The Health Care Manager Volume 34, Number 2, pp. 147–156 Copyright # 2015 Wolters Kluwer Health, Inc. All rights reserved.
Community Health Needs Assessment A Pathway to the Future and a Vision for Leaders Cathy G. Grant, MPA; Roberto Ramos, MEd; Jenna L. Davis, MPH; B. Lee Green, PhD There is a need to implement evidence-based public health practice that integrates targeted and specific strategies and actions with community preferences to improve the health of populations. A community health needs assessment (CHNA) is vital to identifying the health concerns of communities, to learn about the factors that influence their health and the assets, resources, and challenges that impact those factors. It is required for tax-exempt entities to conduct a CHNA and adopt an implementation strategy to meet the identified community health needs. The goal of this article is to chart a pathway for health system leaders utilizing a CHNA process to address disparities in racial/ethnic groups and other medically underserved populations and to meet legal requirements. The efforts of the H. Lee Moffitt Cancer Center and Research Institute in developing its CHNA will be highlighted to provide clear evidence to health system leaders for why and how to conduct a thorough and compelling CHNA to meaningfully address health disparities locally and respond to longstanding historical health inequities at the health system level. Key words: community, health disparities, leadership, needs assessment
HE CURRENT PUBLIC health discussion should not be about whether health and health care disparities or inequities exist, but rather on which strategies and interventions work best to reduce the gaps in the quest to eliminate them. History informs us that inequities in health care access and utilization, health care quality, and health outcomes have long existed in the United States.1 The solutions are going to be multifaceted, extremely difficult, and time consuming and will require adequate resources. The truth is that as leaders of health systems in the pursuit of enhancing and institutionalizing cultural and linguistic competence, it will take much more than strong words or eloquent speeches and statements of support to address
T
Author Affiliations: Moffitt Diversity, Moffitt Cancer Center, Tampa, Florida. The authors have no funding or conflict of interest. Correspondence: Jenna L. Davis, MPH, 12902 Magnolia Drive, MBC-Diversity, Tampa, FL 33612 ([email protected]). DOI: 10.1097/HCM.0000000000000057
these inequities. There will need to be evidencebased public health practice that integrates targeted and specific strategies and actions, as well as strong leadership. The concept of evidence-based public health is centered on ‘‘the process of integrating sciencebased interventions with community preferences to improve the health of populations.’’2(p419) Executing evidence-based public health involves more commitment than just the particular research interest of a researcher or institution. The integral parts in executing evidence-based public health are to conduct community assessments for ascertaining the health and cultural needs/ issues experienced, to develop interventions that address the identified issues based on scientific review, and to assess the process, impact, and outcomes of the interventions.2 For health system leaders seeking to eliminate health disparities and inequities, it is critical to recognize the importance of gaining an awareness and understanding of the needs, assets, and strengths among the communities being served, particularly those who are medically underserved.3 Specifically, conducting a community 147
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
148
THE HEALTH CARE MANAGER/APRIL–JUNE 2015
health needs assessment (CHNA) to collect and analyze information is vital to identifying the health concerns in your communities, to learn about the factors that influence health, and the assets, resources, and challenges that impact those factors.2,4 The process for completing a CHNA should not be considered a 1-time initiative, but rather an ongoing, cyclical, and modifying process. It should be repeated and constantly updated in order to reveal the needs of the community, the gaps that persist, and the vision for the work ahead. Implementing a CHNA consists of 5 key steps. These include (1) summarizing relevant information about the state of health and health needs of the population and the accompanying analysis highlighting the major issues, (2) setting priorities for action, (3) developing strategies to address the priority areas, (4) implementing strategies, and (5) evaluating the process and outcomes. Conducting a CHNA is required by US federal law for tax-exempt entities.5-7 Roughly once every 3 years, the Internal Revenue Service (IRS) requires all not-for-profit organizations receiving preferential tax status to conduct a CHNA. The IRS guidelines state that in order for community benefit reporting of an organizational activity or effort, it must be driven by the community needs. As well, the Affordable Care Act specifically requires that hospitals adopt an implementation strategy to meet the community health needs identified through the CHNA. In addition, the process must take into account input from individuals who represent the broad interests of the community served by the hospital, including those with special knowledge of or expertise in public health. Furthermore, the CHNA must be available and accessible to the public. The goal of this article is to chart a pathway for health system leaders utilizing a CHNA process to address disparities in racial/ethnic groups and other medically underserved populations and to meet legal requirements. This will be accomplished in large part by highlighting the efforts of the H. Lee Moffitt Cancer Center and Research Institute (Moffitt) in conducting its CHNA. The overarching objectives for Moffitt to conduct a CHNA are to (a) identify the healthrelated needs and assets of the primary service area; (b) identify where there are gaps and
potential opportunities for addressing those needs; and (c) develop a plan of action for how Moffitt and its partners can address those needs in a coordinated, collaborative, and systematic approach. Another important aspect of this article is to provide clear evidence to health system leaders for why and how to conduct a thorough and compelling CHNA to meaningfully address health disparities locally and respond to longstanding historical health inequities at the health system level. MOFFITT CANCER CENTER’S CHNA In order to commence the process, Moffitt considered options and strategies for developing the CHNA. It was decided to have its diversity department (Moffitt Diversity) coordinate the effort and to solicit the expertise of a nonprofit health consultancy organization to formally initiate the CHNA development process. The consultants selected were tasked with guiding Moffitt through the CHNA process with coordinating data collection, analysis, and reporting. Moffitt Diversity convened an advisory committee consisting of key employees and community leaders. Table 1 lists the titles and affiliations of the committee members. Moffitt employees represented various departments and leadership, and the community members were composed of representatives from several health, governmental, and social service agencies across the Tampa Bay region and were reflective of the primary services area, with an overrepresentation of members from racial/ethnic minority groups. The committee worked directly with the consultants, offering guidance and feedback regarding the areas to be studied, data collection and methodology, and review and input on draft documents. DATA COLLECTION The data collected for the Moffitt CHNA integrates a social-determinants-of-health framework to acknowledge that the conditions in which individuals are born, grow, live, work, learn, and age affect their health.8 The quantitative data were drawn from existing social,
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Community Health Needs Assessment
149
Table 1. Moffitt Cancer Center Community Health Assessment Advisory Committee Community Members (Title and Organization)
Moffitt Employees (Title and Department)
Executive director—Tampa Bay Healthcare Collaborative Center director, senior manager business assistance—Small Business Development Center, Pinellas County Economic Development Author—community member Interconception coordinator—Central Hillsborough Healthy Start Project Community education coordinator—Gulfcoast South AHEC, Inc. Regional vice president—Tampa Bay Allegany Franciscan Ministries Director of education—Hispanic Alliance of Tampa Senior pastor—Telling the Truth Ministries Asian American and International Liaison—Hillsborough County Board of County Commissioners
economic, and health data from national, state, county, and local sources. Examples of data sources include the US Census, Centers for Disease Control and Prevention (eg, Behavioral Risk Factor Surveillance Survey and Youth Risk Behavior Survey),9,10 and the Florida Department of Health. The health data focused on cancer prevention (eg, smoking status, alcohol consumption, obesity, physical activity levels, and nutrition), cancer screening, incidence and hospitalization, readmission rates, mortality, and survivorship. The qualitative data were gathered from focus groups and key informant interviews conducted by the consultants. The list of questions for the focus groups and key informant interviews are shown in Table 2. The purpose of the focus groups was to assess the perceptions of the participants on the health needs and assets in their communities, on Moffitt and its engagement with community efforts, and on the types of outreach services and programs needed in the community, challenges in seeking current services, and how services should be delivered. The majority of focus group participants were from medically underserved populations including low-income communities, racial/ethnic minority groups, older adults, individuals with limited English proficiency and low literacy, and the uninsured. Focus groups were conducted in English and Spanish. There were a total of 8 focus groups with 91 participants.
Director—Finance Tax manager—Finance Director—Nursing, Amb. Nursing, and System Support Director—Legislative Affairs Director—Moffitt Diversity Executive director—Corporate Business Development and Planning Director—Patient Support and Advocacy Associate member—Genetics Associate Member—Health Outcomes and Behavior Manager—Cancer Center Support Grant Manager—Corporate Planning
Each participant received a $25 gift card for their participation. Key informant interviews were conducted with community-based organization staff, community leaders, and Moffitt employees. The purpose of the interviews was to explore their perspectives on the communities’ health needs and strengths, challenges and successes of working in these communities, gaps in current services and programs, and perceived opportunities for Moffitt to address those needs. They represented a variety of sectors including education, housing, faith institutions, community health clinics, local government, and social services agencies. In total, 29 key informant interviews were conducted.
FINDINGS The results of the CHNA provided Moffitt with a wealth of information in several key areas. These areas include population demographics; cancer incidence, prevalence, and mortality rates (eg, colorectal, breast, prostate, cervical, ovarian, lung and bronchus, bladder, head and neck cancer, lymphoma, melanoma, etc); hospitalization rates; health behaviors; cancer screening and prevention; health care access and utilization; and lastly community awareness, perceptions, and concerns of cancer. This resulted in the development of a comprehensive CHNA
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
150
THE HEALTH CARE MANAGER/APRIL–JUNE 2015
Table 2. Qualitative Data Questionnaires Key Informant Interviews Organization/agency 1. Can you tell me a bit about your organization? 2. What type of programs/services do you provide? What communities or neighborhoods do you work in? Who are the main clients/audiences for your programs? 3. How long has your organization been working in specific neighborhood? 4. What are some of the biggest challenges you face in providing these programs/services in the community? 5. Do you currently partner with any other organizations or institutions in any of your programs/services? Community issues 6. How would you describe the community/ neighborhood which your organization serves? 7. What do you consider to be the community’s strongest strengths/assets? 8. What are some of its biggest problems/concerns? What challenges do residents face day to day? 9. What do you think are the most pressing health concerns in the community? 10. In your opinion, how much of a concern is cancer among community residents relative to other issues? Why? 11. From your experience, what are residents’ biggest barriers to addressing these health issues? 12. What programs/services are you aware of in the community that address some of these health issues? Perceptions of Moffitt Cancer Center and its community programs 13. What have you heard about Moffitt Cancer Center’s programs in the community? Are you aware of any of their community outreach activities/programming? 14. What is your perception of the community outreach activities/programming (if known)? 15. What do you see as their strengths? 16. What do you see as their challenges/limitations? 17. What do you consider Moffitt Cancer Center’s role to be in the community? 18. To what extent do you think Moffitt Cancer Center is currently meeting the health concerns of the community your organization serves? 19. How do you see Moffitt Cancer Center becoming more engaged in the community to address these concerns? 20. Are there specific health issues in the community in which Moffitt Cancer Center should take a lead in addressing? 21. Are there any specific organizations in the community in which you see as being a good fit for partnership with Moffitt Cancer Center to address these health concerns? With whom? Around which programs or issues?
Focus Groups Community and health perceptions 1. How would you describe your community? 2. What are some of the biggest strengths of your community? What are the most positive things about it? 3. What are some of the biggest problems or concerns in your community? 4. What do you think are the most urgent health concerns in your community? Perceptions of cancer and cancer-related programs 5. In your opinion, how much of a concern is cancer in your community? 6. Which types of cancer affect your community the most? 7. What are some things that you think people can do to decrease their chances of getting cancer? 8. How much do you think reducing their chance of getting cancer enters people’s minds when they do things like? Why/why not? 9. When people are being physically active or not smoking, how much do you think about reducing their chance of getting cancer? 10. Let’s talk a bit about these behaviors. Do you know of any programs in your community that try to address these? What are they? 11. What kinds of programs or services would you want to see in your community to address this issue/situation? What would the program look like? 12. Who do you think should be sponsoring these programs? Who needs to be involved in developing them? 13. If an organization was going to be involved in this type of program in your community, what advice would you have for the program planners? 14. We just talked about trying to prevent cancer. Now let’s talk about testing/screening for certain types of cancers—such as prostate cancer, colon cancer, or breast cancer. Has anyone heard of or had any of the tests that screen for these cancers? 15. How did you hear about these tests? 16. If you have had a screening test, where did you go for these types of screening tests? 17. Why do you think some people don’t get screened? What makes it hard or challenging to try to get a cancer screening test? 18. Have you heard of or seen any resources in your community that provide these screening tests for cancer? How about any resources related to cancer education? 19. What do you think organizations or health care institutions can do to help meet the needs of cancer survivors? 20. What kinds of programs or services do you think would be most helpful to cancer survivors? Moffitt Cancer Center perceptions 21. What do you expect out of the health care organizations (hospitals) in the area? What do you think they should be doing in your community? What is their role? 22. If you or a family member were diagnosed with cancer today, which hospital or treatment facility would be your first choice? 23. Before today’s discussion, how many people here had heard of Moffitt Cancer Center?
(continues)
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Community Health Needs Assessment
151
Table 2. Qualitative Data Questionnaires, Continued Key Informant Interviews
Focus Groups Moffitt Cancer Center perceptions 24. What do you think about the Moffitt Cancer Center? If you had to pick a few words to describe your thoughts about the Moffitt Cancer Center, what would you say? 25. If cancer were something that affected you or your family, how likely do you think you would be to get care at Moffitt Cancer Center? Why/why not? 26. If you heard that some of the behavior or screening programs we mentioned before were in your community and were conducted by Moffitt Cancer Center, would that make you more or less interested in the program? Why? 27. Does anything surprise you about what Moffitt does? Was any of this information new? What specifically? 28. Are there certain areas of Moffitt’s work that you would like to know more about? 29. What should Moffitt be doing to get the word out into the community about its work?
report. Several quintessential emerging themes from the CHNA were discovered. The changing demographics of Moffitt’s primary service area impact the demand for services and the need for culturally and linguistically competent services and programs. The total population of Moffitt’s primary service area has increased by 17.8% over a decade, from 3.5 million in 2000 to more than 4 million in 2010, which is similar to the growth of the state’s population (17.6%). Concerns about the cultural competency of providers and language barriers were raised by several respondents. Some respondents reported that health care providers and institutions were not always sensitive to the unique health needs of different populations: ‘‘We have doctors who aren’t willing to provide services unless we provide interpreters’’ (focus group participant); ‘‘I think racism, regardless of insurance coverage, is an issue in health care’’ (focus group participant). Specific populations and counties have rising cancer rates. Among the 7 counties of Moffitt’s primary service area, the cancer mortality rate in 2010 was highest in Hillsborough and Pinellas Counties at approximately 164 deaths per 100 000 population, which was above that of Florida (154 per 100 000 population). In addition, the black population in Florida experiences disparate rates of death due to
cancer, despite having lower cancer incidence rates than the white population. This holds true for the majority of Moffitt’s primary service area as well. Consistent with national statistics, lung cancer (43.9 deaths per 100 000 population) was the leading cause of cancer mortality in Florida, followed by colon and breast cancer (16.4 and 11.8 deaths per 100 000, respectively). Cancer screening rates indicate more than half of adults (aged 50 years) in Florida and Moffitt’s primary service area reported receiving a sigmoidoscopy or colonoscopy in the past 5 years. Across the 7 counties, the proportion of women (aged 40 years) who reported receiving a mammogram ranged from 57.1% in Hillsborough County to 70.6% in Sarasota County. Cancer incidence and hospitalization rates vary across the region. Cancer incidence rates across the Moffitt primary service area ranged from the highest in Polk County at 494.8 per 100 000 population and lowest in Manatee County at 403.1 per 100 000 population. In general, the Hispanic population has lower overall cancer rates than do the white and black populations, except for in Hernando and Manatee Counties. Cancer hospitalization was highest in Hernando County (600.2 per 100 000 population), followed by Sarasota and Pasco
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
152
THE HEALTH CARE MANAGER/APRIL–JUNE 2015
Counties (579.8 and 577.7 per 100 000 population, respectively). Community perceptions differ regarding the importance of cancer as a community health concern, but it was viewed as a serious illness by all. Respondents believed that the seriousness and fear of the disease sometimes evoke barriers to getting people to think proactively and preventively about it. Others reported that in some cultures there is a stigma associated with having cancer that leads people to delay or avoid screening or treatment: ‘‘There is a perception that the general population thinks cancer is a death sentence’’ (focus group participant); ‘‘Cancer is an issue, but not a bigger issue than domestic violence, HIV/AIDS, alcohol abuse, etc’’ (interview participant). Receiving timely screenings, diagnosis, and treatment may be influenced by the ability to obtain a primary care provider and availability of local and accessible health care services. Limited access to care was particularly notable in rural areas and among the Hispanic population, where adults were significantly less likely to have a primary care doctor and most likely to not see a doctor because of cost compared with adults in neighboring counties with large urban areas: ‘‘When we do get information around free screenings, those times often conflict with work schedules. It’s just really hard to get [clients] to those screenings’’ (focus group participant); ‘‘It’s not because people are neglectful; it’s just that they don’t have access’’ (interview participant). Translating knowledge of healthy behaviors into action to prevent cancer is difficult among community residents. When asked about how to reduce their chances of getting cancer, respondents frequently pointed to lifestyle changes including smoking cessation, dietary improvements, and engaging in more physical activity. While respondents indicated that people are generally aware of what is needed to reduce one’s risk of cancer, they acknowledged that it is difficult to translate awareness into action, particularly in light of economic constraints: ‘‘People think cancer is an issue but put off screening and care because of cost and time’’ (interview participant); ‘‘It’s difficult to make the healthy choice when you
also want to make the affordable choice’’ (focus group participant). Barriers beyond having health insurance exist to accessing and utilizing cancer treatment programs and services. While respondents reported that there are substantial barriers to accessing treatment services such as lack of insurance, they also noted other significant challenges in obtaining these services: ‘‘Services are not available in all neighborhoods. Some people have to travel to get services’’ (focus group participant); ‘‘Public transit in the county is not great, so people can’t get health care as easily’’ (interview participant); ‘‘We [migrant workers] don’t access preventive screenings because we don’t have time; there are not a lot of places for us to get services’’ (focus group participant). The changing health care landscape impacts how and where individuals seek services in a complex system. Many respondents saw several parts of the community as abundant in health services; however, they reported that people are not accessing them because of lack of awareness and the ability to navigate the services: ‘‘Knowing where to go and whom to call. It’s the basic stuff, even people who have insurance don’t really understand so it’s even more a challenge for folks who don’t have insurance’’ (interview participant). Increased health literacy and assistance in navigating the public health and health care systems are needed to maintain a healthy community. There is a lack of awareness among community members about how to take care of their health and prevent illness: ‘‘Health literacy is a big problem. When patients leave their doctors knowing very little about their condition, then that impacts compliance, etc’’ (focus group participant); ‘‘The language that doctors use, we don’t want them to know that we do not understand, so we will just say yes and nod our heads’’ (focus group participant). The information gathered from the CHNA will also help Moffitt establish institutional goals. These goals include focusing and prioritizing program planning; evaluating programs, policies, and initiatives; supporting policy development and advocacy; supporting grant writing with data documentation; and identifying existing assets.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Community Health Needs Assessment COMMUNITY BENEFIT IMPLEMENTATION PLAN Each year, Moffitt develops a Community Benefit Report that is designed to comprehensively illustrate the value of services Moffitt provides for the community. Part of the purpose of the CHNA is to inform the investment of community benefit resources with the goal of improving the health of the community, particularly those in the primary service area, and those most vulnerable and medically underserved. Furthermore, the CHNA provided the rubric from which sprung the Community Benefit Implementation Plan. The plan constitutes a roadmap for leadership to target resources and interventions that will improve the health of the vulnerable and medically underserved in the community. Moffitt’s plan provides patient- and family-centered and culturally competent outreach, education, training, and resources to support patients, families, and health professionals. The plan focuses on efforts in advancing cancer prevention, early detection, treatment and services, and research, especially for medically underserved populations that bear a disproportionate burden of cancer. The Community Benefit Implementation Plan set forth 5 priority areas in which Moffitt is to direct resources and develop interventions for improving community health, principally that of the most vulnerable and medically underserved (Table 3). The 5 priority areas are (1) cultural competence, (2) prevention, screening, education and outreach, (3) health disparities, (4) access, and (5) community benefit structure. Each priority area is rooted on CHNA findings. As well, each priority area has a clear and concise goal with corresponding manageable and achievable objectives. Detailed action plans will be developed annually and tracked throughout the course of the year to monitor and evaluate progress and determine priorities for subsequent years. In short, the plan is designed to be reviewed annually and adjusted to accommodate revisions from changes in community needs. IMPLICATIONS FOR LEADERS In order to implement a successful and ultimately an effective CHNA, there are several
153
suggestions hospital leaders should consider throughout the process of conducting the assessment. It is imperative that hospital leaders and board members, and consequently the organization, are educated on the value and role of the community benefit requirement so it is not solely viewed as an unfunded mandate without significance to clinical care and outcomes. According to the IRS mandate, hospital boards have the chief responsibility for community benefit. It is highly recommended that leadership is fully involved in the process and understand their role throughout. Several areas of the hospital will benefit from the CHNA results, and this should be communicated to increase organizational buy-in. The CHNA outcomes can potentially result in increased awareness of cultural and linguistic competence, health disparities, medically underserved populations, and community needs among those who examine the final report. Effective community benefit programs should be used to inform the direction of resources made available to the community. This is best achieved when the CHNA outcomes and implementation plan are tied to the organization’s strategic plan. In addition, community benefit programs should have an existing structure that supports organization-wide participation during the whole process of completing the CHNA: development of an action plan; ongoing monitoring; integration into organizational operations; and data collection, analysis, and reporting. The process of the CHNA typically requires about 1 year to be fully implemented. Lastly, the community should also be educated about the benefit and impact provided by the organization through this process. Leaders should actively and continuously engage the community when planning initiatives that respond to the CHNA outcomes. CONCLUSION The development process and implementation of a CHNA are an important example of evidence-based public health practice. It is a way to address health and health care disparities experienced by medically underserved populations. The process integrates science-based
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Enhance access to screening, prevention, treatment, and recovery services for all community members.
Receiving timely screenings, diagnosis, and treatment may be influenced by the ability to obtain a primary care provider and availability of local and accessible health care services.
Access
Focus prevention and screening education and outreach efforts on at-risk and medically underserved communities (especially cancer areas with greatest racial/ethnic disparities).
Enhance the patient experience by providing culturally and linguistically competent services.
Goal
Address the needs of populations/counties with rising cancer rates (incidence and hospitalizations).
Translating knowledge of healthy behaviors into action to prevent cancer is difficult among community residents.
Community perceptions differ regarding the importance of cancer as a community health concern, but it was viewed as a serious illness by all.
Cancer incidence and hospitalization rates vary across the region.
Provision of culturally and linguistically competent services and programs.
Assessment Finding
Health disparities Specific populations and counties have rising cancer rates
Prevention, screening, education, and outreach
Cultural competence
Priority Area
Table 3. Community Benefit Implementation Plan
(continues)
Enhance access to quality language and communication services that are readily available to patients and family members with limited English proficiency and other communication needs. Educate faculty and staff on strategies for providing care and education that is culturally and linguistically competent and relevant to communities. Collect and share data on cancer incidence and prevalence to support increased community awareness about cancer. Provide healthy lifestyles education and outreach to designated demographics/ populations across 7 counties to translate knowledge to action. Provide culturally and linguistically competent and relevant training to a network of community health workers and community members. Enhance programs that help translate knowledge to behavior change in community (eg, integration of healthy lifestyles into community life). Identify new partners and outreach methods to grow education impact in targeted communities. Provide data on prevalence and importance of cancer to increase community awareness and enhance mobilization efforts. Include messaging of health disparities that enhances education and knowledge among referring physicians and Moffitt Oncology Network members. Alleviate financial, transportation, and housing barriers to primary care and cancer treatment services.
Objectives
154 THE HEALTH CARE MANAGER/APRIL–JUNE 2015
Community Create an organizational-wide plan for Improve infrastructure to support optimal benefit structure community benefit and programming delivery of community benefit services. services that has activities of Moffitt Cancer Center as the centerpiece.
Barriers beyond having health insurance exist to accessing and utilizing cancer treatment programs and services.
Objectives Assessment Finding Priority Area
Table 3. Community Benefit Implementation Plan, Continued
Goal
Enhance positive environment and patient experience. Partner with patients and families to identify and implement policies and practices in support of patient- and family-centered care. Include messaging of screening, prevention, and treatment opportunities for all patients to referring physicians within the primary service area. Formalize a centralized structure for Community Benefit to organize and coordinate outreach, programming, and administrative functions for most effective and impactful delivery of services to patients and their families.
Community Health Needs Assessment
155
interventions and community involvement to improve the health of populations. The development of Moffitt’s CHNA was an organizational and community-based process led by an institutional imperative not only to understand the communities served, but also to learn from them to improve the care, services, and supports provided. The findings from the development of the CHNA will give Moffitt a focused effort and precise direction for targeting programs and initiatives and the appropriate allocation of resources. It is also a clear demonstration of meaningful and authentic community involvement and a basis for ongoing community engagement. The benefit of the CHNA is much more than compliance with a legislative mandate, but the fulfillment of an institutional obligation and duty to understand, acknowledge, and respond to the community’s health and health care needs.
ACKNOWLEDGMENTS The authors thank the consultants, Health Resources in Action, Inc, utilized during the development of the CHNA. Their expertise, organization, and analysis helped in the writing of the manuscript.
REFERENCES 1. Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press; 2003. 2. Brownson RC, Baker EA, Leet TL, Gillespie KN, True WR. Evidence-Based Public Health. New York, NY: Oxford University Press; 2010. 3. Lightfoot AF, De Marco MM, Dendas RC, Jackson MR, Meehan EF. Engaging underserved populations in Affordable Care Act—required needs assessments. J Health Care Poor Underserved. 2014;25:11–18. 4. McKenzie JF, Pinger RR, Kotecki JE. An Introduction to Community Health. Sudbury, MA: Jones & Bartlett Learning; 2012. 5. Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient-Centered Care. Chicago, IL: American College of Surgeons; 2012. 6. Internal Revenue Service. New Requirements for 501(c)(3) Hospitals Under the Affordable Care Act. Washington, DC: Internal Revenue Service; 2013.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
156
THE HEALTH CARE MANAGER/APRIL–JUNE 2015
http://www.irs.gov/Charities-&-Non-Profits/CharitableOrganizations/New-Requirements-for-501(c)(3)-HospitalsUnder-the-Affordable-Care-Act. Accessed August 17, 2014. 7. Patient Protection and Affordable Care Act, 42 U.S.C. x 18001 et seq. 2010. 8. World Health Organization. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Final Report of the
Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008. 9. Centers for Disease Control and Prevention. Behavioral risk factor surveillance system. http://www.cdc.gov/ brfss/. Accessed October 28, 2014. 10. Centers for Disease Control and Prevention. Youth risk behavior surveillance system. http://www.cdc.gov/ HealthyYouth/yrbs/index.htm. Accessed October 28, 2014.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Community Health Needs Assessment A Pathway to the Future and a Vision for Leaders Cathy G. Grant, MPA; Roberto Ramos, MEd; Jenna L. Davis, MPH; B. Lee Green, PhD There is a need to implement evidence-based public health practice that integrates targeted and specific strategies and actions with community preferences to improve the health of populations. A community health needs assessment (CHNA) is vital to identifying the health concerns of communities, to learn about the factors that influence their health and the assets, resources, and challenges that impact those factors. It is required for tax-exempt entities to conduct a CHNA and adopt an implementation strategy to meet the identified community health needs. The goal of this article is to chart a pathway for health system leaders utilizing a CHNA process to address disparities in racial/ethnic groups and other medically underserved populations and to meet legal requirements. The efforts of the H. Lee Moffitt Cancer Center and Research Institute in developing its CHNA will be highlighted to provide clear evidence to health system leaders for why and how to conduct a thorough and compelling CHNA to meaningfully address health disparities locally and respond to longstanding historical health inequities at the health system level. Key words: community, health disparities, leadership, needs assessment
HE CURRENT PUBLIC health discussion should not be about whether health and health care disparities or inequities exist, but rather on which strategies and interventions work best to reduce the gaps in the quest to eliminate them. History informs us that inequities in health care access and utilization, health care quality, and health outcomes have long existed in the United States.1 The solutions are going to be multifaceted, extremely difficult, and time consuming and will require adequate resources. The truth is that as leaders of health systems in the pursuit of enhancing and institutionalizing cultural and linguistic competence, it will take much more than strong words or eloquent speeches and statements of support to address
T
Author Affiliations: Moffitt Diversity, Moffitt Cancer Center, Tampa, Florida. The authors have no funding or conflict of interest. Correspondence: Jenna L. Davis, MPH, 12902 Magnolia Drive, MBC-Diversity, Tampa, FL 33612 ([email protected]). DOI: 10.1097/HCM.0000000000000057
these inequities. There will need to be evidencebased public health practice that integrates targeted and specific strategies and actions, as well as strong leadership. The concept of evidence-based public health is centered on ‘‘the process of integrating sciencebased interventions with community preferences to improve the health of populations.’’2(p419) Executing evidence-based public health involves more commitment than just the particular research interest of a researcher or institution. The integral parts in executing evidence-based public health are to conduct community assessments for ascertaining the health and cultural needs/ issues experienced, to develop interventions that address the identified issues based on scientific review, and to assess the process, impact, and outcomes of the interventions.2 For health system leaders seeking to eliminate health disparities and inequities, it is critical to recognize the importance of gaining an awareness and understanding of the needs, assets, and strengths among the communities being served, particularly those who are medically underserved.3 Specifically, conducting a community 147
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
148
THE HEALTH CARE MANAGER/APRIL–JUNE 2015
health needs assessment (CHNA) to collect and analyze information is vital to identifying the health concerns in your communities, to learn about the factors that influence health, and the assets, resources, and challenges that impact those factors.2,4 The process for completing a CHNA should not be considered a 1-time initiative, but rather an ongoing, cyclical, and modifying process. It should be repeated and constantly updated in order to reveal the needs of the community, the gaps that persist, and the vision for the work ahead. Implementing a CHNA consists of 5 key steps. These include (1) summarizing relevant information about the state of health and health needs of the population and the accompanying analysis highlighting the major issues, (2) setting priorities for action, (3) developing strategies to address the priority areas, (4) implementing strategies, and (5) evaluating the process and outcomes. Conducting a CHNA is required by US federal law for tax-exempt entities.5-7 Roughly once every 3 years, the Internal Revenue Service (IRS) requires all not-for-profit organizations receiving preferential tax status to conduct a CHNA. The IRS guidelines state that in order for community benefit reporting of an organizational activity or effort, it must be driven by the community needs. As well, the Affordable Care Act specifically requires that hospitals adopt an implementation strategy to meet the community health needs identified through the CHNA. In addition, the process must take into account input from individuals who represent the broad interests of the community served by the hospital, including those with special knowledge of or expertise in public health. Furthermore, the CHNA must be available and accessible to the public. The goal of this article is to chart a pathway for health system leaders utilizing a CHNA process to address disparities in racial/ethnic groups and other medically underserved populations and to meet legal requirements. This will be accomplished in large part by highlighting the efforts of the H. Lee Moffitt Cancer Center and Research Institute (Moffitt) in conducting its CHNA. The overarching objectives for Moffitt to conduct a CHNA are to (a) identify the healthrelated needs and assets of the primary service area; (b) identify where there are gaps and
potential opportunities for addressing those needs; and (c) develop a plan of action for how Moffitt and its partners can address those needs in a coordinated, collaborative, and systematic approach. Another important aspect of this article is to provide clear evidence to health system leaders for why and how to conduct a thorough and compelling CHNA to meaningfully address health disparities locally and respond to longstanding historical health inequities at the health system level. MOFFITT CANCER CENTER’S CHNA In order to commence the process, Moffitt considered options and strategies for developing the CHNA. It was decided to have its diversity department (Moffitt Diversity) coordinate the effort and to solicit the expertise of a nonprofit health consultancy organization to formally initiate the CHNA development process. The consultants selected were tasked with guiding Moffitt through the CHNA process with coordinating data collection, analysis, and reporting. Moffitt Diversity convened an advisory committee consisting of key employees and community leaders. Table 1 lists the titles and affiliations of the committee members. Moffitt employees represented various departments and leadership, and the community members were composed of representatives from several health, governmental, and social service agencies across the Tampa Bay region and were reflective of the primary services area, with an overrepresentation of members from racial/ethnic minority groups. The committee worked directly with the consultants, offering guidance and feedback regarding the areas to be studied, data collection and methodology, and review and input on draft documents. DATA COLLECTION The data collected for the Moffitt CHNA integrates a social-determinants-of-health framework to acknowledge that the conditions in which individuals are born, grow, live, work, learn, and age affect their health.8 The quantitative data were drawn from existing social,
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Community Health Needs Assessment
149
Table 1. Moffitt Cancer Center Community Health Assessment Advisory Committee Community Members (Title and Organization)
Moffitt Employees (Title and Department)
Executive director—Tampa Bay Healthcare Collaborative Center director, senior manager business assistance—Small Business Development Center, Pinellas County Economic Development Author—community member Interconception coordinator—Central Hillsborough Healthy Start Project Community education coordinator—Gulfcoast South AHEC, Inc. Regional vice president—Tampa Bay Allegany Franciscan Ministries Director of education—Hispanic Alliance of Tampa Senior pastor—Telling the Truth Ministries Asian American and International Liaison—Hillsborough County Board of County Commissioners
economic, and health data from national, state, county, and local sources. Examples of data sources include the US Census, Centers for Disease Control and Prevention (eg, Behavioral Risk Factor Surveillance Survey and Youth Risk Behavior Survey),9,10 and the Florida Department of Health. The health data focused on cancer prevention (eg, smoking status, alcohol consumption, obesity, physical activity levels, and nutrition), cancer screening, incidence and hospitalization, readmission rates, mortality, and survivorship. The qualitative data were gathered from focus groups and key informant interviews conducted by the consultants. The list of questions for the focus groups and key informant interviews are shown in Table 2. The purpose of the focus groups was to assess the perceptions of the participants on the health needs and assets in their communities, on Moffitt and its engagement with community efforts, and on the types of outreach services and programs needed in the community, challenges in seeking current services, and how services should be delivered. The majority of focus group participants were from medically underserved populations including low-income communities, racial/ethnic minority groups, older adults, individuals with limited English proficiency and low literacy, and the uninsured. Focus groups were conducted in English and Spanish. There were a total of 8 focus groups with 91 participants.
Director—Finance Tax manager—Finance Director—Nursing, Amb. Nursing, and System Support Director—Legislative Affairs Director—Moffitt Diversity Executive director—Corporate Business Development and Planning Director—Patient Support and Advocacy Associate member—Genetics Associate Member—Health Outcomes and Behavior Manager—Cancer Center Support Grant Manager—Corporate Planning
Each participant received a $25 gift card for their participation. Key informant interviews were conducted with community-based organization staff, community leaders, and Moffitt employees. The purpose of the interviews was to explore their perspectives on the communities’ health needs and strengths, challenges and successes of working in these communities, gaps in current services and programs, and perceived opportunities for Moffitt to address those needs. They represented a variety of sectors including education, housing, faith institutions, community health clinics, local government, and social services agencies. In total, 29 key informant interviews were conducted.
FINDINGS The results of the CHNA provided Moffitt with a wealth of information in several key areas. These areas include population demographics; cancer incidence, prevalence, and mortality rates (eg, colorectal, breast, prostate, cervical, ovarian, lung and bronchus, bladder, head and neck cancer, lymphoma, melanoma, etc); hospitalization rates; health behaviors; cancer screening and prevention; health care access and utilization; and lastly community awareness, perceptions, and concerns of cancer. This resulted in the development of a comprehensive CHNA
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
150
THE HEALTH CARE MANAGER/APRIL–JUNE 2015
Table 2. Qualitative Data Questionnaires Key Informant Interviews Organization/agency 1. Can you tell me a bit about your organization? 2. What type of programs/services do you provide? What communities or neighborhoods do you work in? Who are the main clients/audiences for your programs? 3. How long has your organization been working in specific neighborhood? 4. What are some of the biggest challenges you face in providing these programs/services in the community? 5. Do you currently partner with any other organizations or institutions in any of your programs/services? Community issues 6. How would you describe the community/ neighborhood which your organization serves? 7. What do you consider to be the community’s strongest strengths/assets? 8. What are some of its biggest problems/concerns? What challenges do residents face day to day? 9. What do you think are the most pressing health concerns in the community? 10. In your opinion, how much of a concern is cancer among community residents relative to other issues? Why? 11. From your experience, what are residents’ biggest barriers to addressing these health issues? 12. What programs/services are you aware of in the community that address some of these health issues? Perceptions of Moffitt Cancer Center and its community programs 13. What have you heard about Moffitt Cancer Center’s programs in the community? Are you aware of any of their community outreach activities/programming? 14. What is your perception of the community outreach activities/programming (if known)? 15. What do you see as their strengths? 16. What do you see as their challenges/limitations? 17. What do you consider Moffitt Cancer Center’s role to be in the community? 18. To what extent do you think Moffitt Cancer Center is currently meeting the health concerns of the community your organization serves? 19. How do you see Moffitt Cancer Center becoming more engaged in the community to address these concerns? 20. Are there specific health issues in the community in which Moffitt Cancer Center should take a lead in addressing? 21. Are there any specific organizations in the community in which you see as being a good fit for partnership with Moffitt Cancer Center to address these health concerns? With whom? Around which programs or issues?
Focus Groups Community and health perceptions 1. How would you describe your community? 2. What are some of the biggest strengths of your community? What are the most positive things about it? 3. What are some of the biggest problems or concerns in your community? 4. What do you think are the most urgent health concerns in your community? Perceptions of cancer and cancer-related programs 5. In your opinion, how much of a concern is cancer in your community? 6. Which types of cancer affect your community the most? 7. What are some things that you think people can do to decrease their chances of getting cancer? 8. How much do you think reducing their chance of getting cancer enters people’s minds when they do things like? Why/why not? 9. When people are being physically active or not smoking, how much do you think about reducing their chance of getting cancer? 10. Let’s talk a bit about these behaviors. Do you know of any programs in your community that try to address these? What are they? 11. What kinds of programs or services would you want to see in your community to address this issue/situation? What would the program look like? 12. Who do you think should be sponsoring these programs? Who needs to be involved in developing them? 13. If an organization was going to be involved in this type of program in your community, what advice would you have for the program planners? 14. We just talked about trying to prevent cancer. Now let’s talk about testing/screening for certain types of cancers—such as prostate cancer, colon cancer, or breast cancer. Has anyone heard of or had any of the tests that screen for these cancers? 15. How did you hear about these tests? 16. If you have had a screening test, where did you go for these types of screening tests? 17. Why do you think some people don’t get screened? What makes it hard or challenging to try to get a cancer screening test? 18. Have you heard of or seen any resources in your community that provide these screening tests for cancer? How about any resources related to cancer education? 19. What do you think organizations or health care institutions can do to help meet the needs of cancer survivors? 20. What kinds of programs or services do you think would be most helpful to cancer survivors? Moffitt Cancer Center perceptions 21. What do you expect out of the health care organizations (hospitals) in the area? What do you think they should be doing in your community? What is their role? 22. If you or a family member were diagnosed with cancer today, which hospital or treatment facility would be your first choice? 23. Before today’s discussion, how many people here had heard of Moffitt Cancer Center?
(continues)
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Community Health Needs Assessment
151
Table 2. Qualitative Data Questionnaires, Continued Key Informant Interviews
Focus Groups Moffitt Cancer Center perceptions 24. What do you think about the Moffitt Cancer Center? If you had to pick a few words to describe your thoughts about the Moffitt Cancer Center, what would you say? 25. If cancer were something that affected you or your family, how likely do you think you would be to get care at Moffitt Cancer Center? Why/why not? 26. If you heard that some of the behavior or screening programs we mentioned before were in your community and were conducted by Moffitt Cancer Center, would that make you more or less interested in the program? Why? 27. Does anything surprise you about what Moffitt does? Was any of this information new? What specifically? 28. Are there certain areas of Moffitt’s work that you would like to know more about? 29. What should Moffitt be doing to get the word out into the community about its work?
report. Several quintessential emerging themes from the CHNA were discovered. The changing demographics of Moffitt’s primary service area impact the demand for services and the need for culturally and linguistically competent services and programs. The total population of Moffitt’s primary service area has increased by 17.8% over a decade, from 3.5 million in 2000 to more than 4 million in 2010, which is similar to the growth of the state’s population (17.6%). Concerns about the cultural competency of providers and language barriers were raised by several respondents. Some respondents reported that health care providers and institutions were not always sensitive to the unique health needs of different populations: ‘‘We have doctors who aren’t willing to provide services unless we provide interpreters’’ (focus group participant); ‘‘I think racism, regardless of insurance coverage, is an issue in health care’’ (focus group participant). Specific populations and counties have rising cancer rates. Among the 7 counties of Moffitt’s primary service area, the cancer mortality rate in 2010 was highest in Hillsborough and Pinellas Counties at approximately 164 deaths per 100 000 population, which was above that of Florida (154 per 100 000 population). In addition, the black population in Florida experiences disparate rates of death due to
cancer, despite having lower cancer incidence rates than the white population. This holds true for the majority of Moffitt’s primary service area as well. Consistent with national statistics, lung cancer (43.9 deaths per 100 000 population) was the leading cause of cancer mortality in Florida, followed by colon and breast cancer (16.4 and 11.8 deaths per 100 000, respectively). Cancer screening rates indicate more than half of adults (aged 50 years) in Florida and Moffitt’s primary service area reported receiving a sigmoidoscopy or colonoscopy in the past 5 years. Across the 7 counties, the proportion of women (aged 40 years) who reported receiving a mammogram ranged from 57.1% in Hillsborough County to 70.6% in Sarasota County. Cancer incidence and hospitalization rates vary across the region. Cancer incidence rates across the Moffitt primary service area ranged from the highest in Polk County at 494.8 per 100 000 population and lowest in Manatee County at 403.1 per 100 000 population. In general, the Hispanic population has lower overall cancer rates than do the white and black populations, except for in Hernando and Manatee Counties. Cancer hospitalization was highest in Hernando County (600.2 per 100 000 population), followed by Sarasota and Pasco
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
152
THE HEALTH CARE MANAGER/APRIL–JUNE 2015
Counties (579.8 and 577.7 per 100 000 population, respectively). Community perceptions differ regarding the importance of cancer as a community health concern, but it was viewed as a serious illness by all. Respondents believed that the seriousness and fear of the disease sometimes evoke barriers to getting people to think proactively and preventively about it. Others reported that in some cultures there is a stigma associated with having cancer that leads people to delay or avoid screening or treatment: ‘‘There is a perception that the general population thinks cancer is a death sentence’’ (focus group participant); ‘‘Cancer is an issue, but not a bigger issue than domestic violence, HIV/AIDS, alcohol abuse, etc’’ (interview participant). Receiving timely screenings, diagnosis, and treatment may be influenced by the ability to obtain a primary care provider and availability of local and accessible health care services. Limited access to care was particularly notable in rural areas and among the Hispanic population, where adults were significantly less likely to have a primary care doctor and most likely to not see a doctor because of cost compared with adults in neighboring counties with large urban areas: ‘‘When we do get information around free screenings, those times often conflict with work schedules. It’s just really hard to get [clients] to those screenings’’ (focus group participant); ‘‘It’s not because people are neglectful; it’s just that they don’t have access’’ (interview participant). Translating knowledge of healthy behaviors into action to prevent cancer is difficult among community residents. When asked about how to reduce their chances of getting cancer, respondents frequently pointed to lifestyle changes including smoking cessation, dietary improvements, and engaging in more physical activity. While respondents indicated that people are generally aware of what is needed to reduce one’s risk of cancer, they acknowledged that it is difficult to translate awareness into action, particularly in light of economic constraints: ‘‘People think cancer is an issue but put off screening and care because of cost and time’’ (interview participant); ‘‘It’s difficult to make the healthy choice when you
also want to make the affordable choice’’ (focus group participant). Barriers beyond having health insurance exist to accessing and utilizing cancer treatment programs and services. While respondents reported that there are substantial barriers to accessing treatment services such as lack of insurance, they also noted other significant challenges in obtaining these services: ‘‘Services are not available in all neighborhoods. Some people have to travel to get services’’ (focus group participant); ‘‘Public transit in the county is not great, so people can’t get health care as easily’’ (interview participant); ‘‘We [migrant workers] don’t access preventive screenings because we don’t have time; there are not a lot of places for us to get services’’ (focus group participant). The changing health care landscape impacts how and where individuals seek services in a complex system. Many respondents saw several parts of the community as abundant in health services; however, they reported that people are not accessing them because of lack of awareness and the ability to navigate the services: ‘‘Knowing where to go and whom to call. It’s the basic stuff, even people who have insurance don’t really understand so it’s even more a challenge for folks who don’t have insurance’’ (interview participant). Increased health literacy and assistance in navigating the public health and health care systems are needed to maintain a healthy community. There is a lack of awareness among community members about how to take care of their health and prevent illness: ‘‘Health literacy is a big problem. When patients leave their doctors knowing very little about their condition, then that impacts compliance, etc’’ (focus group participant); ‘‘The language that doctors use, we don’t want them to know that we do not understand, so we will just say yes and nod our heads’’ (focus group participant). The information gathered from the CHNA will also help Moffitt establish institutional goals. These goals include focusing and prioritizing program planning; evaluating programs, policies, and initiatives; supporting policy development and advocacy; supporting grant writing with data documentation; and identifying existing assets.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Community Health Needs Assessment COMMUNITY BENEFIT IMPLEMENTATION PLAN Each year, Moffitt develops a Community Benefit Report that is designed to comprehensively illustrate the value of services Moffitt provides for the community. Part of the purpose of the CHNA is to inform the investment of community benefit resources with the goal of improving the health of the community, particularly those in the primary service area, and those most vulnerable and medically underserved. Furthermore, the CHNA provided the rubric from which sprung the Community Benefit Implementation Plan. The plan constitutes a roadmap for leadership to target resources and interventions that will improve the health of the vulnerable and medically underserved in the community. Moffitt’s plan provides patient- and family-centered and culturally competent outreach, education, training, and resources to support patients, families, and health professionals. The plan focuses on efforts in advancing cancer prevention, early detection, treatment and services, and research, especially for medically underserved populations that bear a disproportionate burden of cancer. The Community Benefit Implementation Plan set forth 5 priority areas in which Moffitt is to direct resources and develop interventions for improving community health, principally that of the most vulnerable and medically underserved (Table 3). The 5 priority areas are (1) cultural competence, (2) prevention, screening, education and outreach, (3) health disparities, (4) access, and (5) community benefit structure. Each priority area is rooted on CHNA findings. As well, each priority area has a clear and concise goal with corresponding manageable and achievable objectives. Detailed action plans will be developed annually and tracked throughout the course of the year to monitor and evaluate progress and determine priorities for subsequent years. In short, the plan is designed to be reviewed annually and adjusted to accommodate revisions from changes in community needs. IMPLICATIONS FOR LEADERS In order to implement a successful and ultimately an effective CHNA, there are several
153
suggestions hospital leaders should consider throughout the process of conducting the assessment. It is imperative that hospital leaders and board members, and consequently the organization, are educated on the value and role of the community benefit requirement so it is not solely viewed as an unfunded mandate without significance to clinical care and outcomes. According to the IRS mandate, hospital boards have the chief responsibility for community benefit. It is highly recommended that leadership is fully involved in the process and understand their role throughout. Several areas of the hospital will benefit from the CHNA results, and this should be communicated to increase organizational buy-in. The CHNA outcomes can potentially result in increased awareness of cultural and linguistic competence, health disparities, medically underserved populations, and community needs among those who examine the final report. Effective community benefit programs should be used to inform the direction of resources made available to the community. This is best achieved when the CHNA outcomes and implementation plan are tied to the organization’s strategic plan. In addition, community benefit programs should have an existing structure that supports organization-wide participation during the whole process of completing the CHNA: development of an action plan; ongoing monitoring; integration into organizational operations; and data collection, analysis, and reporting. The process of the CHNA typically requires about 1 year to be fully implemented. Lastly, the community should also be educated about the benefit and impact provided by the organization through this process. Leaders should actively and continuously engage the community when planning initiatives that respond to the CHNA outcomes. CONCLUSION The development process and implementation of a CHNA are an important example of evidence-based public health practice. It is a way to address health and health care disparities experienced by medically underserved populations. The process integrates science-based
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Enhance access to screening, prevention, treatment, and recovery services for all community members.
Receiving timely screenings, diagnosis, and treatment may be influenced by the ability to obtain a primary care provider and availability of local and accessible health care services.
Access
Focus prevention and screening education and outreach efforts on at-risk and medically underserved communities (especially cancer areas with greatest racial/ethnic disparities).
Enhance the patient experience by providing culturally and linguistically competent services.
Goal
Address the needs of populations/counties with rising cancer rates (incidence and hospitalizations).
Translating knowledge of healthy behaviors into action to prevent cancer is difficult among community residents.
Community perceptions differ regarding the importance of cancer as a community health concern, but it was viewed as a serious illness by all.
Cancer incidence and hospitalization rates vary across the region.
Provision of culturally and linguistically competent services and programs.
Assessment Finding
Health disparities Specific populations and counties have rising cancer rates
Prevention, screening, education, and outreach
Cultural competence
Priority Area
Table 3. Community Benefit Implementation Plan
(continues)
Enhance access to quality language and communication services that are readily available to patients and family members with limited English proficiency and other communication needs. Educate faculty and staff on strategies for providing care and education that is culturally and linguistically competent and relevant to communities. Collect and share data on cancer incidence and prevalence to support increased community awareness about cancer. Provide healthy lifestyles education and outreach to designated demographics/ populations across 7 counties to translate knowledge to action. Provide culturally and linguistically competent and relevant training to a network of community health workers and community members. Enhance programs that help translate knowledge to behavior change in community (eg, integration of healthy lifestyles into community life). Identify new partners and outreach methods to grow education impact in targeted communities. Provide data on prevalence and importance of cancer to increase community awareness and enhance mobilization efforts. Include messaging of health disparities that enhances education and knowledge among referring physicians and Moffitt Oncology Network members. Alleviate financial, transportation, and housing barriers to primary care and cancer treatment services.
Objectives
154 THE HEALTH CARE MANAGER/APRIL–JUNE 2015
Community Create an organizational-wide plan for Improve infrastructure to support optimal benefit structure community benefit and programming delivery of community benefit services. services that has activities of Moffitt Cancer Center as the centerpiece.
Barriers beyond having health insurance exist to accessing and utilizing cancer treatment programs and services.
Objectives Assessment Finding Priority Area
Table 3. Community Benefit Implementation Plan, Continued
Goal
Enhance positive environment and patient experience. Partner with patients and families to identify and implement policies and practices in support of patient- and family-centered care. Include messaging of screening, prevention, and treatment opportunities for all patients to referring physicians within the primary service area. Formalize a centralized structure for Community Benefit to organize and coordinate outreach, programming, and administrative functions for most effective and impactful delivery of services to patients and their families.
Community Health Needs Assessment
155
interventions and community involvement to improve the health of populations. The development of Moffitt’s CHNA was an organizational and community-based process led by an institutional imperative not only to understand the communities served, but also to learn from them to improve the care, services, and supports provided. The findings from the development of the CHNA will give Moffitt a focused effort and precise direction for targeting programs and initiatives and the appropriate allocation of resources. It is also a clear demonstration of meaningful and authentic community involvement and a basis for ongoing community engagement. The benefit of the CHNA is much more than compliance with a legislative mandate, but the fulfillment of an institutional obligation and duty to understand, acknowledge, and respond to the community’s health and health care needs.
ACKNOWLEDGMENTS The authors thank the consultants, Health Resources in Action, Inc, utilized during the development of the CHNA. Their expertise, organization, and analysis helped in the writing of the manuscript.
REFERENCES 1. Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press; 2003. 2. Brownson RC, Baker EA, Leet TL, Gillespie KN, True WR. Evidence-Based Public Health. New York, NY: Oxford University Press; 2010. 3. Lightfoot AF, De Marco MM, Dendas RC, Jackson MR, Meehan EF. Engaging underserved populations in Affordable Care Act—required needs assessments. J Health Care Poor Underserved. 2014;25:11–18. 4. McKenzie JF, Pinger RR, Kotecki JE. An Introduction to Community Health. Sudbury, MA: Jones & Bartlett Learning; 2012. 5. Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient-Centered Care. Chicago, IL: American College of Surgeons; 2012. 6. Internal Revenue Service. New Requirements for 501(c)(3) Hospitals Under the Affordable Care Act. Washington, DC: Internal Revenue Service; 2013.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
156
THE HEALTH CARE MANAGER/APRIL–JUNE 2015
http://www.irs.gov/Charities-&-Non-Profits/CharitableOrganizations/New-Requirements-for-501(c)(3)-HospitalsUnder-the-Affordable-Care-Act. Accessed August 17, 2014. 7. Patient Protection and Affordable Care Act, 42 U.S.C. x 18001 et seq. 2010. 8. World Health Organization. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Final Report of the
Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008. 9. Centers for Disease Control and Prevention. Behavioral risk factor surveillance system. http://www.cdc.gov/ brfss/. Accessed October 28, 2014. 10. Centers for Disease Control and Prevention. Youth risk behavior surveillance system. http://www.cdc.gov/ HealthyYouth/yrbs/index.htm. Accessed October 28, 2014.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
