monroe, J. A., M.D., Pestronk, R. M., M.P.H., Martinez,
L. S. S., PhD., & Peréa, F. C., PhD. (2012). Better Health Requires Partnerships And A
Systems Approach/Sprague Martinez And Peréa Respond. American Journal of Public
Health, 102(11), E4-E5. Retrieved from http://search.proquest.com/docview/
1220637903? accountid= 14709
11. LaRosa, Mark. Personal interview. 11 March. 2014.
12. "Pediatric Specialty Hospital." The Children's Home & Lemieux Family Center. N.p., n.d.
Web. 7 Mar. 2014. <http://www.childrenshomepgh.org>.
13. Phillips, Kim. Personal interview. 27 Jan. 2014
30
14. Principe, K., Adams, E. K., Maynard, J., & Becker, E. R., PhD. (2012). The impact of
the individual mandate and internal revenue service form 990 schedule H on community
benefits from nonprofit hospitals. American Journal of Public Health, 102(2), 229-37.
Retrieved from http://search.proquest.com/docview/963360462?accountid=14709
15. Rubin, D. B., M.A., Singh, S. R., PhD., & Jacobson, P. D., J.D. (2013). Evaluating
hospitals' provision of community benefit: An argument for an outcome-based approach
to nonprofit hospital tax exemption. American Journal of Public Health, 103(4), 612-616.
Retrieved from http://search.proquest.com/docview/ 1340553574?accountid=14709
16. Stine, N. W., M.D., & Chokshi, D. A., M.D. (2012). Opportunity in austerity -- A
common agenda for medicine and public health. The New England Journal of Medicine,
366(5), 395-7. Retrieved from
http://search.proquest.com/docview/919683987?accountid=14709
17. Stoto, Michael A., Ph.D. "Population Health in the Affordable Care Act Era."
Academy Health (2013): http://www.academyhealth.org/files/AH2013 pophealth.pdf
18. Thompson, Deborah. Personal interview. 17 Feb. 2014.
19. Young, Gary J,J.D., PhD., Chou, C., PhD., Alexander, J., PhD., Lee, S. D., PhD., &
Raver, E. (2013). Provision of community benefits by tax-exempt U.S. hospitals. The
New England Journal of Medicine, 368(16), 1519-27. Retrieved from
http://search.proquest.com/docview/1329147503?accountid=14709
31