Please note that as of January 1, 2018, this service line is offered exclusively under INCompliance, an affiliate of QMCG.

The 2010 Affordable Care Act requires that all 501(c)(3) hospitals conduct a community health needs assessment (CHNA) to maintain tax-exempt status. QMCG provides the support you need to develop a CHNA report and implementation strategy that complies with this requirement. Specifically, we can help address the following frequently asked questions.

What is meant by “describing the community served by the hospital facility”?

The IRS rules allow some flexibility. In most cases, it should be defined geographically (zip codes, counties, MSAs, etc.), but in special circumstances (e.g., children’s hospitals, cancer hospitals, specialty units) may also be described by patient populations. Should include not only those the hospital would like to serve, but those available to serve (including through emergency department). Often, this will be the hospital’s service area which is generally a geographic area comprising 75 percent of the admissions.

What kinds of data are required?

Data for the CHNA should include federal, state and local sources and identify the following:

  • Current and projected service area population and demographic information
  • Existing hospital services
  • Other health care providers and resources in the service area
  • Health Professional Shortage Areas within the service area
  • Health conditions of the area population

Where do we go for data?

Data can be obtained from a variety of sources, including the following:

  • State Health Department
  • Community Health Rankings and Roadmaps
  • Community Commons
  • HRSA Data Warehouse
  • Kids Count Data Center

Once we have data, what do we do with it? How do we determine that the data indicates a need? What kinds of steps or processes could be used to analyze the data to turn it into a list of health needs for the community?

Once the data is compiled, identify deficiencies in hospital capacity and physician resources for the projected population. Identify disease and risk factor behaviors that are significant to the service area and determine if the issues are related to an unmet need.

How should organizational or individual resources for “community input” be identified?

The following organizations or groups may be considered for community input:

  • Associations – Ohio Hospital Association, Children’s Hospital Association, regional hospital associations
  • Consumers and individuals residing in the community
  • Local business owners
  • Physicians – both those on the medical staff and perhaps those who are not
  • Local Departments and organizations – Job and Family Services, ADMHS Board, FQHCs, County Health Department, Aging, school districts, United Way

How can community input be assessed or used?

One way gather and then assess and use community input is to form a group of interested stakeholders from both within and outside of the hospital (could be called an “Advisory Council”) to assist with considering the data and input and identifying and prioritizing needs.

What should be considered in prioritizing needs and identifying which needs are not going to be addressed by the hospital?

The hospital should review each significant need and consider the following:

  • The burden, scope, severity or urgency of the need
  • Estimated feasibility and effectiveness of possible interventions
  • Health disparities associated with the need
  • The importance the community places on the need
  • Whether the need can be addressed alone or does it require partnering with another organization
  • Whether the hospital has the capabilities and resources (e.g., skills, funding, knowledge) to address the need
  • Services the hospital has that can help address the need
  • Whether the hospital can change current business practice to help address the need

What should be included in the implementation strategy?

For each significant need addressed in a CHNA, the implementation strategy should include the following:

  • Action steps
  • Anticipated impact
  • Programs and resources to commit to addressing the need
  • Planned collaborations

We have done community benefit reports and community needs assessments in the past – can we just update these?

While those may be a resource considered as a part of the CHNA, it is extremely unlikely that those activities followed the steps and included the level of external input required for CHNAs.

What happens if a need is identified and not addressed?

All significant needs are not required to be addressed. The implementation strategy must address each significant health need, indicating whether the need is one the hospital will address or not. If the need is not being addressed by the hospital, indicate the reason (e.g., limited resources, lacking expertise, etc.).

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Key Contact

Christine Kenney
Director of Regulatory Services

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