The Potential Value of Joint Health Assessments to Community Health
Community health assessments (CHAs)/community health needs assessments (CHNAs) are an integral part of public health practice and are conducted regularly on behalf of communities across the US. Yet, while there are many examples of joint CHAs/CHNAs between Nonprofit Hospitals (NPHs) and Local Health Departments (LHDs)/State Health Agencies (SHAs) across the country, too many assessments are conducted with minimal involvement from their organizational counterparts, particularly among NPHs conducting CHNAs. Hank Stabler explains why NPHs are not involving LHDs/SHAs in their CHNAs.
Community health assessments (CHAs) are an integral part of public health practice and are conducted regularly on behalf of communities across the United States. CHAs typically use a combination of available primary and secondary data sources to measure prevalence of health behaviors and associated morbidity/mortality across a range of common health conditions for the entire community; the data can also be used to observe the health status of certain particularly vulnerable subgroups residing in the community. Health assessments provide a critical foundation for public health planning because they enable the prioritization of urgent health issues for the community-at-large and for community members who are disproportionately at-risk for poor health due to, for example, structural racism – and this prioritization process can then inform how scarce resources are allocated to best support community health and improve health equity via public health programming.
State Health Agencies and Local Health Departments and local health agencies (SHAs and LHDs) historically have been key initiators of CHAs. Assessment-related activities comprise two of the Centers for Disease Control and Prevention’s (CDC) 10 Essential Public Health Services; the Public Health Accreditation Board (PHAB) also requires health agencies to conduct a CHA within every five years in conjunction with a community health improvement plan (CHIP) as one of their conditions for achieving accreditation. Over the past 10-12 years, hospitals – in particular, nonprofit hospitals (NPHs) – have increasingly conducted their own health assessments, often termed community health needs assessments (CHNAs), every three years as a condition for keeping their federal and state tax exemptions. Like CHAs, CHNAs are used to inform NPHs’ implementation plans, which specify how NPHs will address key community health issues. As part of the CHNA process, NPHs must consider the input of “those with special knowledge of or expertise in public health” as well as “persons who represent the broad interests of the community” when prioritizing health issues.
Given their respective organizational requirements and the potential benefits of sharing resources and expertise, both NPHs and SHAs/LHDs have clear incentives to collaborate on their respective health assessments rather than producing separate assessments based on the same or similar data sources. Apart from the required timing of assessments (every three years for CHNAs, at least every five years for CHAs), the Internal Revenue Service (IRS) CHNA regulations and the PHAB accreditation requirements are well-aligned and flexible enough to fit the needs of both organizational types. There is evidence that joint CHA/CHNAs are of higher quality and are more comprehensive in their scope. Joint CHA/CHNAs also increase the likelihood of collaboration in other areas, particularly via programming developed as part of a CHIP and/or implementation strategy. More broadly, joint CHAs/CHNAs represent an opportunity for organizational collaboration between local entities that ideally would share responsibility for improving community health.
Yet, while there are many examples of joint CHAs/CHNAs between NPHs and LHDs/SHAs across the country, too many assessments are conducted with minimal involvement from their organizational counterparts, particularly among NPHs conducting CHNAs. A 2018 study found that 72% of LHDs reported undergoing a collaborative CHA process with their local hospital, although the extent of their collaboration was not discussed. Within my own dissertation research examining how NPHs conducted their CHNAs, 58% of CHNAs involved an LHD and/or SHA during the first NPH reporting cycle (2011-2013), which increased to 71% in the third reporting cycle (2018-2021). Most of these contributions from LHDs were advisory in nature and limited in scope – ie, public health professionals providing their opinion on priority health issues and no actual sharing of resources.
There are likely several reasons why NPHs in particular are not involving LHDs/SHAs in their CHNAs. Many rural communities with an NPH do not have an LHD or an SHA operating on the same geographic scale, for example, or have LHDs with limited capacity. The incongruent timing of CHAs and CHNAs also is likely limiting the feasibility of joint assessments.
This is still a missed opportunity. It does not make sense for multiple health assessments to be produced within similar time frames and for the same communities, especially since public funding directly or indirectly supports the provision of both CHAs and CHNAs (that is, NPHs produce CHNAs in exchange for tax exemptions and SHAs/LHD activities are typically supported via public funding). Not only is this a potential waste of resources, but it also lacks synchronicity in terms of what health issues are prioritized and where programming is targeted when NPHs and SHAs/LHDs identify different health issues to address.
This last point may be especially critical. Finding a way to align the resulting programming that both NPHs and LHDs / SHAs implement based on their respective health assessments could potentially go a long way towards filling gaps in community health programming. For one, public health funding is notoriously patchwork and inconsistent. NPHs, many of whom are better financed than their public health counterparts, could buttress the public health system by collaborating with LHDs and SHAs and contributing needed resources. LHDs and SHAs have also long recognized the importance of addressing their communities’ upstream determinants of health and worked to foster multisectoral collaboration with organizations that are best equipped to address these needs, such as social service agencies. Hospitals have begun investing in these upstream determinants as well, but too often prefer to deliver these types of services on their own (eg, creating their own short-term housing program) If LHDs/SHAs can help facilitate NPHs’ investments in social determinants via a CHIP (or SHIP), it could go towards addressing community members’ needs.
Policymakers in several states have noted the potential benefits of aligning LHDs/SHAs and NPHs around community health. New York, for example, has required NPHs and LHDs to produce their health assessments together and then work jointly on CHIP that address their identified health issues. This requirement has resulted in New York-based NPHs spending $393,000 – $786,000 more per year on population health initiatives than other states’ NPHs.
Many experts have noted the very significant potential issues of involving clinical entities in community health – eg, the risk of ‘medicalizing’ critical public health services for patients rather than those who need such services more; crowding out those already implementing these services; or the difficulty that hospitals have with collaborating with smaller, less politically well-connected organizations. These concerns are extremely valid. However, many health care stakeholders – especially those from large health systems – have substantial resources now that can be brought to the aid of other critical support systems, including public health. There is also a very real need for better oversight and increased accountability for NPHs, whose business practices have run counter to a not-for-profit ethos of charity and good works that are supposed to underlie the justification for tax exemptions. Requiring NPHs to invest more resources in their local community’s health may help alleviate short-term resource issues, but it may also be an important step in ensuring other local stakeholders and agencies are aware of their local NPH’s obligations to help their communities.
Other Stories Referenced in this Post You Should Read:
- Nonprofit Hospitals: Profits And Cash Reserves Grow, Charity Care Does Not
- This Nonprofit Health System Cuts Off Patients With Medical Debt
- They Were Entitled to Free Care. Hospitals Hounded Them to Pay
- How a Hospital Chain Used a Poor Neighborhood to Turn Huge Profits
- How the Cleveland Clinic grows healthier while its neighbors stay sick
- Hank Stabler, PhD, is a postdoctoral research student with the UMN Center for Public Health Systems with experience in program evaluation, policy analysis, and mixed methods research. Dr. Stabler’s research interests relate to hospital-community relationships and multisectoral collaboration. He holds a PhD from the University of Minnesota’s Health Services Research, Policy, & Administration program with a focus on Health Policy, and an MPH from the University of Michigan.
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