When it comes to hospitals giving back to their communities, it doesn’t only matter how much hospitals spend, but how they spend it.
That’s why hospitals are required to conduct a Community Health Needs Assessment (CHNA) every three years. These CHNAs have to be created in collaboration with the broader community, with the goal of identifying priority health needs for the hospital to address with their programming. This way, hospital spending on community health programs will target the areas most impactful for improving health.
Sounds like a great system, but unfortunately it doesn’t always go according to plan. Here’s what the research shows about the quality of CHNAs and their impact on community health spending.
Fair Share spending, community investments, and the CHNA
Nonprofit hospitals are given tax exemptions; in exchange, they’re expected to invest back into their communities. However, there is little regulation ensuring they give back enough. In fact, research from the Lown Institute indicates many hospitals are not following through on their end of this social contract, resulting in a $25.7 billion fair share deficit.
Even if hospitals were required to spend more on community investments, we still need them to direct those investments to where they’re needed most. In theory, CHNAs are perfect for this and can inform hospitals exactly where they should be focusing their resources. But in reality, the efficacy of that help is dependent on the both the strength of the CHNA and the commitment to community investments.
CHNA quality varies by hospital
The IRS requires that a hospital facility must complete the following steps when conducting their CHNA:
- Define the community it serves.
- Assess the health needs of that community.
- In assessing the community’s health needs, solicit and take into account input received from persons who represent the broad interests of that community, including those with special knowledge of or expertise in public health.
- Document the CHNA in a written report that is adopted for the hospital facility by an authorized body of the hospital facility.
- Make the CHNA report widely available to the public.
The extent to which hospitals achieve these five goals and involves community groups varies widely. A 2021 review of 500 hospital CHNAs in JAMA found that 42% did not include an evaluation of impact description, and 25% did not describe the resources available to address the health needs they identified. Another study from 2023 found that “more female, White, college-educated, and older” adults were represented in CHNA community feedback and “survey recruitment was not inclusive of individuals who did not have Internet access, could not read, or did not speak English fluently.”
And a series of interviews with community groups found that “many hospitals engaged and involved community stakeholders in certain aspects of the assessment process, but very few engaged a broad array of community stakeholder and community members in meaningful participation” in this process.
When done right, CHNAs can both be used as a tool to direct progress as well as a tool to foster connection.
Fortunately, some states provide additional guidance and requirements to hospitals, specifying types of community groups or government bodies who must be involved in the CHNA process. On the plus side, as hospitals willingly invite community members in for collaboration, they’re also given the opportunity to build trust and rapport between the community and the hospital. When done right, CHNAs can both be used as a tool to direct progress as well as a tool to foster connection.
Weak link between CHNA and community investments
Even when hospitals do a great job in creating their CHNA, there is no guarantee that hospitals will target the health needs they identified in the document. That’s because there are no federal regulations requiring nonprofit hospitals to spend a minimum amount on the health needs identified in the CHNA. The onus is on hospitals to allocate resources as they see fit. This has resulted in a weak link between CHNA findings and community investments, indicating significant missed opportunities to improve community health.
Take this CHNA from Parkview Medical Center in Pueblo, CO. Their CHNA showed that the most important health needs for the community were: 1) access to care, 2) alcohol and other drug use, and 3) information accessibility. Their stated solutions for these problems were to develop a telehealth app and create a series of preventive health videos. These small efforts ring hollow to some Pueblo residents who are facing high rates of medical debt and saw Parkview close their inpatient psychiatric unit. KFF Health News reported that residents are organizing to engage Parkview and other local hospitals on their community benefit spending.
When they’re done right, hospitals meaningfully acting on the findings of their CHNAs can really bring communities together. Rush University Medical Center, for example, published an extensive framework outlining their CHNA process, implementation plan, and results. By focusing on their findings of a racial gap in breast cancer mortality, and subsequently leaning into their community partnerships to address this gap, the medical center and community partners were able “to reduce the Black-to-white breast cancer mortality disparity in Chicago by 20% (from 51% to 41%), an outcome not seen in any other American city studied.”
CHNAs have the potential to identify health needs, guide hospital administrators and clinicians on where to focus their efforts, and foster trust and connection between healthcare workers and community members. If done correctly, they can be an essential tool in building the just and caring healthcare system that we need and deserve.