Original Article

POPULATION HEALTH MANAGEMENT Volume 0, Number 0, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/pop.2015.0075

Community Health Needs Assessment: Potential for Population Health Improvement Cara L. Pennel, DrPH, MPH,1 Kenneth R. McLeroy, PhD,2 James N. Burdine, DrPH, MPH,2,3 David Matarrita-Cascante, PhD,4 and Jia Wang, PhD 5

Abstract

Derived from various health care policies and initiatives, the concept of population health has been newly adopted by health care and medicine. In particular, it has been suggested that the Patient Protection and Affordable Care Act provision that requires nonprofit hospitals to conduct a community health needs assessment (CHNA) and implement strategies to address health priorities has the potential to improve population health. A mixed methods study design was used to examine the potential for population health improvements to occur through the Internal Revenue Service (IRS)-mandated nonprofit hospital CHNA and planning processes. Methods involved a 2-phased approach composed of (1) content analysis of 95 CHNA/implementation strategies reports and (2) interviews with key informants, consultants, and community stakeholders involved in CHNA and planning processes. Although this is a great opportunity for the nonprofit hospital assessment and planning processes to influence population health outcomes, the findings from the first 3-year assessment and planning cycle (2011–2013) suggest this is unlikely. As nonprofit hospitals begin the second 3-year assessment and planning cycle, this article offers recommendations to increase the potential for nonprofit hospitals to improve population health. These recommendations include clarifying the purpose of IRS CHNA regulations, engaging community stakeholders in collaborative assessment and planning, understanding disease etiology and identifying and addressing broader determinants of health, adopting a public health assessment and planning model, and emphasizing population health improvement. (Population Health Management 2015;xx:xxx–xxx)

Introduction

Population health framework

Although there is not agreement on the definition of population heath, one of the most commonly used is ‘‘the health outcomes of a group of individuals, including the distribution of such outcomes within the group.’’7 Population health includes the following interrelated elements:

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opulation health is a concept historically linked to public health. However, there is a newfound focus on strategies and approaches to improving population health derived from other disciplinary perspectives and various health care policies and initiatives.1–6 In particular, it has been suggested that the Patient Protection and Affordable Care Act provision that requires nonprofit hospitals to conduct a community health needs assessment (CHNA) and implement strategies to address health priorities has the potential to improve population health.4–5 However, little research is available to document the effects of the Internal Revenue Service (IRS)-mandated CHNA on population health.



Using a broad definition of health to include well-being and quality of life 4,7–10  Defining the community beyond hospital or clinic patient populations 4,7–11  Recognizing population health improvement as a shared responsibility among health care, public health, community-based organizations, and others 4,7,9,10,12

1 Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas. NOTE: At the time the manuscript was written, Dr. Pennel was with the Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania. 2 Department of Health Promotion and Community Health Sciences, School of Public Health, Texas A&M Health Science Center, College Station, Texas. 3 Center for Community Health Development, School of Public Health, Texas A&M Health Science Center, College Station. Texas. 4 Department of Recreation, Park and Tourism Sciences, Texas A&M University, College Station, Texas. 5 Educational Administration and Human Resource Development, Texas A&M University, College Station, Texas.

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Identifying broader determinants of health and points of intervention 4,7–10, 12  Identifying drivers or root causes of health issues 9,10,12  Implementing clinical and nonclinical interventions, including health promotion and disease prevention programs and policies 4,7,10,12  Measuring health outcomes and performance 4,7–10,12 Using these elements as a population health framework, this study examined the potential for population health improvements through the draft IRS regulations, during the first 3-year cycle, that mandate nonprofit hospitals to conduct a CHNA and implement strategies to address health priorities.13 The research team thinks some CHNA requirements are critical to making population health improvements and are, therefore, important to study. First, it is important to understand how nonprofit hospitals interpret the IRS regulations. Because of the vagueness of the draft regulations and only recently issued final IRS rules, the explicit purpose of the legislation and IRS regulations have been unclear. Second, to improve population health as already described, it is important to broadly define the community. Third, it is important to understand engagement efforts with community stakeholders and, particularly, collaboration with local health departments in assessment and planning activities. Although the IRS regulations mandate that hospitals take into account input from persons who represent the broad interests of the community, including governmental public health, the draft regulations did not specify community engagement beyond soliciting and taking that input into account.13 Fourth, it is important to examine broader influences on health (eg, income, education, transportation, housing) in regard to improving population health as well as strategies identified to address these priorities.14–15 Although the final IRS rules expand the examples of health needs to include disease prevention, adequate nutrition, or social, behavioral, and environmental influences on health, neither the draft nor final regulations require that nonprofit hospitals identify broader determinants of health or strategies to address these determinants.13,16 Finally, evaluating programs and monitoring health outcomes are important to ensure the effectiveness of interven-

tions and demonstrate improvements in population health. Thus, it is important to assess the plans nonprofit hospitals develop to evaluate community health improvement strategies, as well as to monitor and measure health outcomes. These elements are summarized in Table 1, which illustrates the evaluation criteria juxtaposed with elements of population health. Using these criteria as indicators of population health improvement, a mixed methods study was conducted to examine the potential for population health improvement through IRS-mandated, nonprofit hospital CHNA and planning processes. Although these are not the only criteria necessary for population health improvement, the research team believes these provide some indication of the CHNA regulations’ ability to improve population health. Methods

The methods reported in this study were part of a larger 2-phase, mixed (quantitative and qualitative) methods study design approved by the Texas A&M University Office of Research Compliance Human Subjects Protection Program. Other methods and findings for this study can be found elsewhere.17 Quantitative content analysis

Publicly available Texas CHNA/implementation strategies reports were accessed through Web-based searches. There were 179 nonprofit hospitals in Texas at the time of this study. The research team located 135 CHNA/implementation strategies reports (both report sections, the CHNA report and the implementation strategies report, were required to meet study inclusion criteria). Forty had not yet included the implementation strategies report section and were excluded from the sample. The team reviewed and conducted content analysis for 95 CHNA/implementation strategies reports for population health-related elements. Descriptive statistics were generated for these items: 

Health priority types were categorized as medical conditions, health behaviors, community conditions, or health systems priorities;

Table 1. Population Health CHNA Criteria Population Health Elements Using a broad definition of health to include wellbeing and quality of life Recognizing population health improvement as a shared responsibility among health care, public health, community-based organizations, and others Identifying broader determinants and points of intervention Identifying drivers or root causes of health issues Implementing clinical and nonclinical interventions

CHNA Evaluation Criteria 

Identification of health priorities: medical conditions, health behaviors, community conditions, or health systems priorities  Interpretation of IRS regulations by nonprofit hospitals  Extent of community stakeholder involvement  Types of activities in which stakeholders were involved   

Measuring health outcomes and performance



Defining the community served beyond hospital or clinic patient population



Identified broader determinants of health beyond clinical: social, behavioral, environmental, and other Identified underlying etiologies/root causes of health issues Identified implementation strategies to address health priorities beyond clinical Included plans to measure health improvement strategies and health outcomes through development of an evaluation plan with clear goals/measurable objectives Community served: patient population or more broadly by geographic or geopolitical boundaries

CHNA, community health needs assessment; IRS, Internal Revenue Service

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Community stakeholder involvement was examined by types of assessment and planning activities in which the stakeholders participated;  Strategies identified to address health priorities were classified as within or outside hospitals’ normal scope of practice;  Broader determinants of health, identification of underlying etiologies of health issues, and development of clear goals/measurable objectives and an evaluation plan were examined using a 6-point scale (0 = not addressed; 1 = low quality/no detail; 2 = quality weak/very limited detail; 3 = quality/detail partial or variable; 4 = good, solid quality/good detail; 5 = high quality/ highly detailed). This scale was used previously to assess obesity prevention state plans.18,19  Hospital definition of the community served Phase I also informed the Phase II research questions for the study, site selection, and key informant, consultant, and community stakeholder interview questions. Site selection and interviews

To enhance understanding of CHNA/implementation reports, 6 hospitals were selected from the 95 reports reviewed and interviews were conducted with key informants, consultants, and community stakeholders involved in CHNA and planning processes at these 6 sites. Site selection. Six nonprofit hospitals were selected using purposive sampling. Selection criteria were primarily based on a score representing CHNA/implementation strategies report quality17 and hospital location. Two low-scoring, 2 mediumscoring, and 2 high-scoring reports were selected in metropolitan and nonmetropolitan counties. Other characteristics included hospital and CHNA report characteristics. Selecting a range of contrasting sites added confidence to the findings.20 To verify the site sampling strategy, a confirmatory cluster analysis was conducted to substantiate the representativeness of the sites selected. All 6 selected hospital sites agreed to participate. Participants. Among the 6 selected sites, 27 individuals were contacted for interviews. Sixteen people were interviewed: 9 key informants (3 system level, 6 hospital level), 3 consultants, and 4 community stakeholders. Initial key informants and consultants were identified using contact information provided in the CHNA/implementation strategies reports. A snowball sampling technique was used to identify other key informants and community stakeholders involved in the CHNA/implementation strategies process. Three community stakeholders contacted thought they had little information to contribute because of their lack of involvement in the assessment and planning processes and were not interviewed. Data collection. Semi-structured interviews were conducted during March–May 2014, using open-ended interview questions and a flexible interviewing technique.21 Interview questions were created for each group (health system and hospital key informants, consultants, and community stakeholders) to aid triangulation and validation. Prior to conducting interviews, 3 health care systems professionals, known to the research team, reviewed the inter-

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view questions for content validity and provided feedback on the usefulness and relevance of the questions. Interviews were conducted face-to-face when permitted, and otherwise were conducted by telephone. All interviewees consented to audio recordings, which were transcribed by a professional transcription service. Upon receipt, transcripts were reviewed for accuracy and de-identified. Immediately following each interview, the research team completed site-specific memos with reflections about the interview based on the information provided, the CHNA/ implementation strategies reports, and key points or themes that emerged. Table 2 provides more detailed information about interview participants and data sources. Analysis. Qualitative data were analyzed through the constant comparative analysis method, an iterative process involving concurrent data collection and analysis followed by preliminary coding, categorizing based on codes, and developing preliminary broad themes or concepts.22 The research team organized sources, analyzed data, and documented interpretations of the data using NVivo 10 (QSR International Pty Ltd, Doncaster, Victoria, Australia). Several data collection, maintenance, interpretation, and analysis methods were used to judge and ensure the adequacy of the study by establishing credibility, transferability, dependability, and confirmability.23,24 Given space limitation, these are not discussed in detail in this article, but the information can be obtained by contacting the lead author. Results

Results of the CHNA/implementation strategies report content analysis provided a broad view of population health improvement through nonprofit hospital assessment and planning activities. Interviews with health system and hospital key informants, consultants, and community stakeholders at the 6 selected hospital sites helped elucidate approaches to and experiences during this first 3-year assessment and planning cycle as they related to population health improvement. Health priorities

Of 473 health priorities identified among the 95 CHNA reports, almost half (46.5% [n = 220]) related to health systems (Table 3). The most frequently cited health systems priority was access to care, including primary care, specialty care, mental/ behavioral health care, and dental care. Health condition priorities followed with almost 40% of all priorities, which included obesity, diabetes, mental health, substance abuse (as a condition), cardiovascular disease, asthma, and sexually transmitted diseases. Health behaviors were less than 9% of the total priorities identified. These most often included physical activity, nutrition, and smoking. Finally, community conditions made up about 5% of the priorities, which included environmental and infrastructural conditions, such as air quality, transportation, community collaboration, and access to healthy food and exercise facilities. Table 3 identifies health priorities by type. Community participation

Based on content analysis, the assessment and planning activities in which community stakeholders participated

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Table 2. Data Sources Hospital Site

Key Informant Interviews

Community Stakeholders Interviews

1

Key Informant (hospital level)

2

Key Informant (system level)

Public Health Official*

3

Consultant 1 Consultant 2 Key Informant Key Informant Key Informant Key Informant Consultant Key Informant Key Informant Key Informant

Public Health Official*

4 5 6

(hospital level) (system level) (hospital level) (hospital level) (system level) 1 (hospital level) 2 (hospital level)

----

FQHC CEO Public Health Official* YMCA CEO Faith-based Nurse Public Health Official

Document Sources Hospital CHNA and Implementation Plan report Hospital CHNA report Hospital Community Benefit Implementation Plan report Hospital CHNA and Implementation Plan report Hospital CHNA Hospital Implementation Plan report County CHNA Assessment report CHNA Update (December 17, 2014) County Community Health Assessment report Hospital Implementation Strategy report

*These community stakeholders were contacted by telephone and e-mail. They were willing to participate in an interview but did not think they had anything to add because of their lack of involvement in the CHNA/implementation strategies process. They received study information and informed consent and documentation of consent was waived. CEO, chief executive officer; CHNA, community health needs assessment; FQHC, federally qualified health center; YMCA, Young Men’s Christian Association

varied across the 95 reports. The 8 types of activities identified along a ‘‘degree of community engagement’’ continuum were:        

no attempt to engage community stakeholders; engaged only health-related (ie, health clinic) stakeholders to represent community members; engaged broader community stakeholders to represent community members; engaged members of the community; verified or validated health needs or priorities with community stakeholders; involved community stakeholders in priority identification or ranking; involved community stakeholders in strategy selection; and involved community stakeholder and partners in carrying out strategies.

Although the IRS regulations required hospitals to solicit and take into account input from stakeholders with public health knowledge and expertise as well as leaders, representatives, or members of medically underserved, lowincome, and minority populations in the community, 18% (n = 17) of hospitals made no attempt to engage community stakeholders. This occurred when existing assessment reports, conducted and published by organizations or agencies other than the nonprofit hospital in the same region (eg,

Table 3. Health Priorities Identified Health Priority Type Health System Health Condition Health Behavior Community Condition Total Priorities

Frequency

Percentage

220 187 41 25 473

46.5% 39.5% 8.7% 5.3% 100%

local health department), supplanted an original hospitalconducted assessment. Simply adopting existing assessment resources rather than conducting a hospital CHNA or collaborative community assessment is a missed opportunity for nonprofit hospitals to engage, learn from, and collaborate with community stakeholders. The majority (80%; n = 76) of hospitals engaged broader community stakeholders to represent community members in surveys, interviews, and/or focus groups to identify health needs (Table 4). These frequently included communitybased organizations and local governmental agencies, such as public schools, youth- and older adult-serving organizations, local elected officials, and organizations that represented underserved community populations. More than one quarter of the assessment processes involved hospital patients, family members, or other community members in surveys, interviews, and/or focus groups to identify health needs. Often, surveys were disseminated electronically, but occasionally paper-based surveys were placed in locations to reach underserved populations (eg, United Way, free clinics, food pantries). Only 2 hospitals requested input solely from health-related community stakeholders to identify health needs (eg, local clinics). Twenty hospitals verified or validated health needs or priorities with community stakeholders. Four hospitals involved community stakeholders in priority identification or ranking. Only 2 hospitals involved community stakeholders in strategy selection. Two hospitals involved community stakeholders or partnerships in carrying out strategies. Table 4 provides descriptive statistics of hospital engagement of community stakeholders by activity type. Implementation of strategies

When evaluating CHNA/implementation strategies reports for the strategies to address health priorities, the majority of hospitals (70.5%; n = 67) identified and implemented community benefits activities as they had in the past (Table 5).

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Table 4. Community Health Needs Assessment (CHNA) and Implementation Strategies Activities CHNA Community Engagement Activities* No attempt to engage community Community engagement to identify health needs through surveys, interviews, and/or focus groups:  Health-related community stakeholders only  Broader community stakeholders  Community members Verify/validate health needs/priorities with local experts Community stakeholders involved in priority identification Community stakeholders involved in strategy selection Partnerships developed to carry out strategies

Frequency

Percentage

17

18

2 76 27 20 4 2 2

2 80 28 21 4 2 2

*Activities are not mutually exclusive, as hospitals could engage in multiple assessment and planning activities.

These strategies included continuation of existing programs and activities (eg, screenings at health fairs), physician recruiting, and providing governmental assistance program applications to patients. These strategies also included the implementation of programs or activities identified as already under way, such as specialist telemedicine programs and integrated delivery systems for underserved patients. Only 9 reports suggested hospitals’ intent to implement strategies outside their normal scope of activities (Table 5). Examples of new strategies included establishing partnerships with businesses, schools, and ministerial alliances to address general wellness, asthma, children’s well-being, and other health priorities for program and policy development. One hospital made plans to initiate a farmers’ market in an identified food desert, so healthy foods could be made available at low cost. For the 19 remaining reports, the research team was unable to determine if hospitals were diverging from or adopting the same past community benefits approaches. Table 5 summarizes approaches to community benefits activities. This was echoed in interviews with key informants when asked about identifying implementation strategies. One key informant said, ‘‘We were already doing quite a few things that met those priorities. We didn’t really add any different services. We just reported what we’re doing already.’’ According to another key informant, ‘‘They [hospitals] weren’t coming up with 15 new things.they were really documenting what they were already doing and how that was meeting the needs.’’ Determinants of health

Two criteria for which CHNA/implementation strategies reports were evaluated reflected broader determinants of

Table 5. Nonprofit Hospitals’ Implementation of Community Benefits Community Benefits Approach type Approach congruent with normal operations Approach varies from normal operations Unable to ascertain approach Total

Frequency

Percentage

67

70.5%

9

9.5%

19 95

20% 100.0%

health: (1) examination of underlying etiologies of health problems (ie, expressed some understanding of root causation) and (2) identification of influences and strategies that reflected broader determinants, using a social ecological framework. One half (49.5%; n = 47) did not address or did a very poor job of addressing underlying etiologies of health problems (score of 0 or 1 on a 6-point scale). Only 7% (n = 7) did a good or better job of expressing an understanding of root causes of needs being addressed (score of 4 or 5). The remaining 43% (n = 41) fell in the midrange (score of 2 or 3). Almost three quarters (72.7%; n = 69) did not address or did a very poor job of addressing social determinants of health by identifying issues influencing health or implementing strategies that reflected these determinants (score of 0 or 1 on a 6-point scale). Only 2% (n = 2) did a good or better job of identifying these issues and strategies (score of 4 or 5). The remaining 25% (n = 24) fell in the middle (score of 2 or 3). Evaluation and monitoring

Two population health improvement criteria for which reports were assessed were evaluation and monitoring. The first was the inclusion of an evaluation plan in the CHNA/ implementation strategies report (eg, plans for evaluating interventions, using findings for program improvement, continuing data collection to assess progress). Although one third (32.6%; n = 31) did a good job of developing evaluation plans (score of 4 on a 6-point scale), just under half (44.2%; n = 42) did not include an evaluation plan or did a very poor job of developing their plan (score of 0 or 1 on a 6-point scale). The remaining 23% (n = 22) scored in the midrange (2 or 3). The second evaluation and monitoring item for which reports were evaluated was the inclusion of health improvement or program goals and objectives (eg, setting clear goals; defining SMART objectives—specific, measurable, attainable, realistic, time specific; linking goals and objectives; outlining strategies to support objectives, developing indicators for determining whether objectives were met). Although the aforementioned evaluation plan criteria assessed reports on having a plan, this item was an indicator of the quality of this plan. Only 10 hospitals (10.6%) did a good or better job of establishing linked goals, objectives, and strategies (score of 4 or 5 on a 6-point scale). One quarter of hospital reports (25.3%; n = 24) did not include

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well-developed goals, objectives, and activities or did a very poor job of developing and linking these items (score of 0 or 1). The remaining 64.2% (n = 61) scored in the midrange (score of 2 or 3). Interpretation of the draft regulations

Noncompliance of the IRS requirements may result in a $50,000 fine and possible revocation of nonprofit hospitals’ tax-exempt status.13 Thus, all hospitals intended to meet the minimum assessment and planning requirements. However, some variations in interpretation emerged in this study, including hospitals’ intentions to (1) improve documentation and reporting, (2) increase responsibility for enhanced community benefits, and (3) shift toward population health improvement. The interpretation of the regulations for most hospitals was simply to improve documentation and reporting of community benefits to the federal government. According to one consultant, who worked with hospitals throughout the United States, ‘‘We really feel like not-for-profit hospitals are doing a good job meeting the community needs, and so a lot of this is [about] documentation.’’ When asked what this process might change, a hospital-level key informant said, ‘‘The only thing that might change is better record keeping of what we are doing.just to make sure we’re capturing the things that we’re doing. We do a lot of services. I don’t think we needed to add anything. I just think we need to make sure we’re capturing it all.’’. Improving documentation and reporting.

Enhancing community benefits. Other sites interpreted the IRS requirements as greater than improving documentation and reporting; it was about doing more to fulfill the expectations of the government and the community, given their tax-exempt status. A hospital-level key informant shared her thoughts on the purpose: ‘‘[It is about] nonprofit organization[s] and how we justify that status.We’re having a business without paying the taxes, so we need to be able to justify, explain what services we are providing equivalent to what we would’ve been paying in taxes.’’ A consultant also thought the IRS requirements were asking more of nonprofit hospitals to rightfully justify their taxexempt status: ‘‘I believe what they’re [IRS] trying to say is ‘If we are going to tax exempt you, hospital, then you’ve got to be able to provide us with the documentation and rationale for what that is.’ It’s really important because.the amount of taxes that all of the community nonprofit hospitals would have to pay in the United States if they weren’t tax-exempt is astronomical.’’

Improving population health. Very few hospitals interpreted the IRS regulations as an attempt to shift hospitals’ focus toward improving population health. One system-level key informant indicated the community benefits staff and system-level leadership were shifting their perspective toward community health improvement. Although a struggle for hospitals, she began noticing a difference in the way staff, particularly nonclinical staff, were thinking: ‘‘[This] is new for [our] health care system. That’s been difficult for

me and for a lot of my team to say, ‘No, it’s not just about treating them [patients].’’’ According to one consultant, ‘‘This is very high risk if it’s not taken seriously for a hospital.‘What we’re [IRS] gonna do is try to incentivize hospitals to really improve the health status as opposed to just delivering care.’ That’s their main intent with this legislation.’’ Another consultant agreed: ‘‘It would not surprise me in the least bit if the [IRS Form] 990 starts asking questions like, ‘Have you improved the health of the community by your implementation strategy, and how?’’’ However, she was doubtful this would bring about changes in population health status: ‘‘I don’t think that because we’ve had to go through this process, hospitals are going to influence the health of the community any more than they already were doing.’’ Defining the community

Another element of the draft regulations that created confusion was how hospitals define the communities they serve: ‘‘One of the things that was most difficult about not having final regulations was around the community served. Is it the health system’s community? Is it the hospital-specific community? Is that just where the majority of our patients reside? Is it the county where the hospital resides? We had to just consider all of these different things, and within the hospital, different departments would identify a community differently. Your strategy, your business development, your marketing [department] sees your community as much bigger than your quality or community benefits [department] that’s really looking at the underserved population. That was a conversation that has been a Pandora’s Box, honestly. Every time we look at that definition of community, it becomes a bigger problem.’’

Although no CHNA reports defined the community served by the hospital strictly as their patient population, the vast majority identified their community served through inpatient and discharge zip code data and primary and secondary service area. This information was used to identify counties, and less often cities or regions, for which hospitals focused their data collection and data analysis efforts. The few CHNA reports that did not identify the community served using hospital inpatient and discharge data defined the community served as a city or county in which the hospital resided; the methods for determining the community served were not described. Given the countybased nature of Texas and the availability of state and national data at the county level, it is not surprising Texas hospitals defined counties as the geographic community served. Discussion

Over the past 30 years, there have been concerns as to whether nonprofit hospitals are meeting minimum community benefit standards in return for their tax-exempt status. In 2006, the Congressional Budget Office estimated the value of federal, state, and local tax exemptions for nonprofit hospitals was $12.6 billion.25 However, studies suggest there is little difference between community benefit provided by nonprofit and for-profit hospitals, and the community benefit nonprofit hospitals provide is much less than

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the tax exemption benefits the hospitals receive.25–28 Further, despite the expectation 85% of community benefit expenditures were devoted to patient care services.29 The research team believes there is great opportunity for the nonprofit hospital assessment and planning processes to improve population health. However, based on this study during the first 3-year assessment and planning cycle in Texas, population health improvements are unlikely. As nonprofit hospitals begin the second cycle, the team offers recommendations based on these and other CHNA findings17 to increase the potential for nonprofit hospitals to improve population health. Recommendations 1. Define the purpose of IRS regulations. Even with the recent release of the final IRS regulations, the intent is still unclear with regard to improving population health. Interpretations could include improved transparency, documentation, and reporting; expectations that nonprofit hospitals provide stronger evidence to justify their tax-exempt status; increased provision of charity care; and/or enhanced emphasis on disease prevention, health promotion, and population health improvement. It is likely hospitals’ interpretations inform the overall approach to the assessment and planning process. If the intent of the IRS, policy makers, and government officials is for nonprofit hospitals to move beyond improved documentation and reporting, they should clearly state the purpose of the CHNA process and report to ensure more consistent interpretation and implementation. Moreover, this is an opportunity to move beyond accountability and require nonprofit hospitals to identify issues and implement strategies to improve population health status. 2. Engage community stakeholders and community members. The benefits of engaging community stake-

holders in all phases of community health improvement are widely recognized.30–35 The IRS regulations provide opportunities for nonprofit hospitals, health departments, and other community organizations to collaborate and create opportunities for communities to be healthy. Nonprofit hospitals should make concerted efforts to engage a broad array of community stakeholders in meaningful participation throughout the assessment and planning processes. Additional stakeholder types might include representatives of public, private, and higher education, law enforcement officials, business owners, community and faith-based organizations, policy makers, governmental agencies (eg, planning and zoning, parks and recreation), other health care-related entities, grassroots and neighborhood organizations, parents, youth, and other private residents. Most hospitals are not strangers to working with community partners; however, they may be unaccustomed to collaborating with partners in community assessment and planning activities. Collaboration benefits hospitals by garnering support to address issues beyond hospitals’ expertise and capabilities, diffusing the work among multiple organizations and agencies, and increasing the potential to improve population health and build community capacity. Community collaboration can improve efficiency, eliminate duplication, and pool, leverage, and mobilize resources. Further recommendations related to community engagement

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can be requested from the lead author (Pennel CL et al, unpublished data, 2015). 3. Understand disease etiology and identify determinants of health. Many factors contribute to health, including

economic stability, education, social and community context, health and health care, and neighborhood and built environment.14 Research strongly suggests clinical measures, such as quality of and access to health care, contribute little to overall health compared to these other factors.14–15 Recommendation #2 will provide a broader perspective and broader range of resources that can be leveraged to identify and begin addressing social, environmental, cultural, political, economic, and behavioral determinants of health. Further, by including a broader sector of stakeholders, a ‘‘health in all policies’’ approach can identify and address nonclinical determinants of health. Although the final IRS rules expand examples to include social, behavioral, and environmental influences, nonprofit hospitals should expand their frame of health to explore root causes of health issues and identify broader determinants of health as well as solutions beyond clinical and individual education interventions. 4. Adopt a public health framework. Nonprofit hospitals should use a public health assessment and planning model, such as Planned Approach to Community Health, Mobilizing For Action Through Planning And Partnerships, Community Health Improvement Process, or the community health development model.36–40 Using elements from these would aid hospitals in meeting recommendations #2 and #3, provide much-needed standardization to the process, and increase the likelihood of improving population health status. This also provides a model to enhance opportunities for alignment between nonprofit hospital CHNAs and other assessment and planning processes (eg, health department accreditation). A public health assessment and planning model should include the following:           

Engage and mobilize the community throughout the assessment and planning process Collect data using multiple sources and quantitative and qualitative methods Identify health disparities Use broad social determinants to identify influences on health issues Identify clinical and nonclinical resources Organize and broadly share findings Set health priorities with community stakeholders Develop an action plan with goals and objectives to address health priorities Identify and implement clinical and nonclinical, evidence-based, and culturally appropriate strategies Provide opportunities for continual feedback with input from community members Recognize and include community capacity-building elements in population health improvement initiatives

5. Emphasize population health improvement. Assessment and planning activities provide an opportunity to build on other national policies and initiatives to improve population health.1–6 Hospitals tend to view health as the treatment of sick patients. Taking a health promotion and disease prevention approach to assessment and planning can align the

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IRS requirement with other initiatives. For population health improvement to occur, following recommendations #2, #3, and #4 will aid the identification of root causes of health issues, adoption of clinical and nonclinical strategies to address health priorities, and identification of clinical and nonclinical community resources. A key and often effective nonclinical strategy is policy development. Hospitals and their leadership are often viewed as trusted community leaders with power, authority, and influence. This leadership role places hospitals in a valuable position to influence broader policy changes to affect population health. Limitations

This cross-sectional study provided a snapshot at a single point in time; the research team was not able to directly observe processes. The team was reliant on reports and reconstructed perspectives represented by the key informants, consultants, and community stakeholders interviewed. Further, subjectivity, particularly as it related to the team’s beliefs about nonprofit hospitals’ responsibility to communities, imposed their perspective on the methodology, the research questions, and data collection, analysis, and interpretation. The parameters set for this study limited it to nonprofit hospitals in Texas. The review and evaluation of the CHNA/ implementation strategies reports included 53% of the nonprofit hospital population in the state. Although the research team thinks these results are applicable to nonprofit hospitals in other states, they recognize state differences that may influence generalizability. Six nonprofit hospitals were selected that were thought to be representative of this population and their selection was corroborated with confirmatory cluster analysis. For each site, the research team was limited by the ability to reach participants, particularly community stakeholders, who were involved in the assessment and planning processes. Finally, this study is limited in that it only includes reports completed under the draft IRS regulations during the first 3-year cycle (2011–2013). Although the final regulations issued on December 31, 2014, have not changed significantly in content, much clarification has been provided that could foster uniformity of reports and interpretations of regulation. Author Disclosure Statement

Drs. Pennel, McLeroy, Burdine, Matarrita-Casconte, and Wang declared no conflicts of interest with respect to the research, authorship, and/or publication of this article. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. References

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Address correspondence to: Dr. Cara L. Pennel Director, Public Health Practice Department of Preventive Medicine and Community Health University of Texas Medical Branch 301 University Boulevard Galveston, Texas 77555-1110 E-mail: [email protected]