Hospitals Come Together for Community Health

By Candace Tkachuck

Under the Affordable Care Act (ACA), nonprofit, tax-exempt hospitals are required to conduct a community health needs assessment (CHNA) at least once every three years. They must also show they are providing a community benefit. In King County, Washington, CHNAs have led to increased collaboration between hospitals and public health.

The ACA stimulates hospitals to become involved with community health in new ways. A significant mechanism for this involvement is the community health needs assessment (CHNA) process outlined in section 9007 of the law. Hospitals must conduct these assessments every three years and then demonstrate a strategic response to the needs the assessments identify.

As organizations conduct these assessments, the ACA specifies that hospital staff must consult with individuals who can speak to the “broad interests of the community served by the hospital facility.” The law then goes on to identify those “with special knowledge of or expertise in public health” as suitable partners in the CHNA process.

In Washington State, this has spurred hospitals throughout the state to reach out to local health jurisdictions with collaborations in place in Pierce, Snohomish, and Spokane counties. In King County, hospitals and Public Health - Seattle & King County have formed a collaborative for the CHNA process: King County Hospitals for a Healthier Community. All nonprofit hospitals in King County are part of the collaborative. “Community health needs assessment regulations in the ACA are really clear about collaboration with public health. It’s a lot more robust than just having the health department provide data,” said Anna Markee, Health Reform Project Manager at Public Health - Seattle & King County.

In fact, the collaborative has the potential to improve health on a population level—to make King County healthier. Over time, as the hospitals in the collaborative work on shared goals and track health outcomes, it will be possible to know what differences are being made and how. This result—for a county to know definitively if the health of its citizens is improving—is a compelling destination.

In many contexts, hospital systems are highly competitive with each other. The chance for these same hospitals to be partners is welcomed by those involved in the CHNA process. 

“I remember the first meeting the Washington State Hospital Association organized in 2012 to begin to bring people together about CHNAs. There was real energy in the room,” said Ingrid Ougland Sellie, Community Benefit Manager at Virginia Mason. “The community health assessment is not a competitive space. For us at Virginia Mason, it is rewarding to work with others to focus on where our community needs our help.”

It’s not that hospitals are just now wading into activities that benefit the community. In the past, many hospitals provided non-clinical services designed to help communities. Some hospitals may have even assessed these efforts to see what effect they were having. What is different now is that the CHNA process provides an opportunity for a hospital to collaborate with others in public health and health care so that efforts can be systematic and strategic.

“CHNAs are a different way of approaching what hospitals have typically done. The process may result in new programs, but hospitals will also use the data they have from the CHNA process to rethink the programs they already have,” said Markee.

All the hospitals in the collaborative have completed their first ACA-mandated CHNAs and implementation plans. Although it is possible that this process identified unknown needs in some locations, it is more likely that the assessment validated what hospital staff already knew about their community. “All of the health needs that were identified in our CHNA, we weren’t surprised with,” said Jamilia Sherls, Community Outreach Liaison, MultiCare Health System. “But our implementation plan prompts us to come up with new approaches for addressing these community health issues.” As a result of the CHNA process, Sherls and her colleagues at MultiCare Auburn Medical Center are in the midst of a three-year focus to reduce chronic disease, obesity, tobacco use, depression, and anxiety rates in the Auburn, Washington, area.

Some needs may be identified in the CHNA process that are impractical for hospitals to address, either due to resources or scope. In these cases, it is up to the hospital leadership to decide what they want to take on. “We looked at how we could respond to community needs and considered how these could be addressed based on our current resources and where we believed we could be most impactful,” said Linda Gainer of the Seattle Cancer Care Alliance. “We found that our four focus areas (tobacco cessation, outreach to Hispanic/Latino community, breast cancer screening, colon cancer screening) are also in alignment with our strategic goals.”

“Some of this has been a bit of a judgment call,” said Joe Larson, Community Health Assessment Coordinator at Snoqualmie Valley Hospital in Snoqualmie, Washington. “When you start going upstream with a health issue, you very quickly get beyond the traditional scope of clinical work. My sense of the ACA is that we are asked to paint a picture of health in collaboration with the community and then demonstrate a coherent response.”

Ultimately, the CHNAs are meant for the public. (The law requires that these documents be made publically available.) As it has been a learning curve for the hospitals involved, so also for people in the community. “Right now the biggest response we are getting is, ‘What is this and why is it important?’ said Ougland Sellie. “It feels like our 2013 CHNA was a good launching pad to educate our patients about population health.”

The enhanced connections between hospitals and communities around population health are time intensive, but valuable. “Ninety percent of the work it takes to produce the health assessment and the implementation plan is civic engagement. This way we can genuinely strive together to come up with a collective impact,” said Larson.