Assessing NE Ohio Community Health Needs Assessments: Standards, Best Practice, and Limitations

Assessing NE Ohio Community Health Needs Assessments: Standards, Best Practice, and Limitations Tegan Beechey, MPA, Doctoral Candidate, Kent State University College of Public Health John Corlett, President and Executive Director, The Center for Community Solutions June 5, 2015

Assessing NE Ohio Community Health Needs Assessments: Standards, Best Practice, and Limitations By Tegan Beechey, MPA, Doctoral Candidate, Kent State University College of Public Health John Corlett, President and Executive Director, The Center for Community Solutions June 5, 2015 Introduction A review of 63 community health needs assessments (CHNA) conducted by Northeast Ohio hospitals across 16 counties revealed a lack of standardized data sources in conducting the assessments, limited coordination among hospitals conducting community health needs assessments in the same communities, and no clear plan for hospitals to follow through on community health needs assessment based community improvement plans. Governor John Kasich s proposed language in the two year state budget, which the Ohio House of Representatives removed, would have created the Population Health Planning and Hospital Community Benefit Advisory Workgroup with a wide array of health stakeholders from around the state. The workgroup would have been charged with making recommendations on population health planning, health needs assessments, health improvement plans, forming health and wellness trusts, and hospital community benefit funding. The Governor s office has indicated they will move ahead, in some form, with this initiative regardless of whether language is included in the budget. There is potential for a stronger role for entities like the Ohio Hospital Association on the state level or The Center for Health Affairs on a regional level to improve coordination, standardizing data collection, and tracking follow through on CHNAbased community improvement plans. CHNAs would also benefit from more formal involvement by local departments of public health which undertake their own community health assessments. Understanding Community Health Needs In March of 2010, The Patient Protection and Affordable Care Act (ACA) introduced sweeping changes to the American health care system. While the ACA primarily sought to increase the number of Americans covered by health insurance, the law also modified many aspects of the public health system, from program financing, to eligibility standards for social support programs such as Medicare, to the introduction of health data collection and assessment policies. For nonprofit across the country, one of the most significant administrative changes introduced by the ACA was the Community Health Needs Assessment (CHNA). Designed with the goal of establishing the health needs of the population served by nonprofit hospitals across the country through primary and secondary health data analyses, CHNAs may serve as a community specific source of information for local, state, and federal entities if conducted with carefully designed 2

methodology and appropriate regulatory oversight. In the first cycle, guidance was limited for hospitals required to conduct CHNAs. Initial CHNAs varied significantly in quality, content, and detail as a result. Final IRS rules and associated guidance were released in February, 2015, providing greater support for coordination and structure for future assessments. Given the labor and cost associated with the collection of community health needs assessment data and preparation of mandated reports, understanding the methodology and utility of past CHNAs is key to improving the efficiency and success of the future CHNAs considering new IRS rules and guidance. Inconsistent Information, Limited Access Historically, local public health systems and community health care providers relied on a blend of client data, mandatory disease reporting, demographic information, vital statistics, surveillance data, and state and federal guidance when developing long term goals and objectives. Each organization or institution had considerable flexibility in terms of the depth, breadth, and frequency with which this information was integrated into strategic planning. While nonprofit organizations faced some regulation in terms of planning and documentation, there was a great deal of variation in the content and quality of data used to inform planning, as well as the relevance of the data to individual communities. Additionally, accessibility of subsequent planning documentation varied community to community. Further, the majority of nonprofit hospitals focused on data related to individual health policy and outcomes, rather than adopting a public health perspective. Without consistent, clear, broadly accessible community specific data and appropriate public health interpretation, long term planning and coordination of health services can be limited. As a result, community level public health and individual health care systems find themselves susceptible to a range of inefficiencies, including programmatic redundancy, inefficient use of funds, poor inter agency coordination, slow response to emerging community health needs, and difficulty identifying at risk populations. In response, Federal legislators introduced a standardized requirement for community health needs assessments in section 9007(a) of the ACA, tied to the tax exempt status of a hospital. The CHNA requirement was designed to identify unmet community health needs by creating an inventory of health programs (preventive services, screening, education), health outcomes (disease, violence, health behaviors), health infrastructure (environment, facilities, transportation), demographic data (racial, economic, geographic, age, and gender related data), and resources (funding streams, professionals). In December of 2014, the IRS released additional documentation further specifying the required methodology, content, and reporting associated with CHNAs. Final rules were released in February, 2015. 3

The CHNA Process In conducting CHNAs, hospitals impacted by section 9007(a) must identify gaps in each community s health system, with the goal of improving access to care, health behaviors, and mediation of health infrastructure related barriers to care, all to improve health outcomes (From: IRS Notice 2011 52. http://www.irs.gov/pub/irs drop/n 11 52.pdf). The administrative bodies associated with enforcing the CHNA requirement include the Internal Revenue Service and the Treasury Department. The CHNA requirement applies to all nonprofit hospitals and government hospitals seeking 501(c)(3) status. Additionally, if hospital organizations run multiple hospitals, a CHNA report must be completed for each hospital. All organizations governed by the regulation must produce a CHNA report every 3 years. Each CHNA must include the following components, per IRS guidance: 1. Description of community served by the hospital, methods of determining this area 2. Description of process and methods used to conduct the assessment, including sources, dates of data collection, and analytical methods; should also include gaps that impact the hospital organization s ability to assess the needs of the community. Should include collaborators 3. Description of how the hospital collected input from persons representing the broad interests of the community includes a description of when and how these people were consulted, who they were, what the methods were (meetings, focus groups, interviews, surveys, written correspondence) 4. A prioritized listing of all of the community health needs identified through the CHNA and a description of the process and criteria used to prioritize 5. Description of existing health care facilities and other resources in the community which might be of use in meeting community health needs Data and the CHNA The CHNA process consists of three major phases: data collection, identification of health needs, and development of a community improvement plan based on CHNA findings. During the data collection process, participating organizations are encouraged to draw from a variety of secondary data sources. Under the revised guidance, the sources recommended on the Centers for Disease Control and Prevention CHNA resources include: Leading Health Indicators Healthy People 2020 Health Indicators Warehouse MMWR Health Disparities and Inequalities Report Behavioral Risk Factor Surveillance System (BRFSS) Youth Risk Behavior Surveillance System (YRBS) County Health Rankings National Environmental Public Health Tracking Network Uniform Data System (UDS) Mapper 4

This list of recommended sources was not available in the first round of CHNAs, resulting in considerable variation in secondary data sources. In addition to secondary data, organizations conducting a CHNA analysis must consult with community stakeholders, resulting in primary data collection. Methods of primary data collection include community surveys, stakeholder interviews, community focus groups, stakeholder focus groups, written correspondence with community stakeholders, and meetings with other organizations involved in community health services. In addition to establishing a timeframe for conducting CHNAs and introducing content requirements, the CDC recently produced detailed guidance materials providing insight into health indicators that should be explored during the CHNA process. Health organizations choose from a broad range of indicators that could be used to assess the health needs of a community. Case Study: Northeast Ohio To better understand the identified health needs, practices, and diverse forms CHNAs take on, The Center for Community Solutions (CCS), in partnership with Kent State University, collected the CHNAs conducted by nonprofit hospitals and partner organizations in the 16 county region of Northeast Ohio as of January 1, 2015. Health indicators and health needs identified in each CHNA were documented, as well as data sources and collection methods. In total, 92 separate health indicators were identified across 62 CHNAs. While the CHNAs CCS reviewed explored a broad range of health factors, the health indicators generally fell into one of five broad categories: Data on the major medical conditions affecting the community were consistently collected, including chronic diseases such as heart disease, and infectious diseases such as HIV. Data on a range of health indicators was often collected, including obesity, premature birth, substance abuse, and other behavioral and medical factors associated with health outcomes. Some nonprofit hospitals identified gaps in health care delivery, including preventive care and disease treatment. Healthcare infrastructure, including funding streams, health insurance coverage, medical institutions, community resources, health care services offered, and health care professionals in service were explored less frequently. Some CHNAs examined other community level factors that influence access to health care, health behaviors, social determinants of health, and health outcomes, including transportation, food availability, and environmental factors such as air and water quality. 5

Data Utilization and Outcomes The majority of hospitals and health districts that completed Community Health Needs Assessments used a variety of different secondary data sources. Some data sources (outlined in the Appendix), were relatively broad and covered a diverse set of demographic characteristics and outcomes (general 4 ), but other data sources had a narrower focus, including data sources which focused on geographic regions (county and community specific data 1 ), specific populations by age (age specific data 7 ), external predictors of health (environment, demography and population data 2,6 ), access issues (hospital and claims data 8 ), and/or mortality and morbidity (diseases and outcomes, public safety and violence 3,5 ). Some health indicators, such as medically underserved communities and linguistic barriers, were only identified by one or two health organizations, and likely represent unique health needs within those specific communities. Many health indicators were noted across more than a quarter of all reporting organizations, suggesting that these indicators, while a common source of concern, can be specifically identified as absent or present within each community. A few indicators, such as heart disease and diabetes, were noted in almost every CHNA, suggesting that these indicators may not only provide insight into the needs of an individual community, but may also reflect the needs of a specific region or American society in general. Finally, a handful of indicators were noticeably under represented, including infant mortality and other maternal and child health indicators, sexually transmitted infections, and environment related indicators. To better understand the needs of the region as a whole, critical health indicators were broken into quartiles. Health indicators identified in more than three quarters of CHNAs are recorded in the Appendix, as are health indicators identified in more than half (but fewer than three quarters) of the CHNAs. 9,10 Data Challenges: Inconsistent Information and Accessibility While the CHNA process has centralized relevant health indicator data, the review of Northeast Ohio CHNAs reveals several data related challenges. These problems generally fall into three categories: Issues related to data collection, barriers to data availability, and problems related to specificity of data to community needs. The CHNA requirements do not require participants to utilize data from a specific source, nor does the CHNA process mandate data collection on a core set of health indicators. While many CHNAs drew upon the health indicators established by Healthy People 2020, the blend of secondary sources each organization uses to obtain data differ considerably, even across organizations within the same community. Communities that utilize, for instance, BRFSS and YRBS data will have different indicator mixes than communities that utilize the Health Indicators Warehouse. This reduces the comparability of CHNA results, and limits external organizations ability to compare and contrast the needs and resources of communities across the country. 6

The quality and variety of data available varies considerably from community to community. Metropolitan areas often have access to unique data sources generated by community level programs, trained epidemiologists, and information collected by external organizations seeking information on the health needs of service populations within the community. Similarly, economically well off communities are able to collect additional data with greater frequency and depth, and are also able to consult with epidemiologists for more in depth analysis of disease trends. Further, many communities simply do not have complete data to provide to the surveillance systems recommended by the CDC, resulting in incomplete secondary datasets. This limits the functionality of the CHNA in planning and further inhibits the comparability of CHNA reports across communities. CHNAs were established to build a consistent, centralized set of information for both participating and external organizations to use when developing policy objectives and creating strategic plans. Inconsistencies in the health indicators tracked by CHNAs and variation in the source of secondary data limit the usefulness of CHNA data sets when considering the needs of communities seeking funds or programmatic intervention. The secondary sources recommended by the CDC track a standard set of health indicators. For communities with unique public health challenges, special service populations, or specific infrastructural issues, secondary data may not provide meaningful insight into these challenges. While independent primary data collection provides helpful guidance for organizations within the community, individualized data collection limits the comparability of results in other communities. Conversely, a CHNA that relies primarily on secondary data is, in essence, little more than a consolidation of multiple publically available data sets. Given that the vast majority of the CHNAs utilized an approach that focused heavily on diverse combinations of secondary data, the utility of CHNAs is thrown into question. Application Issues: Utilization and Dissemination Just as the process associated with the development of a CHNA could benefit from standardization and clarification, the process of utilizing and disseminating the findings of a CHNA could benefit from additional regulatory guidance and oversight. Utilization of CHNA findings introduces several challenges, chiefly in relation to the development of the community improvement plan. As previously noted, the utility of a CHNA report is limited by the type of data collected, the comparability of data across communities, and the level of insight offered for challenges unique to the community. Developing a community improvement plan based upon a CHNA that primarily used secondary data results in a plan that is not tailored to the population served by the organization conducting the CHNA. Consequently, to maximize the value of the community improvement plan, 7

organizations conducting a CHNA should pursue a blend of more general secondary data and more specific primary data. This approach introduces contrasting challenges, however, in light of the second purpose of the CHNA: to provide a centralized source of information on the health needs of communities across the country. If primary data collections are not standardized, and the blend of secondary data collected is left to the discretion of the organization conducting the CHNA, the comparability of CHNA findings, and subsequent utility in policy and programmatic decision making is limited. Additionally, the issue of improving accessibility of community specific data is not entirely resolved by CHNAs, as each organization maintains CHNA records in different locations, limiting ease of access. Finally, and perhaps most significantly, the agencies in charge of enforcing the CHNA process and collecting CHNA reports have offered little insight into how the reports are utilized at the Federal level. While the law requires both CHNA reports and a community improvement plan, there is no specific system in place to ensure that organizations execute the community health improvement plan. Given the amount of time, energy, and resources that go into conducting a CHNA, administrators at the Federal level might consider potential avenues for CHNA utilization. Recommendations In light of the limitations and challenges identified above, and the tremendous amount of time and energy used in data collection and report development, the following recommendations, intended to improve the effectiveness of the CHNA process and the utility of CHNA reports, are offered. 1. Standardize accepted health indicators and secondary data sources To improve the generalizability of individual CHNAs and to develop a comparable set of CHNA reports, regulators are encouraged to consider developing a standard set of health indicators tracked by all organizations required to conduct a CHNA, as well as a specific set of secondary data sources. This would not limit CHNA studies to the standardized set of health indicators, but it would offer a baseline of information for all participating organizations and communities. 2. Standardize primary data collection tools To improve the comparability of individual CHNAs while providing insight into the unique challenges of each individual community, administrators are encouraged to consider development of a standardized primary data collection instrument. The instrument should be customizable by the organization administering the CHNA, but should establish consistency in the wording of questions, the definition of health indicators, and the measurement of indicators. Development of an instrument would not only improve generalizability, it would also reduce costs for organizations conducting CHNA. 8

3. Create a system that enables improved coordination across communities conducting CHNA Given the resource demands of CHNAs, policymakers and administrators should consider developing a centralized system, which allows organizations conducting a CHNA to connect with other organizations conducting a similar analysis in their community. In Northeast Ohio, several organizations coordinated their efforts, reducing costs by spreading the expense of researchers and report preparation across multiple organizations. Developing a system that encourages and enables such strategic partnerships would be beneficial and cost effective. 4. Establish a system that oversees follow through on CHNA based community improvement plans To maximize the information gathered through CHNAs and subsequent community improvement plans, enforcing agencies should consider introducing a system of oversight designed to assess organizational follow through for improvement plans. Such a policy could ensure that targeted community health improvements are realized and would be a clear use of the CHNAs. 5. Utilize emerging guidance Insights provided by reports developed by the Health Policy Institute of Ohio (HPIO, released in April 2015), the final IRS rules, IRS supplemental documentation, the Ohio Department of Health, and the CDC will help hospitals to conduct more focused, structured, and effective CHNAs. 6. Coordinate data collection between existing surveillance systems and CHNA researchers Given that the secondary data sources recommended in the CDC guidance are largely collected through various surveillance systems that operate at the local level (such as YRBS and BRFSS), administrators might consider coordination between these established surveillance programs and the organizations conducting CHNAs. Such partnerships would allow detailed, standardized data collection, while also reducing the burdens placed on organizations effected by the CHNA regulation. In Conclusion The CHNA process provides an opportunity for communities to prioritize health resources based on local data. Considered at the regional and state level, these planning processes have the potential to add a rich source of primary data not otherwise collected, to established surveillance systems. The next round of CHNAs will benefit from coordination and standardization efforts at all levels to maximize the planning resources of hospitals, health departments and the communities they serve. 9

Appendix 1: Secondary Data Sources 1 COUNTY AND COMMUNITY SPECIFIC DATA n Cleveland Department of Public Health 12 Cleveland Community Health Needs Assessment 2 Lorain County Health and Wellbeing Fact Book 2 Lorain County Ohio Health Assessment Project 2 Public Services Institute of Lorain County Community College Integrated Assessment 2 Akron Metropolitan Area Transportation Study 1 Cuyahoga County Department of Health Website (Unspecified) 1 Cuyahoga County Human Service Briefing Book 1 Health Improvement Partners Cuyahoga 1 Health Profile of Lorain County 1 Richland County Community Health Improvement Committee 1 Richland County Partners Community Health Assessment Collaborative 1 2 ENVIRONMENT n US Department of Agriculture (Unspecified) 14 US Department of Agriculture Food Environment Atlas 3 Environmental Protection Agency 2 Safe Drinking Water Systems 1 3 PUBLIC SAFETY AND VIOLENCE n Ohio Department of Health Violence and Injury Prevention 5 Ohio Attorney Generalʹs Domestic Violence Report 4 Ohio Department of Public Safety Traffic Crash Facts 4 Ohio Department of Public Safety (Unspecified) 3 Akron Police Department 1 Federal Bureau of Investigation Uniform Crime Reporting 1 10

4 GENERAL n Behavioral Risk Surveillance System 41 Ohio Department of Health (Unspecified) 31 Community Health Status Indicators Project 20 Healthy People 2020 20 Centers for Disease Control (Unspecified) 16 US Health Resources and Services Administration (Unspecified) 15 Community Needs Index 13 Association of American Medical Colleges 12 Catholic Healthcare West Community Needs Index 12 Prevention Quality Indicators 12 Ohio Department of Health Vital Statistics 11 American Community Survey 9 Community Health Needs Assessment Toolkit 8 Ohio Family Health Survey 8 Annie E Casey Foundation 7 Ohio Department of Education 7 Ohio Department of Health Information Warehouse 7 Ohio Policy Research and Strategic Planning Office 5 Unspecified 5 Health and Human Services County at a Glance 4 Regional Health Needs Assessment Project 4 American Fact Finder Reports 2 Healthy Ohio Community Profiles 2 Northeast Ohio Regional Impact and Outcomes Indicator Report 2 The Community Guide 2 Truven health analytics 2 World Health Organization Social Determinants of Health 2 Agency for Healthcare Research and Quality 1 Dartmouth Atlas of Health Care 1 Dataplace 1 Guttmacher Institute 1 Health and Human Services (Unspecified) 1 Health and Human Services Community Status Indicators 1 Health Metrics and Evaluation 1 National Center for Education Statistics 1 National Center for Health Statistics 1 Northeast Ohio Data and Information Services 1 US Health Resources and Services Administration Area Resource File 1 World Life Expectancy 1 11

5 DISEASES AND OUTCOMES n Ohio Trauma Registry 12 National Cancer Institute 6 Northeastern Ohio Regional Trauma Network 6 Stark County Mental Health and Recovery Board 6 National Center for Chronic Disease Prevention and Health Promotion 5 American Cancer Society Cancer Facts and Figures 4 American Diabetes Association 4 Centers for Disease Control Arthritis at a Glance 4 Centers for Disease Control Asthma 4 Mental Health and Recovery Board of Wayne and Holmes County 4 National Alliance on Mental Health 4 Ohio Cancer Incidence Surveillance System 4 Ohio Oral Health Surveillance System 3 Ohio Department of Health Infectious Diseases 2 Suicide Prevention Resource Center 2 Centers for Disease Control National Diabetes Surveillance System 1 National Center for HIV/AIDS/Viral Hepatitis/STD/ TB Prevention 1 Ohio Department of Drug and Alcohol Addiction Services 1 6 DEMOGRAPHY AND POPULATION DATA n County Health Rankings 31 Bureau of Labor Statistics Unemployment Data 13 Claritas Demographic data 13 US Census Bureau poverty Data 13 US Census Bureau (Unspecified) 6 Ohio Department of Job and Family Services 5 Center for Marketing and Opinion Research 4 Cuyahoga County Employment and Family Services 4 Office of Minority Health 4 Bureau of Economic Analysis 3 US Census County Business Patterns 3 Ohio Census Quickfacts 2 US Bureau of Labor Statistics 2 Census Bureau 1 County Business Patterns 1 Ohio Birth Certificate Data 1 Small Area Health Insurance Estimates 1 Small Area Income and Poverty Estimates 1 Truven Market Planner 1 12

7 AGE SPECIFIC DATA n Youth Risk Behavioral Surveillance System 13 Help Me Grow 5 Ohio Youth Survey 5 Oral Health Survey of Ohio Schoolchildren 5 Ohio Department of Health Third Grade BMI Report: Childhood Overweight 2 Our Youth Our Community Our Future: Communities that Care 2 Lorain County Office of Aging 1 Summit County Adult Protective Services 1 8 HOSPITAL AND CLAIMS DATA n Ohio Hospital Association Discharge Data 8 University Hospital Discharge Data 7 Ohio Department of Health Hospital Data 5 Hospital Discharge Data 2 Medicare Claims Data 1 Ohio Department of Health Annual Hospital Registration and Planning Report 1 Ohio Department of Health Regional Assessment Project for Critical Access Hospitals 1 13

Appendix 2: Leading Health Indicators 9 INDICATORS IDENTIFIED BY MORE THAN ¾ OF CHNAs Access to Affordable Health Care Access to Primary Care Providers and Non Emergency Clinics Diabetes Low Physical Activity Uninsurance or Underinsurance 10 INDICATORS IDENTIFIED BY MORE THAN ½ BUT FEWER THAN ¾ of CHNAs Access to Dental Care Access to Hospitals and Urgent Care Facilities Adult Obesity/ Overweight Cancer Heart Disease/ Stroke High Tobacco Consumption Limited Health Education and Outreach Mental Health Non Opioid Illegal Drug Abuse Poor Diet Poverty Suicide Youth Obesity/ Overweight Published by The Center for Community Solutions. Copyright 2015 by The Center for Community Solutions. All rights reserved. Comments and questions about this edition may be sent to jcorlett@communitysolutions.com. 1501 Euclid Ave., Ste. 310, Cleveland, OH 44115 101 E. Town St., Ste. 520, Columbus, OH 43215 P: 216-781-2944, F: 216-781-2988 www.communitysolutions.com 14