Thomas Bias * Christiaan Abildso Emily Sarkees
In order to fulfill the Patient Protection and Affordable Care Act's Community Health Needs Assessment requirements, hospital systems sometimes vary in detail between individual hospital sites or locations and performing an assessment for the entire system. This article examines needs assessments and their accompanying implementation plans across a large university hospital system and finds support for conducting assessments at the local site-level but evidence that system-wide approaches may also have significant benefits, especially at the implementation phase. It suggests a hybrid approach to the needs assessment process where systems and their individual hospitals work together to maximize health benefits to the communities served.
Since the inception of the 2010 Patient Protection and Affordable Care Act's (ACA's) requirement for non-profit hospitals to conduct Community Health Needs Assessments (CHNAs) every 3 years, most hospitals should have completed at least two cycles of identifying health needs in the community, developing implementation plans, and working to improve the health of their local service areas. Large hospital systems, made up of multiple individual hospital locations, have differed in their approach to conducting these CHNAs. Some have completed one CHNA report and its accompanying implementation plan for all hospitals within the system whereas others have completed CHNA and implementation plans for each individual hospital within a system. The 2010 ACA required non-profit hospitals across the United States to complete Community Health Needs Assessments whereby the hospital gathers community input and examines other data sources to identify the most important public health issues facing their service areas. After identification, hospitals must choose health issues to prioritize and create implementation strategies to address those needs. This requirement is tied directly to the tax-exempt status of hospitals and must be completed every 3 years (1). Activities related to the CHNA implementation plan are reported on the Internal Revenue Service Form 990. Prior literature has indicated the wide variation of quality among CHNAs, (2) including a lack fo consistency in method and content (3).
While community benefit has been notoriously hard to capture by non-profit hospitals, it was estimated that spending in 2012 was over 60 billion dollars in the United States (4). This enormous influx of money, part of which should now be directed toward significant public health need in communities served by these hospitals, underscores the importance of further understanding best practices for CHNA processes and the need for clarity and consistency in CHNA reporting (5). There is wide variation in the amount of this spending across hospitals, and while research has shown that prior to the CHNA act much of this spending was patient-care related (6), there is also some variation in how sites have moved this toward higher community benefit spending, tied directly to the level of CHNA implementation planning (7).
In light of these large sums of public health spending, the CHNA process has potential to be an important mechanism for improving public health at the population level and addressing systemic and environmental factors, including social determinants of health, that have proven to be difficult problems for public health practitioners to solve (8). Over the past decade there has been a tremendous growth in both the number of hospital systems (more than one hospital formally affiliated with each other) and the number of independent hospitals who have moved toward affiliation with a system (9). Hospital systems have the potential to reach large populations with both healthcare services and public health interventions through the CHNA process. Systems generally complete separate reports for each site affiliated with the hospital system, although in some cases system reports combine one or more sites into one report (10). The presence of one overarching report summarizing needs and implementation strategies across all sites within systems also varies from system to system.
Research has pointed to the importance of collaboration across hospital systems (11) and between hospitals and community partners, both through input from the public (12–14) and with local stakeholders such as health departments (15). The literature also emphasizes that increasing the scope of collaboration can help increase the resources brought to bear on projects and the benefits of expanded partnerships (11) and regional coordination (16). Potential areas where hospitals and other public partners could share needs assessment data have also been highlighted (3). Using the West Virginia University Medicine hospital system, we identify the variation in responses to the health needs identified by each local hospital siteindependently and determine which health needs were prioritized by each. Further, we attempt to cross-reference implementation strategies across each and discuss the potential for intra-system overlap and collaboration. The findings here, which will lead to a system-wide plan for the specific hospital system, also hold lessons learned for other hospitals who are a part of a larger healthcare system, but potentially also for hospitals who could coordinate or collaborate with other regional hospitals and community partners to extend resource availability for implementation around common public health goals.
We examined eight hospitals within the West Virginia University Medicine system who went through a nearly-identical process of CHNA within the past 5 years. Table 1 describes each hospital.
