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Building Leaders – Transforming Hospitals – Improving Care
Building Leaders – Transforming Hospitals – Improving Care
Community Health Needs Assessment
Round 2
Building Leaders – Transforming Hospitals – Improving Care
45 Years of Delivering Superior Results
Strategy – Solutions – Support
Building Leaders – Transforming Hospitals – Improving Care
• Turnaround
Strategy
• Financial
•Operations
•Corporate
Compliance
• Board
Development
•Regulatory Compliance and Accreditation Preparation
• Lean Process
Improvement
•CHNA
•Gaffey Revenue Cycle Management
•CrossTX Population Health Platform
•Optimum Productivity
• Execuitve Recruiting
• Interim Executive Placements
•Mid-level and Specialty Placements
Formerly known as Brim
Healthcare we have a
45 year track record of
delivering superior
clinical & operating
results for our clients.
We believe that the combination of People, Process & Technology transforms healthcare & provides the required results
Our Company
Our Executive Team
has experience in
managing hospitals
from multi-billion $
healthcare systems to
community hospitals
Our Team Our Mission
Management Placement Consulting Technology
Strategy – Solutions – Support
Building Leaders – Transforming Hospitals – Improving Care
Opex Categories
%
Revenue Cumulative
Salaries and Wages 41%
Fringe Benefits 10%
Contract Labor 2%
Total Labor Expense 53% 53%
Supply Expense 14% 67%
Purchased Services 9% 76%
Physicians Fees 4% 80%
* Data from HealthTechS3 Comparative Financial Benchmark Database
80% of Hospital Operating Expenses Fall into 4 Categories
Executive Search
Productivity
Management
Software
Benchmarking
Lean Projects
GPO Services
Cost Benchmarking
Lean SC Consulting
GPO Services
PPM Consulting
Physician Comp
Consulting
Increasing Efficiency/Reducing Waste Our Mission
Management Placement Consulting Technology
Building Leaders – Transforming Hospitals – Improving Care
HealthTechS3 is a trusted partner our hospitals. We are fair, honest, professional, and provide ongoing support. Integrity
HealthTechS3 has been around for 45 years and successfully navigated many hospitals through an ever changing healthcare market. Longevity
HealthTechS3 knows how to work with community hospitals and health systems to best leverage their assets and resources to serve their market and maintain independence.
Market
HealthTechS3 is flexible and affordable relative to many large national consulting firms who focus on strategic work and ideas rather than implementation and impact.
Value
HealthTechS3 is an award winning healthcare services company. We are a renowned management company with award winning hospitals, health systems and physician practices with CEOs of long tenure.
Performance
HealthTechS3 only has consultants with deep experience; Consultants are former hospital leaders and executives, clinical resources are best in the
industry. Expertise
Who we are and what drives us?
Building Leaders – Transforming Hospitals – Improving Care
• HealthTechS3 – currently provides hospital management,
consulting, turnaround, supply chain management, and
professional and physician recruitment services to:
– More than 50 hospitals and health systems
nationwide
– Community hospitals, Critical Access hospitals,
district hospitals, non-profit hospitals
– Most operate physician clinics
– Net Revenue between $20M and $400M
– Business Partner Illinois Critical Access Hospital
Network (ICAHN)
– Preferred vendor with California Critical Access
Hospital Network and Texas Organization of
Rural and Community Hospitals
A Nationwide Client Base Management
Building Leaders – Transforming Hospitals – Improving Care
January 2015 Becker’s 50 Rural CEOs to Know • Nicole Clapp, Grant Regional Health Center
• John Gallagher, Sunnyside Community Hospital
• Chandler Ralph, Adirondack Health
• Phil Stuart, Tomah Memorial Hospital
April 2015 HealthStrong Top 100 Hospitals (iVantage Health Analytics)
• Barrett Hospital & Healthcare
• Carlinville Area Hospital
• Grant Regional Health Center
• Hammond-Henry Hospital
• Hillsboro Area Hospital
• Tomah Memorial Hospital
May 2015 Becker’s Top Hospitals for Physician Communication (scored 92% or higher) • Spooner Health System – score 94%
• Tri Valley Health System – score 93% • Grant Regional Health Center - score 92%
June 2015 Becker’s 100 Great Community Hospitals • Adirondack Health
• Grant Regional Health Center
• Hammond-Henry Hospital
June 2015 Top 100 Critical Access Hospitals (iVantage Health Analytics)
• Barrett Hospital & Healthcare
• Hillsboro Area Hospital
• Tomah Memorial Hospital
July 2015 Most Wired Hospitals – Small & Rural (published H&HN magazine)
• Hammond-Henry Hospital
• Sunnyside Community Hospital
September 2015 Becker’s 50 CAH CEOs to Know • Nicole Clapp, Grant Regional Health Center
• Florence Spyrow, Hammond-Henry Hospital
• Ken Westman, Barrett Memorial Hospital
Client Recognition and Awards Management
Building Leaders – Transforming Hospitals – Improving Care
Strategy
Growth Strategy Market Positioning
Network Collaboration and Development
Physician Relations and Integration
Turnaround Strategy Financial and Operational
Restructuring
Risk Advisory
Creditor Consultancy
Transaction Advisory Merger Integration
Deal Structuring
Contract Analysis and Negotiations
ACO Transition Analysis
Payment Strategy
Transitions
Financial Modeling
Capital Sourcing
Operations
Financial Budgeting/Financial
Planning
Capital Programs
Supply Chain
Labor Productivity
Managed Care Negotiations
Risk Advisory
Revenue Cycle
Business Office Consolidation
Clinical Documentation and Coding Reviews
Operations Lean Workflow Analysis and
Redesign
Patient Access, Throughput,
Level of Care
Corporate Compliance
Clinical & Quality
Quality Improvement Quality Program Development
Clinical Process Redesign
Care and case Management Process
Benchmarking and Reporting
Regulatory Compliance and Accreditation Preparation
Survey Readiness
Plans of Correction
Public Reporting of Quality and safety Indicators
Evidence Bases care
Population Health Management
Care Coordination
Transitional Care Management
Governance &
Leadership
Board Advisory Education
Retreats
Hospital Governance Management
Licensing Advisory Services
Regulatory Strategy Development
Annual Report Preparation
Expert Led Solutions Consulting
Building Leaders – Transforming Hospitals – Improving Care
Community Health Needs Assessment Consulting
Phase 1
Strategy and Planning
Phase 2
Research and Analysis of Community
Phase 3
Identification and Prioritization
of Community Health Needs
Phase 4
Multi-Year Implementation
Plan
Phase 5
Annual Review of
Implementation Plan
In consultation with your governing board, steering committee and community partners, HealthTechS3 consultants facilitate development and documentation of your Community Health Needs Assessment –
and we assist with development of a multi-year implementation plan that is actionable and measurable.
Building Leaders – Transforming Hospitals – Improving Care
Your Solution for Continuous Survey Readiness and Development of Effective Plans of Correction
Critical Access Hospitals PPS Hospitals SNF
Long Term Care
Home Health
Hospice Rural Health Centers
Surveys based on your
accreditation status
CMS Conditions of Participation
State Regulations
The Joint Commission DNV
HFAP
Continuous Survey Readiness Consulting
Building Leaders – Transforming Hospitals – Improving Care
Finding The Right Leader
Peter Goodspeed leads our Executive Placement Services group.
With over 30 years experience Peter understands the unique
challenges of today’s hospitals. Whether finding a candidate for a
rural hospital or searching for a multi-hospital system, we focus on
your desired qualifications and specific needs. Services include:
Interim
Permanent
Executive Search Process
45 Years of Excellence
• HTS3 has been recruiting Senior
Executives for over 45 Years
• Our extensive understanding of
hospitals & healthcare helps us
find the right candidates for you.
Placement
Management Placement Consulting Technology
Building Leaders – Transforming Hospitals – Improving Care
Technology Solutions that Target Key Areas of Pain
Revenue Attrition / Automation & Efficiency / Closed Loop Learning
Increase in Clean &
Complete Claims
Claims Management
Lack of Collection
Automation
AutoStatus
Poor Workflow &
Task Efficiency
AlphaCollector
Under Payment &
Revenue Integrity
Contract Calculator
Correct Patient
Information
Integrated Eligibility
Integrated Reporting
&
Process Insight
AlphaAnalytics
Revenue Cycle - GAFFEY Technology
Building Leaders – Transforming Hospitals – Improving Care
The Complete Solution.
The Optimum Productivity Enhancer program
provides you with the tools and support
services necessary to ensure your success in
addressing today’s productivity challenges.
For over 40 years, our experienced
Consulting Staff have been assisting hospitals
in developing sustainable financial
improvement solutions.
Optimize Productivity
Performance.
HealthTechS3 provides your managers,
supervisors and C-suite the
confirmation needed to accurately
calculate workload staffing and
appropriately adjust staffing on a
timely basis.
Productivity– Optimum Technology
Building Leaders – Transforming Hospitals – Improving Care
The estimated average approximate reimbursement is $42.60* per patient per month, which amounts to over $500 per year that your primary care providers are eligible to be
paid. With an average patient panel size of 3,2791 this can add substantial revenue to
your organization’s bottom line.
Patient Panel Size1 3,279
% of Panel on Medicare1 21.85%
Medicare Patients 716
% of Medicare patients CCM Eligible2 68.6%
Number of CCM Eligible Patients 491
Annual Billing for CCM Patient $511.20
Annual CCM Revenue Potential $250,999
Population Health : CrossTX Technology
Community Connect Platform
Building Leaders – Transforming Hospitals – Improving Care
Carolyn St. Charles, RN, BSN, MBA
Regional Chief Clinical Officer Carolyn began her healthcare career as a staff nurse in Intensive Care. She has worked in a variety of staff, administrative and consulting roles and has been in her current position as Regional Chief Clinical Officer with HealthTechS3 for the last fifteen years. In her role as Regional Chief Clinical Officer, Carolyn St.Charles is the lead consultant for
development of Community Health Needs Assessments and conducts mock surveys for Critical Access Hospitals, Acute Care Hospitals, Long Term Care, Rural Health Clinics, Home Health and Hospice. Carolyn also provides assistance in developing strategies for continuous survey readiness and developing plans of correction.
Sara Stanton Vice President Marketing and Business Development Sara Stanton is responsible for marketing and business growth for both new and existing clients. She is a business development leader with over 15 years of experience in healthcare strategy, consulting, data analytics, and patient communications. Sara has worked with large provider organizations, community hospitals, regional health systems, national ASCs and specialty providers, and the largest IDN’s in the nation. This experience and exposure has given her a broad understanding of the American healthcare market and the initiatives, challenges, and mandates that hospital executives are facing. Stanton earned a BA in Communication Studies from Baylor University.
Strategy – Solutions – Support
Building Leaders – Transforming Hospitals – Improving Care
Building Leaders – Transforming Hospitals – Improving Care
Community Health Needs Assessment
Round 2
Building Leaders – Transforming Hospitals – Improving Care
Instructions
• You may type a question in the text box if you have a question during the presentation
• We will try to cover all of your questions – but if we don’t get to them during the webinar we will follow-up with you by e-mail
• You may also send questions after the webinar to Carolyn St.Charles (contact information is included at the end of the presentation)
• The webinar will be recorded and the recording will be available on the HealthTechS3 web site
www.healthtechs3.com
HealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this information is not intended to be definitive. HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof. HealthTechS3 does not have responsibility for nor does it develop or provide policies intended for direct use by any hospital, clinic or their respective personnel. Any and all responsibility for such and for compliance with state and federal requirements remains exclusively with the hospital, clinic or their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of this information consult original source materials and qualified healthcare regulatory counsel for
specific guidance in adopting and customizing policies for your particular healthcare entity’s use.
Building Leaders – Transforming Hospitals – Improving Care
The Affordable Care Act added 501(r) to the Internal Revenue Code. This provided that hospital organizations will not be treated as tax-exempt under 501(c)(3) unless they meet certain requirements. All of the provisions apply to taxable years beginning after March 23, 2010, except the Community Health Needs Assessment (CHNA).
1. Establish written financial assistance and emergency medical care policies.
2. Limit amounts charged for emergency or other medically necessary care to
individuals eligible for assistance under the hospital's financial assistance policy.
3. Make reasonable efforts to determine whether an individual is eligible for assistance under the hospital’s financial assistance policy before engaging in extraordinary collection actions against the individual.
4. Conduct a community health needs assessment (CHNA) and adopt an implementation strategy at least once every three years. – A $50,000 excise tax will be imposed on a hospital that fails to meet the
CHNA requirements with respect to any taxable year.
Page | 20
Building Leaders – Transforming Hospitals – Improving Care
Final Regulations December 2014
The final rules issued December of 2014 are consistent with earlier guidance issued by the IRS in April of 2013. However, they include the following clarifications:
1. Expands examples of health needs to include preventing illness and addressing the social determinants of health
2. Gives hospitals flexibility if they are unable to obtain required community input
3. Adds requirement to use community input in setting priorities as well as in the assessment process
4. Requires that CHNA documentation must include evaluation of impact of any actions that were taken to address significant health needs since the previous assessment
5. The requirement that implementation strategies include a plan to evaluate planned actions was deleted from the final rule but the strategy still must include anticipated impact of planned actions
Sources:
• “Additional Requirements for Charitable Hospitals; Community Health Needs Assessments for Charitable Hospitals; Requirement of a Section 4959 Excise Tax Return and Time for Filing the Return; Final Rule,” 79 FR 78953 [December 31, 2014], pp. 78953-79016)
• “Community Health Needs Assessments for Charitable Hospitals,”78 FR 20523 [April 2, 2013], pp. 20523-20544
• Catholic Health Association: Assessing & Addressing Community Health Needs 2015 EDITION I I
Building Leaders – Transforming Hospitals – Improving Care
Who is required to complete a CHNA?
The IRS takes the position that §501(r) applies to all
hospitals exempt under §501(c)(3), whether or not
they may be owned by government or political
subdivisions. Accordingly, the IRS intends to apply the
CHNA requirements to every hospital that is been
recognized as an organization under §501(c)(3).
Critical Access Hospitals are NOT excluded IF they are
a §501(c)(3)
Government or District Hospitals are NOT excluded IF
they are a §501(c)(3)
Building Leaders – Transforming Hospitals – Improving Care
WHY~
Building Leaders – Transforming Hospitals – Improving Care
Community Health Needs
Assessment Definitions
“A community health needs assessment is a systematic process involving the community to identify and analyze community health needs and assets in order to prioritize these needs, and to plan and act upon significant unmet community health needs.”
“An implementation strategy is the hospital’s plan for addressing community
health needs, including significant health needs identified in the community health needs assessment. The implementation strategy is also known as the hospital’s overall community benefit plan.”
Source: Catholic Health Association: Assessing & Addressing Community Health Needs 2015 EDITION I I
Building Leaders – Transforming Hospitals – Improving Care
CHNA Basic Requirements
Conduct a community health needs assessment every three years. The assessment must:
1. Take into account input from persons who represent the broad interests the community served by the hospital facility, including those with special knowledge of or expertise in public health
2. Document the CHNA in a written report that is adopted by an authorized body of the facility
3. Make the CHNA report widely available to the public
4. Adopt an implementation strategy to meet the community health needs identified through the assessment
5. Report how the hospital is addressing the needs identified in the community health needs assessment … and a description of needs that are not being addressed with the reasons why such needs are not being addressed
Page | 25
Building Leaders – Transforming Hospitals – Improving Care
Catholic Health Association
Guiding Principles
• Health care organizations must demonstrate the value of their community service.
– Government (at all levels), community members, funders and others committed to improving community health want to know that tax-exempt hospitals are aware of the major needs of the community and that their community benefit planning takes into account these needs.
• Community benefit programs must be integrated into the organization’s overall planning.
– The results of the assessment and the community benefit plan should be integrated with the strategic and operational plans of the organization. This will ensure that the organization allocates the necessary resources to carry out these processes effectively.
• Leadership commitment is required for successful community benefit programs.
– As leaders of charitable organizations, hospital board members, chief executive officers and senior managers should view access to health care and improved community health as important concerns of their organizations. Leadership commitment helps ensure that assessment and planning processes are viewed as organizational priorities and the results are used to implement programs that will improve community health.
Source: Catholic Health Association: Assessing & Addressing Community Health Needs 2015 EDITION I I
Building Leaders – Transforming Hospitals – Improving Care
Catholic Health Association
Guiding Principles
• Those who live in poverty and at the margins of our society have a
moral priority for services. – While assessments will look at the health needs of the overall community, low-income
and other disadvantaged people deserve special attention and priority. Their needs should be a top priority and implementation strategies should include interventions to address these needs.
• Not-for-profit health care has a responsibility to work toward improved
health in the communities they serve. – While assessment and planning are key steps in the overall process to improve
community health, they are not ends in themselves. Assessment results and the implementation strategy must be put into action and these actions should be evaluated and refined, as needed, to ensure that the community and community partners are achieving their ultimate goal – improved community health.
• Health care facilities should actively involve community members,
organizations and agencies in their community benefit programs. – Collaboration among providers and community partners expands the community’s
capacity to address health needs through a shared vision, shared resources and skills, and creates a foundation for coordinated efforts to improve community health.
Source: Catholic Health Association: Assessing & Addressing Community Health Needs 2015 EDITION I I
Building Leaders – Transforming Hospitals – Improving Care
HealthTechS3
Community Health Needs Assessment
In consultation with your governing board, steering committee
and community partners, HealthTechS3 consultants facilitate
development and documentation of your initial or subsequent
Community Health Needs Assessment.
Our process includes five phases:
Phase 1
Strategy and Planning
Phase 2
Research and Analysis of Community
Phase 3
Identification and Prioritization
of Community Health Needs
Phase 4
Multi-Year Implementation
Plan
Phase 5
Annual Review of
Implementation Plan
Building Leaders – Transforming Hospitals – Improving Care
Phase 1: Strategy and Planning
Questions Thoughts and Ideas
1. Will the CHNA be for the hospital only –
or – will this be a multi-organization
CHNA?
2. Are there other organizations conducing
or planning to conduct a community
health needs assessment?
Multi-organization CHNAs can be very powerful in both
identifying community health needs and developing
strategies.
3. Who will facilitate the CHNA process?
• Internally developed
• Consultant
If internal, determine if there sufficient expertise and
resources to complete the CHNA and meet the IRS
requirements.
4. Will there be a CHNA steering
committee?
It is very important to identify an individual and/or group to
guide the process. A steering committee that includes
community stakeholders including public health, can help
ensure the CHNA is not hospital-centric.
5. Who will function as staff support to the
process?
Regardless of if you develop the CHNA internally or hire a
consultant, there should be staff identified to assist with the
logistics such as advertising, etc.
6. How will the governing board and senior
leadership be involved? How will you
provide education and regular updates
about the process?
The governing board is vitally important to the process.
They represent the community and can provide important
insights. They also are required to approve the final CHNA.
Building Leaders – Transforming Hospitals – Improving Care
Phase 1: Strategy and Planning continued
Questions Thoughts and Ideas
7. What is the impact of any actions that
were taken to address significant health
needs since the previous assessment?
Utilize a multi-disciplinary team, including community
representatives.
Consider including questions about the impact if you conduct a
community survey and/or include a question for key community
stakeholders.
8. What is the service area for the CHNA? The IRS states that hospitals should define community taking into
account, “all of the relevant facts and circumstances”
concerning the service area including geographic area served,
target populations and principal functions”.
Hospitals may not define their communities in a way that
excludes certain populations served by the hospital (for
example medically underserved, low-income or minority
populations). Medically underserved populations include
populations experiencing health disparities or at risk of not
receiving adequate medical care as a result of being uninsured
or underinsured or due to geographic, language, financial or
other barrier.
Building Leaders – Transforming Hospitals – Improving Care
Phase 1: Strategy and Planning continued
Questions Thoughts and Ideas
9. Are there specific / targeted
populations to be included in the
CHNA?
Your previous CHNA, secondary data and your patient
population are good sources.
10. What is the timeline for the CHNA
completion?
The CHNA must be approved by the governing board by
the end of the fiscal year in which it is due.
11. What is the budget for the CHNA? When constructing a budget ensure you include:
• Consultant Fees, if applicable
• Staff time
• Advertising to community to solicit input
• Focus Groups
• Editing and Publication
Building Leaders – Transforming Hospitals – Improving Care
Phase 2: Research and Analysis of the
Community
Questions Thoughts and Ideas
1. What are the existing healthcare facilities and
resources within the community that are
available to respond to the health needs of
the community?
• Inventory existing healthcare facilities and
services
• Identify demand for services
• Review internal supply with demand
Hospital Social Services is a good source of information as are
community resource guides.
2. What secondary data will be collected and
what are the sources?
• Population demographics by Age/Race
• Socioeconomic characteristics
• Income
• Unemployment
• Poverty
• Uninsured - Underinsured
• Mortality and Morbidity
• Communicable diseases
• Access to healthcare
• Community safety
• Health behaviors
• Maternal and Child Health
• Mental Health
• Chronic Disease
• Other focused populations
Review prior CHNA for sources that were used. Examples:
• Proprietary Data Bases
• American Community Survey (ACS)
• Centers for Disease Control – Behavioral Risk Factor Surveillance
• National Health and Nutrition Examination Survey (NHANES)
• Center for Disease Control – Morbidity and Mortality Report
(MMWR)
• Community Health Status Indicators Report (U.S. Department of
Health and Human Services)
• Healthy People 2020
• Health Indicators Warehouse
• Local, County and State Health Departments
• Hospital information
• Hospital and Emergency Dept.
• Charity Care
Building Leaders – Transforming Hospitals – Improving Care
IMPORTANT
Access the most current data available! Look carefully at dates of
data!
Comparison: Healthy People 2020
State - 2011 69
County - 2005-2009 76.5
Goal/Target 83.9
Building Leaders – Transforming Hospitals – Improving Care
Questions Thoughts and Ideas
3. Who are the individuals with special
knowledge of public health? Who are key
stakeholders?
IRS regulations require
• Input from persons who represent the broad interests
of the community serviced by the hospital, including
those with special knowledge of public health
• At least one state, local, tribal, or regional
governmental public health department with
knowledge, information, or expertise relevant to the
health needs of the community
• Leaders, representatives, or members of medically
underserved, low-income and minority populations &
populations with chronic disease needs
4. How will you gather community input?
• Key informant interviews in person or by
phone
• Focus groups
• Surveys
• Social media
Key informants may include leaders of community
organizations, service providers, healthcare providers,
rural health clinics or federally qualified rural health
clinics, government, school administrators, etc.
Involve individuals who are aware of health needs in your
community.
5. What format will you use for interviews / focus
groups / surveys?
Consider including questions from last CHNA priorities
and/or target specific issues.
• Standardize formats so they are consistent and
address health issues of uninsured persons, low-income
persons, minority groups and those with chronic disease.
Phase 2: Research and Analysis of the
Community continued
Building Leaders – Transforming Hospitals – Improving Care
IMPORTANT
You are not required to collect reliable, statistically valid and
comparable health data! The best sources for health data are federal
and other public health agencies.
“Hospitals and those working with them on community health
needs assessment should focus their time and resources on
validating and supplementing public health data findings
through interviews and forums with community members and
key informants.”
“Some hospitals may think “conduct a community health needs
assessment” means “conduct a population survey to learn
about the health of the community.” This is not usually
advisable, and in many situations resources will be spent
collecting data that is not statistically valid because the
population sample is not representative or the survey questions
are not validated.”
Source: Catholic Health Association: Assessing & Addressing Community Health Needs 2015 EDITION I I
Source: Florence Reinishch, Healthy Communities Institute
Building Leaders – Transforming Hospitals – Improving Care
IMPORTANT
Internal data is a vital source of information such as:
• Discharge data by MS-DRG
• Discharge data by payor
• Readmissions by MS-DRG and Payor
• Emergency department visits
• Emergency department “frequent flyers”
• Emergency departments visits by payor
• Prenatal Care
• Low Birth Weight Babies
• Medicaid
• Charity Care
Building Leaders – Transforming Hospitals – Improving Care
Phase 3: Analyze
Primary and Secondary Data
Questions Thoughts and Ideas
1. How does your community compare to other
communities / counties / state and the U.S.?
Most secondary data sources have comparative
data.
2. Are the indicators getting better, staying the
same or getting worse?
Review external data as well as your previous CHNA.
3. Is the community meeting external
benchmarks?
Secondary data sources such as Healthy People 2020
have established benchmarks.
4. What are the disparities based on race,
income, age, chronic disease, etc.?
Ensure that you drill down in the data to see if there
are disparities for specific populations.
5. Are there causal factors? Does the secondary data show causal factors that
can be identified? If so, include those factors in the
analysis.
Building Leaders – Transforming Hospitals – Improving Care
Phase 4: Identify and Prioritize
Community Health Needs
Questions Thoughts and Ideas
1. Based on the analysis, what are the most significant
health needs?
Develop a list of all of the significant health needs based
on primary and secondary data.
Categorize the health needs by type. Separate health
needs from causal factors if possible.
2. What criteria will be used to establish priority health
needs? Consider:
• Magnitude
• Severity
• Historical Trends
• Ability to impact problem
• Impact on vulnerable populations
• Available resources
• Feasibility
The Hospital may develop their own criteria for establishing
priority health needs.
3. Who will be involved in determining priorities?
How will you include community input in setting
priorities?
The IRS requires community input in setting priorities as well
as in the assessment process.
Include a question about priorities if you conduct a
community survey.
Include community representatives to assist in developing
priorities.
Building Leaders – Transforming Hospitals – Improving Care
Phase 5: Develop a
Multi-Year Implementation Strategy
The implementation strategy is adopted on the date it is
approved by the governing body
The implementation strategy must be adopted on or before the
15th day of the fifth month after the end of the same taxable year
in which the hospital conducts the CHNA.
The additional time after the end of the fiscal year for
development of the implementation plan was intended to
provide time to collaborate with community partners.
“Collaborating across the community allows the hospital to:
1. Leverage existing assets in the community creating the opportunity for broader impact
2. Avoid unnecessary duplication of programs or services thereby maximizing the use of scarce resource; and
3. Help build the capacity of community members to engage in civic dialog an collaborative problem solving, positioning the community to build upon and sustain health improvement activities.”
Source: Catholic Health Association: Assessing & Addressing Community Health Needs 2015 EDITION I I
Building Leaders – Transforming Hospitals – Improving Care
Phase 5: Develop a
Multi-Year Implementation Strategy Questions Thoughts and Ideas
1. Who will be involved in developing the
implementation plan?
Consider community partners / key stake-holders
who participated in the CHNA development.
Include other providers of healthcare to avoid
duplication of effort.
2. How will you ensure that the implementation
plan is comprehensive and includes goals –
objectives – accountability – impact of actions?
Develop a template.
3. Who will be responsible for implementing the
strategy?
Consider the same group that developed the
Implementation Strategy with regular meetings and
updates.
4. Who will be responsible for evaluating the
strategy at least annually?
Assign one individual to ensure there is an annual
evaluation.
Note: The requirement that implementation strategies include a plan to evaluate planned actions was deleted
from the final rule but the strategy still must include anticipated impact of planned actions
Building Leaders – Transforming Hospitals – Improving Care
Make the CHNA
“Widely Available”
• The written CHNA report must be "conspicuously posted" on the
hospital facility's website, or the hospital organization's website
• The definition of "widely available" contains detailed
requirements for website posting and document accessibility,
including the following:
– Hospitals must provide individuals who ask how to access a copy with
the direct website address or URL of the web page on which the CHNA
Report is posted
– Website must clearly inform reader how to download the report
– Download may not require special equipment or fee
– Report must be maintained on the website until two subsequent CHNA
reports are made available
– Paper copies must be available for public inspection without charge
Building Leaders – Transforming Hospitals – Improving Care
Community Health Needs Assessment
Make it work for you! Find value in the process
– Great marketing opportunity
– Integrate findings in your Strategic Plan
– Increase reimbursement by reducing readmissions, lower LOS, etc.
Improve Population Health – It’s your community too!
Building Leaders – Transforming Hospitals – Improving Care
It Takes a Community
Building Leaders – Transforming Hospitals – Improving Care
Questions?
Building Leaders – Transforming Hospitals – Improving Care
Contact Information
If you would like us to send you a proposal for a
Community Health Needs Assessment,
please contact:
Carolyn St.Charles
Regional Chief Clinical Officer
Email: [email protected]
Phone: 360-584-9868
© HTS3 2016 | Page 46
Documentation - Self-Assessment 990 Y N Page
1 Description of the community served by the facility (geographic area, populations etc.) X
2 Description of how the community served was determined
3 Description of community demographics X
4 List of existing healthcare facilities and resources within the community that are available
to respond to the health needs of the community
X
5 Description of sources of data and other information used in the CHNA. X
6 Information gaps that impact the faculties ability to assess the community X
7 List of all organizations with which facility collaborated in conducting the CHNA X
8 Identification of any third parties with which facility contracted to assist in conducting
CHNA, including qualifications
9 Description of how the facility took into account input from persons who represent the
broad interests of the community it serves (At least one state, local, tribal or regional
governmental public health department (or equivalent department or agency) with
knowledge, information, or expertise relevant to the health needs of the community
X
10 Description of how the facility took into account input from persons who represent the
broad interests of the community it serves : Members of medically underserved, low-
income, and minority populations in the community, or individuals or organizations serving
or representing the interests of such populations.
X
11 Description and process for taking into account input from persons who represent the
broad interests of the community it serves: Written comments received on the most
recently conducted CHNA and most recently adopted implementation strategy.
X
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12 Description of when and how facility conducted with these persons (focus groups,
interviews, surveys
13 If input from an organization, name and title of at least one individual in each organization,
with whom the hospital consulted.
X
14 Description of primary and chronic disease needs and other health issues of uninsured persons, low income
persons and minority groups X
15 Process and criteria used in identifying certain health needs as significant X
16 Process and criteria for prioritizing significant health needs X
17 Prioritized description of ALL of the significant health needs of the community X
18 Description of existing health care facilities and other resources in the community to meet
the needs identified.in the CHNA
X
19 Actions facility intends to take to address each significant health needs X
20 Provide explanation of reason for not addressing significant health needs, including resource
constraints or lack of expertise
X
21 Evaluation of impact and effectiveness of any actions taken in prior CHNA X
22 Implementation strategy approved by governing board
23 CHNA available on web site and/or information on how to download report X
24 Report on website until two subsequent CHNA reports are made available X
25 Paper copies available without charge X