Conducting A Health Equity-Focused Community Health Assessment

As shared in the recent Google Health's Health Equity Summit, the “evidence is overwhelming" that inequities affect many people's health, and there are “promising avenues" to cause positive change. Now is the time to move from sharing “the story of health equity" to action through the community health needs assessment.

The community health needs assessment (CHNA) is one of the fundamental tools that public health departments, community officials and, increasingly, healthcare organizations are using to uncover and prioritize challenges to overall health. As health equity becomes a focus, the nature of CHNAs should change. Here, we look at the increasing use of CHNAs and some bold steps to put equity at the center of assessment.

What is a community health needs assessment and who conducts one?

A community health needs assessment (also called a community health assessment), is conducted to examine the current health status of residents in a particular geographical location. Through data gathering and analysis, a CHNA report describes patterns in population health strengths and challenges. It posits priorities for improving overall health and identify available resources to address priorities, as well as gaps in resources.

CHNAs use a variety of secondary and, increasingly, primary research tools to gather quantitative and qualitative data from a variety of community health stakeholders:

Secondary research sources:

• Public community health databases
• U.S. Census Bureau
• Provider-based data through EMR and claims
• Health People community health services profiles

Primary research sources:

• Stakeholder meetings
• Community focus groups
• Surveys
• Interviews with community leaders

Ultimately, a CHNA should inform community decision-making and be part of a two-step process where a community health implementation plan (CHIP) is created based on assessment. The CHIP outlines specific steps, people, timelines, and budgets needed to act on the priorities outlined in the assessment.

When is a community health needs assessment required or strongly recommended?

For some organizations, the CHNA/CHA is a federal requirement or the route to accreditation.

For others, it is the basis for all public health planning or the foundation for data-driven population health strategic planning. There are, primarily, six scenarios where conducting a CHNA is a requirement, a part of voluntary accreditation, or strongly recommended.

ACA/IRS requirement for tax-exempt healthcare facilities

The Patient Protection and Affordable Care Act of 2010 (ACA) requires tax-exempt hospitals to create a hospital community health needs assessment every three years. Under Section 501 of the IRS tax code with penalties up to $50,000 in fines for each year a hospital is non-compliant. A CHNA also fulfills IRS requirements for hospitals under Section 990, regarding community benefit, and health centers under Section 330. Key to claiming tax-exempt status, the community health needs assessment must be transparent, specific, data-driven, and accountable to responding to community needs that they identify.

CDC grants requirements

The Centers for Disease Control and Prevention (CDC) have programs that often require or recommend completing a CHNA/CHA. Grants for public health initiatives or community transformation are examples.

ACO REACH requirements and value-based care contracts

In 2022, the Center for Medicare and Medicaid Innovation (CMS) announced their launch of a redesigned payment model now called Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH). REACH explicitly names promoting equity, and going beyond value, as its primary purpose. The model incorporates many health equity-focused elements that pertain to upfront payments, data collection, provider selection, community governance, as well as delivery and benefit design. It's a novel step toward aligning payment reform with health equity.

While a CHNA/CHA is not required for the ACO REACH program, a health equity plan is required. A CHNA, however, can provide key information to support REACH. This payment model looks specifically at granular evaluation to find gaps in individual health needs that may require allocating resources in tailored ways to achieve the same outcome without disparity. Ensuring that any assessment balances high-level, community analysis with outlining the needs of underserved groups is key.

Other value-based care contracts may require a community health assessment as part of a provider or payer agreement to demonstrate how the VBC arrangement will address a particular population's unique needs.

State-specific requirements for mandates

Some states, like Florida, Illinois, New York, and Washington, require CHNAs as part of funding requests and strategic planning. The Journal of Public Health Management and Practice published a matrix with states that outlines CHA/CHIP requirements by state as of that year.

Public health department accreditation

In 2011, the Public Health Accreditation Board (PHAB) launched a national voluntary accreditation program for state, tribal, local, and territorial health departments. Their accreditation standards and measures for 2022 make health equity a foundation across all 12 domains. In particular, health equity is embedded as part of a comprehensive CHA and CHIP, which is highlighted in their brief document. PHAB requires that these processes be conducted collaboratively and that the documents be dated within the last five years.

National Association of County and City Health Officials

The National Association of County and City Health Officials (NACCHO) offers the Mobilizing for Action through Planning and Partnerships (MAPP) strategic planning process that can be used as part of a CHNA/CHA. This “framework helps communities apply strategic thinking to prioritize public health issues and identify resources to address them." There are six phases to the MAPP process:

• Organize for success and partnership development
• Visioning
• The four assessments
• Identify strategic issues
• Formulate goals and strategies
• Action cycle

How are community health needs assessments changing with the quickening of health equity?

Traditionally, public health departments have focused on how behaviors influence an individual's lifestyle. In recent years, the field has recognized social determinants of health as a key component to health. A shift towards incorporating health equity was born out of a realization of and commitment to reducing and eliminating disparities in health among various groups of people. Some research estimates that health disparities cost the U.S. up to $309B annually in healthcare costs. If these disparities were eliminated, up to 80K early deaths could be prevented each year.

This shift in the public health field has brought more attention and energy to the goal of health equity, a commitment to reduce and ultimately eliminate disparities in health and strive for the highest possible standard of health for all people. Health equity is concerned with creating better opportunities for health and giving special attention to the needs of those at the greatest risk for poor health.

Because health equity factors have such a profound impact on community and public health, it is a natural progression to integrate it as part of community health assessments. A region committed to reducing and eliminating health disparities will recognize it's paramount to assess the disparities as part of the primary tool in public health analysis and strategic planning.

National, states and regional public health policies and processes are integrating health equity

Many U.S. states have a diversity, equity, and inclusion officer or department. Most major U.S. cities do as well. Public health departments have also been leading the way to integrate health equity into fundamental processes and policies.

One such example is the PHAB that, as mentioned earlier, offers a national voluntary accreditation program. In 2020, they adopted a comprehensive plan that prioritizes strategies focused on anti-racism, diversity, equity, and inclusion. In 2022, they didn't simply infuse health equity into some of their measures or 12 domains; they made it the foundation for all their accreditation standards and measures.

Jessica Kronstadt, MPP, PHAB's Vice President of Program, Research & Evaluation, shared, “After the revision of the Essential Public Health Services (EPHS) in 2020, we decided to have 10 domains align more closely with the current EPHS framework. Examples Kronstadt shared include:

• Analyzing data—both quantitative and qualitative—to understand disparities between subpopulations and the factors that contribute to those disparities.
• Broadening partnerships and including those from historically and currently oppressed population groups.
• Tailoring communications to different audiences and striving for cultural humility as part of health education efforts.
• Collaboratively implementing strategies to address factors that contribute to specific populations' higher health risks and poorer health outcomes, or inequities.
• Considering diversity, equity, and inclusion in recruiting and hiring staff and in other internal organizational policies and processes.

Steps to integrate health equity more deeply in any health needs assessment

When asked about how health departments (HD) will embrace or struggle with health equity as the foundation to PHAB's requirements, Ms. Kronstadt shared a perspective that many outside of the public health department will share. "For many, this reflects work they are already doing; for others, these requirements will help give them additional support to do the work they know needs to be done. That being said, there are some HDs that are less sure of how to begin undertaking equity work, in particular, how to engage with communities on what can be difficult conversations."

While the basic structure of a CHNA is standard – gather data, assess data, summarize health issues, prioritize issues, and identify possible resources – integrating health equity requires a mental and practical shift in practice.

Including community residents as stakeholders

According to Austin's Public Health Director, Adrienne Sturrup, “While research and studies are important for our work as a health department, they only get us so far. We need input from our community." Primary research, conducted through personal interactions with community leaders and residents is becoming commonplace. Their work with Austin-Travis County residents included primary research via interviews, focus groups, listening sessions and social media campaigns.

Qualitative and primary data focuses on “the individual" as part of the community

Public health research relies heavily on quantitative and evidence-based, validated sources. Health equity, however, requires not only looking at groups and cohorts, but individuals who have stories, experiences, and opinions of value. No matter the omnichannel tool to approach and engage residents, including qualitative health equity data collection alongside quantitative can provide context and insights to layer on top of other types of measurable data.

Expanding data to include equity-related sources

Collecting community and population data is very useful. When viewed through an equity lens, that data should be stratified by race, ethnicity, age, preferred language, gender, sexual orientation, gender identity, and disability status. Other equity-related information, like a social vulnerability index or hardship index, help analyze patterns in health and identify disparities:

• Education level
• Income level
• Health insurance coverage
• Food security
• Unemployment rate
• Housing status
• Internet access
• Transportation access
• Life expectancy

Using inclusive language and language resources in CHNAs

Any equity-centered activity or engagement with the community starts with understanding others' context and speaking with them with respect and inclusivity, using Person (or People) First Language (PFL). It's a type of linguistic approach that places a person before their diagnosis. For example, any communication outreach would describe the condition a person "has" rather than stating a disease as what a person "is." Saying that a person is a “diabetic" is replace by saying the person “is living with diabetes." It highlights that each person has more in common with each other as people versus separating people by disease, disability, or other label.

In addition to sensitivity to the language used, it's important to make communication available in the preferred language of groups within the population. In the Bay Area of San Francisco, public health materials are often distributed in up to six languages – English, Spanish, Chinese (Cantonese and/or Mandarin), Tagalog, Vietnamese, and Korean.

Tapping into trusted resources

Trust is the prerequisite to conducting an effective community health needs assessment, particularly when engaging community residents and organizations who have a history of mistrust or poor relations. When mapping stakeholders for a CHNA, it's important to partner with organizations that have established and positive relations with underserved or communities that have historically been precluded.

Additionally, being transparent and behaving with cultural humility are important. Many communities who experience disparities have inherent mistrust of institutions they believe overstate the benefit to residents without consistent delivery on those promises. Pledge of commitment without continued action can further erode trust rather than build rapport when the objective is to elicit honest, open sharing.

RTI Health Advance works with healthcare organizations to realize their health equity and population health goals. Through data analytics and community health assessment support, our experts work alongside your teams to uncover health issues, establish priorities, and plan action.

Learn more about RTI Health Advance and connect with us.