1 Best Practices for Community Health Needs Assessment and Implementation Strategy Development: A Review of Scientific Methods, Current Practices, and Future Potential

1 Best Practices for Community Health Needs Assessment and Implementation Strategy Development: A Review of Scientific Methods, Current Practices, and Future Potential Report of Proceedings from a Public Forum and Interviews of Experts Public Forum convened by The Centers for Disease Control and Prevention Atlanta, Georgia | July 11–13, 2011 Kevin Barnett, DrPH, MCP | February 2012 Best Practices for Community Health Needs Assessment and Implementation Strategy Development: A Review of Scientific Methods, Current Practices, and Future Potential Report of Proceedings from a Public Forum and Interviews of Experts Kevin Barnett, DrPH, MCP February 2012 Submitted to The Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333 Submitted by The Public Health Institute 555 12th Street, 10th Floor Oakland, CA 94607 Developed with Funding was provided by the Centers for Disease Control and Prevention under cooperative agreement U38HMh with the National Network of Public Health Institutes. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. ACKNOWLEDGEMENTS............................................................................................................................. i EXECUTIVE SUMMARY........................................................................................................................... iiii I. INTRODUCTION ............................................................................................................................... 1 A. Project Purpose ........................................................................................................................... 1 B. Impetus/ Rationale ...................................................................................................................... 2 C. History/Background ..................................................................................................................... 4 D. Project Design.............................................................................................................................. 7 1. Expert Panel Meeting............................................................................................................... 7 2. Key Informant Interviews ......................................................................................................... 8 3. University of Kansas Compendium ........................................................................................... 9 4. Report of Proceedings............................................................................................................ 10 E. Putting it All Together: A Logic Model ........................................................................................ 10 F. Definitions ................................................................................................................................. 12 II. COMMUNITY HEALTH NEEDS ASSESSMENT ................................................................................... 12 A. Shared Ownership of Community Health ................................................................................... 13 B. Defining Community – Jurisdictional Issues ................................................................................ 18 C. Data Collection and Analysis ...................................................................................................... 27 D. Community Engagement............................................................................................................ 37 E. Priority Setting........................................................................................................................... 46 III. IMPLEMENTATION STRATEGY DEVELOPMENT AND EXECUTION................................................. 61 A. Alignment Opportunities............................................................................................................ 61 B. Monitoring and Evaluation......................................................................................................... 70 C. Institutional Oversight ............................................................................................................... 77 D. Shared Accountability and Regional Governance........................................................................ 87 E. Strategic Investment and Funding Patterns................................................................................ 96 F. Public Reporting: Federal, State, and Local Issues..................................................................... 105 IV. CONCLUSION / NEXT STEPS.......................................................................................................... 120 APPENDIX A BIOGRAPHIES...................................................................................................................... i APPENDIX B. FINAL AGENDA................................................................................................................... xi tant theme in the project is the opportunity for collaboration between hospitals and local public health agencies in conducting community health needs assessments and the development of community health improvement strategies. With this in mind, an opening plenary presentation was given by John Bluford, MBA, FACHE, Chief Executive Officer of Truman Medical Centers in Kansas City, MO. Mr. Bluford was also the Chair of the Board of Trustees of the American Hospital Association (AHA). Leaders from health systems and hospitals such as Aurora Health Care, Baylor Health Care System, Catholic Healthcare West, Duke University Medical Center, Kaiser Permanente, Trinity Health, and UMASS Memorial Health Care also participated on expert panels. Important input in the planning of the meeting was also provided by Janelle Gillings from the Association of State and Territorial Health Officers (ASTHO) and Julia Joh Elliger and Barbara Laymon from the National Association of County and Community Health Officers (NACCHO). NACCHO also sponsored a national webinar that provided an opportunity for over 300 public health leaders to address topics covered in the expert panel meeting. In addition, we are grateful for the opportunity to collaborate with colleagues Stephen Fawcett, Christina Holt, and Jerry Schultz of the Work Group for Community Health and Development at the University of Kansas. Dr. Fawcett and his colleagues developed a companion report in the project entitled Recommended Practices for Enhancing Community Health Improvement, and made important contributions to the meeting. We would also like to acknowledge the contributions of Public Health Institute team members Smruti Shah and Reggie Jackson, contributed to the development of content for each element of the community health improvement process addressed as part of this report, and for their support of the meeting. We would also like to acknowledge the contributions of Keith Hearle, Principal of Verité Consulting, who provided invaluable input in the editing of this report. Last, but certainly not least, we would like to acknowledge the contributions of key leaders in the field for their ii participation in the key informant interview process, as well as those who served as expert panelists and participants in the meeting. vii This panel examined the potential benefits of regional partnerships between hospitals, local public health agencies and other stakeholders, considered existing mechanisms for local and regional accountability, and discussed and array of issues and challenges. Panelists also shared current examples of regional partnerships and tools and resources to guide and support different levels and forms of shared governance. While acknowledging an array of challenges and obstacles to shared accountability and regional governance, panelists and participants stressed the importance of identifying and building on positive examples. As with other issues discussed during the meeting, participants encouraged a more systematic documentation and diffusion of innovations to encourage the advancement of practices. Strategic Investment and Funding Patterns This session focused on the potential roles of public and private sector funders in facilitating a more strategic approach to community health improvement, and considered options for public policy development that support and sustain comprehensive approaches. One panelist examined the historical role of the United Way as a national entity that serves as a local funder and partner in CHNAs and community health improvement initiatives, including an increasing emphasis on building community capacity to engage in public policy development. Panelists, participants, and key informants discussed emerging innovations in public and private sector philanthropy, and identified specific mechanisms that will foster mutual accountability for results. Public Reporting The final two expert panel sessions focused on the role of public reporting at the local, state, and national level in the advancement of community health improvement practices. Panelists and participants discussed issues for hospitals and local public health agencies in meeting reporting requirements. A common theme was how to move from an emphasis on compliance with minimum standards to meaningful actions that transform institutions and produce measurable health improvement in communities. Panelists and participants also examined the role of local officials, advocacy groups, and the general public in fostering shared accountability for health with hospitals, local public health agencies, and diverse stakeholders. An important opportunity identified and discussed among panelists and participants is the alignment between the new reporting requirements for hospitals and the release of national accreditation standards for local public health agencies. On a parallel level, participants encouraged the identification of alignment opportunities between public reporting on community benefit and the broader national health reform process. A significant focus of the panel presentation and public comment period in the second session focused on practical issues in local hospital interpretation and implementation of new federal reporting requirements. Participants emphasized the value of increased transparency associated with public reporting and the availability of new technologies (e.g., GIS data mapping) as creating the conditions for increasing focus on local accountability. Shared Accountability and Regional Governance viii Throughout the two and a half day meeting and in prior interviews, panelists, participants, and key informants identified areas of concern in the language in the IRS 990 Schedule H, section 501(r) of the Internal Revenue Code, and Notice 2011-52. The stated concerns and associated dialogue are captured in the body of this report, and a set of recommendations based upon this input has been submitted to Treasury and the IRS as a separate document. 1 I. INTRODUCTION A. Project Purpose This project is sponsored by the Centers for Disease Control and Prevention (CDC), which is located within the federal Department of Health and Human Services (HHS). The purpose of the project is to provide insights into the science, methods, and current practices in the community health improvement process. The primary audience is the CDC, which is providing input to the Internal Revenue Service to inform the development of reporting guidelines and oversight mechanisms for nonprofit hospital engagement in community health improvement activities. Other government agencies at the federal, state, and local level are also important audiences. At the federal level, agencies such as CMS and HRSA have an interest in hospital engagement of stakeholders such as community health centers in efforts to reduce health care costs through increased investment in prevention activities. State government agencies with oversight responsibilities for hospital community benefit practices are also key audiences. The hospital community is also a key audience, as well as an important contributor to the project. Many health systems have provided important leadership in the advancement of practices, and the input provided by hospital representatives and other key stakeholders in the meeting is intended to inform and accelerate innovation in the field. Another key audience is the public health community. In July 2011, the national Public Health Accreditation Board (PHAB) released accreditation standards and measures for local public health agencies that are closely aligned with the new report requirements for nonprofit hospitals. Key elements in the accreditation standards are community health assessments and the development of community health improvement plans. Other key audiences include community and consumer advocates, researchers, and philanthropy, all who have a stake in the practice and advancement of community health improvement. As the federal agency with the primary responsibility for public health in the United States, CDC is in the unique position to draw upon the expertise of academicians, researchers, and practitioners across the country. In the process, the intent is to address key questions raised by the IRS and provide insights based upon the expertise and experience of leaders in the field. In the process, the central goal is to inform the development of guidelines for reporting that minimize administrative burden, preserve the flexibility needed to foster innovation, and contribute to the advancement of practices in the field. 2 B. Impetus/ Rationale The passage of the Patient Protection and Affordable Care Act (PPACA), Pub. L., No. 111-148, 124 Stat. 119 on March 23, 2010 established four new federal requirements for tax-exempt hospitals under section 501(r) of the Internal Revenue Code. They include:  Conduct a community health needs assessment (CHNA) every three years and adopt an implementation strategy to meet needs identified in the assessment.  Adopt a written financial assistance policy that includes eligibility criteria, methods used to calculate charges, applications for assistance, and actions associated with billing and collections.  Limit charges for services to levels equivalent to amounts generally billed for insured patients.  Make reasonable efforts to determine an individual’s eligibility for financial assistance prior to extraordinary measures to secure payment. Section 6033(b)(15)(A), also amended by the PPACA, requires a hospital organization to report on its Form 990 a description of how the organization is addressing the needs identified in each CHNA and a description of any needs that are not being addressed together with the reasons why the needs are not being addressed. To satisfy this requirement, Treasury and IRS intend to require a hospital organization to attach the most recently adopted implementation strategy for each of its hospital facilities to its annual Form 990. Hospital organizations must also include 990-Schedule H when submitting Form 990 and their implementation strategies. The IRS released the first draft of a redesigned 990 Schedule H for public comment on June 14, 2007. The impetus for the review and redesign of the 990- Schedule H was an observation by the Acting IRS Commissioner Kevin Brown1 that the form had not undergone a review and revision for over 25 years, and a judgment that revisions were needed to better reflect the structures and functions of hospitals in the 21st century. This judgment was reinforced by extensive dialogue in the public and policy arena (see section I.C) regarding the charitable activities of tax-exempt hospitals. The Senate Finance Committee in particular had convened a series of hearings, calling upon IRS staff and other key stakeholders to provide testimony to address public expectations and associated public reporting requirements for these organizations. The IRS received over 600 comments on the first draft of the revised 990 Schedule H, a second draft was released on April 7, 2008, and further revisions have been made in 2009, 2010, with the most recent version released on February 23, 2011. 1 IRS-2007-117, June 14, 2007 3 The revised 990, Schedule H and section 501(r) represent a significant expansion in the scope of reporting for tax-exempt hospitals. Areas where IRS requests more detail include:  Listing of community benefit services/activities by category (Part I)  Listing of community building activities2 by subcategory (Part II)  Bad debt, Medicare, and collection practices (Part III)  Management companies and joint ventures (Part IV)  Facility information (Part V – including information on CHNA process)  Charity care and discounted care eligibility criteria and calculation methods In addition, Part VI, Supplemental Information asks for additional information on a number of processes, including, but not limited to the following:  Description of CHNA process  Description of community(ies) served by the organization  Description of how the reported community building activities promote the health of the communities served by the organization  Patient education of eligibility for financial assistance In the course of the IRS review of input from stakeholders, it was concluded that there were a number of issues associated with the CHNA and implementation strategy development processes where greater clarity and guidance for the field was needed. With this in mind, IRS issued a formal request to HHS/CDC to provide technical guidance. CDC was selected consistent with its mission to “create the expertise, information, and tools that people and communities need to protect their health – through health promotion, prevention of disease, injury and disability.”3 As such, CDC identified elements and issues along the continuum of a model community health improvement process, with particular focus on the CHNA and implementation strategy development. The analysis did not include an examination of charity care, bad debt, Medicare and Medicaid reimbursement, billing and collections, or other issues associated with hospital financial accounting. The timing of the request from the IRS was optimal for CDC, as it had been engaged in a review of community benefit issues and was exploring opportunities for involvement and alignment with other initiatives such as the Community Transformation Grant Program. Increased investment by tax-exempt hospitals in community health improvement activities is also aligned with the major goals of national health reform: to improve health and reduce health care costs through more cost effective and strategic allocation of resources. In this context, CDC has a 2 Require reporting, but currently prohibit inclusion in financial totals 3 CDC Mission Statement – “Collaborating to create the expertise, information, and tools that people and communities need to protect their health – through health promotion, prevention of disease, injury and disability, and preparedness for new health threats.” 4 critically important role to play in facilitating the rapid dissemination of practices and strategies that will help to achieve these important goals. The development of guidelines and related resources and tools for “best practices” is intended to support community health planning and implementation activities by diverse stakeholders, including state and local health departments conducting community health assessments and developing community health improvement plans to meet national public health accreditation standards. They may also assist a charitable hospital organization to conduct a CHNA and adopt an implementation strategy. Currently, there is considerable variation in CHNA and related processes, and many available tools lack standards to support their use in fulfilling various regulatory and accreditation requirements. An important first step is to establish a common understanding of what constitutes a “best practice” in the community health improvement arena. Is a practice deemed the best because it is generally viewed as better than others in the field, or because it meets a set of objective measures of excellence? If there are objective measures, in what ways do they accommodate different and distinct circumstances? The institutions, stakeholders, and environments in which they interact in the community health improvement process vary significantly, and any framework for classification and ranking of practices must seek to accommodate this diversity. With these challenges in mind, a core purpose of the project is to closely examine the current status of scientific methods and their practical application at all stages of the community health improvement process. Through this initial inquiry and dialogue, the field will be in a better position to understand, articulate, and evaluate what constitutes a best practice. C. History/Background In 1969, the IRS issued Ruling 69-545, which expanded the concept of charity from an exclusive focus on the poor (IRS Ruling 56-185 in 1956) to the community benefit standard, where “the promotion of health, like the relief of poverty and the advancement of education and religion, is one of the purposes in the general law of charity that is deemed beneficial to the community as a whole even though the class of beneficiaries eligible to receive a direct benefit from its activities does not include all members of the community… provided that the class is not so small that its relief is not of benefit to the community.” The expanded definition begins to move in the direction of a population health orientation, in that it moves beyond care to individuals to consider “a class of beneficiaries,” and perhaps more importantly, that it suggests an emphasis on achievement of a measurable impact. That is, the “class of beneficiaries,” i.e., the numerator, must be sufficiently large relative to the total population of the community; i.e., the denominator, to produce an aggregate impact. While it is unclear whether it was the intent of the IRS, it began to advance the idea that nonprofit hospitals have a more substantive role in addressing the health needs of community than simply providing acute medical care services. 5 States began to take a more active role by the mid-late 80s, starting with a legal challenge to the tax-exemption of Intermountain Health Care by the Utah State Tax Commission in 1985. The legal case served as a driver for the development of a state statute in 1990; a second statute was passed in New York State the same year. There are currently community benefit statutes in 17 states. Most require some form of a CHNA; three of the states (PN, TX, UT) have established minimum financial annual commitments. In Massachusetts, the Office of the Attorney General oversees implementation of Voluntary Guidelines for community benefit programming by hospitals and health maintenance organizations. State agencies with oversight responsibilities vary, as does their approach. In Massachusetts, the Office of the Attorney General posts annual community benefit plans of hospitals and managed care plans on a searchable website, providing opportunities for diverse stakeholders to quickly access program information within targeted geographic areas. In most cases, state agency oversight is limited, and has been scaled back in the context of recent budgetary challenges. Emerging evidence suggests that hospitals may be responding to the lack of oversight by giving less attention to quality and completeness in the reporting process. Hospital trade associations have played an important role in the development and dissemination of information, guidelines, and strategies to enhance community benefit practices. The Catholic Health Association of the United States (CHAUSA) provided early guidance with the release of the Social Accountability Budget in 1989, a set of guidelines and instructions for documentation of charitable practices. These guidelines served as the core framework for the development of the revised 990, Schedule H. Since their 1989 release, CHAUSA has continued to develop and disseminate a wide array of publications to encourage the enhancement of community benefit programming including the conduct of CHNAs, and has hosted numerous educational meetings. Leadership and educational support has also been provided by other trade associations such as VHA, Inc. (formerly Voluntary Hospital Association), the Health Research and Educational Trust (HRET) of the American Hospital Association, and more recently by the Association for Community Health Improvement (ACHI), also based at the American Hospital Association, and the Alliance for Advancing Nonprofit Health Care. The primary form of charitable contributions by hospitals is the provision of free and/or discounted medical services to uninsured and underinsured populations. While there are a growing number of excellent programs in communities across the country, the program portfolio of many nonprofit hospitals includes a large number of small programs spread over a wide geographic area, most insufficient in scale, targeting, or design elements necessary to produce measurable outcomes. In recent years, there has been an increasing professionalism in the community benefit function. There is growing recognition that dedicated staffing is needed to develop and manage a portfolio of charitable programs and activities that are guided by a clear and consistent set of standards. There is also increased awareness that an oversight structure is needed to guide and support the management function, and perhaps more importantly, to ensure that the actions of the institution are aligned with its core charitable mission. 6 Adoption of these practices by a growing number of nonprofit hospitals reflects an understanding that as tax-exempt institutions, they have a responsibility to be good stewards of public resources, and to ensure that there is institution-wide engagement in the fulfillment of their charitable mission. This understanding, however, is not universal among hospitals across the country. There is a need for education, engagement, and increased accountability. A combination of increased public scrutiny, regulatory engagement, and emerging opportunities are providing the impetus for meaningful and broadly implemented reform. 7 D. Project Design The project includes five components, each of which are described in this section, including 1) a national expert panel meeting, 2) a series of approximately 50 key informant interviews with key leaders from across the country, 3) the development of this report of proceedings to document the input from the meeting and interviews, and 4) the development of a compendium of tools and resources to support key elements in the community health improvement process. 1. Expert Panel Meeting CDC hosted a two and a half day expert panel meeting on July 11-13 to examine key process elements in the community health improvement process, with particular focus on issues in community health needs assessments (CHNAs) and implementation strategy/plan development. There were 13 expert panels of 2-3 presenters, with each panel addressing a specific element in the community health improvement cycle. In putting together each panel of 2-3 people, attention was given to individuals with scientific knowledge in the area and to practitioners in the field who could share specific experiences. Moreover, given a commitment to ensure broad engagement of relevant stakeholders, effort was made to secure the participation of hospital leaders, community and consumer advocates, public health practitioners, and other key community stakeholders. Panelists were given 10-15 minutes each to cover the requested content (10 minutes each for three panelists, 15 minutes each for two panelists). Panel presentations were followed by 10- 15 minutes of questions from the moderator. Approximately 30 minutes was allocated for public comment in each expert panel session. In order to maximize the opportunity for public comment, the moderator solicited 2-3 public comments at a time, encouraging participants to limit themselves to one minute per comment or question. These were summarized by the moderator for responses by panelists as a group. The purpose of the meeting was to identify issues, challenges, and opportunities, and illuminate lessons from experience in the field. Participants were informed of the request from the IRS, the purpose of the meeting, the breadth of audiences, and encouraged to put all relevant issues on the table. Meeting organizers emphasized the meeting as an early step in an ongoing process, not simply to provide insights and information to the IRS, but to facilitate the advancement of practices in the field.