Community Health: From Assessment to Action June 5, 2013

The Affordable Care ActNew IRS Requirements for Tax-Exempt Hospitals

Hospitals Required to Comply

All hospitals recognized as a 501(c)(3), including governmental hospitals. Must complete a CHNA and adopt an

implementation strategy, but are not required to file a form 990. Hospitals with this status should make their assessments and implementation strategies widely available.

If more than one hospital is operated by an organization, each hospital is required to complete a CHNA and adopt an implementation strategy.

Timing and Frequency of CHNAs

The CHNA must be conducted once every three years, beginning in the hospital’s first taxable year after March 23, 2012.

To be considered conducted, the written report must also be made widely available to the public. Posted “conspicuously.”*

Conducting and Documenting

Collaboration – New

Hospitals may collaborate to conduct a CHNA if:the collaborating hospitals define their community to be the samethe report clearly identifies that it applies to the hospitalthe governing body of each hospital adopts the joint report

Defining Community – New

Hospitals have flexibility in defining the community they serve. The proposed facts and circumstances approach recognizes variance in defining community (e.g. geographic area, target populations, principal function) Community may be defined by a

particular area of specialty or disease. Medically underserved, low-income or

minority populations may not be excluded.

Identifying Health Needs – New

Hospitals must identify the “significant” health needs of the community rather than “all” needs. Prioritize needs and identify potential

measures, resources and facilities to address them. Hospitals have flexibility for determining what is significant and setting priorities.

Broad Community Input

Two categories of persons must have input taken into account in conducting the assessment. one nonfederal governmental public

health department members of medically underserved, low-

income and minority populations (or organizations representing their interests)

Broad Community Input – New

When subsequent CHNAs are conducted, written input received on a hospital’s existing CHNA or implementation strategy must be taken into account. This requires a hospital’s most recent

CHNA remain widely available until its two subsequent CHNAs are adopted and made widely available.

Implementation

Collaboration

Hospitals that collaborate on a CHNA may collaborate on an implementation strategy but must clearly identify that it: applies to each hospital outlines and identifies each hospital’s

particular role and responsibilities, including programs and resources it will commit

provides a summary or tool to help the reader locate the strategies that relate to each hospital

Addressing Significant Needs

Every significant need identified must include a description of how the hospital will address the need or why it will not be addressed. For needs to be addressed, include: the actions the hospital will take the anticipated impact a plan to evaluate the impact identification of the programs and

resources the hospital will commit

Transition Relief – New

The implementation strategy must be adopted by the hospital’s governing body in the same tax year as the hospital finishes the CHNA. Recognizing that many hospitals will not

be able to meet this initial requirement, the proposed rule adds four and a half months to the original three-year period for adoption of the first implementation strategy.

Noncompliance – NewProposed penalties for non-compliance.Excused noncompliance. Forgives immaterial failures to comply as well as those that were corrected under two circumstances:

if the infraction is minor, inadvertent and due to reasonable cause and the hospital promptly takes remedial steps

if the infraction is more serious, but is neither willful nor egregious and is corrected by the hospital and disclosed to the IRS

Willful and Egregious Noncompliance that may result in revocation of a hospital’s tax-exempt status.

determined after a review of all facts and circumstances including prior infractions, magnitude and reasons for noncompliance, size and functions of the noncompliant facilities, policies and procedures implemented and followed to comply

Noncompliance

Facility-level tax If one organization in a multi-hospital

system egregiously or willfully fails to comply, but does not warrant loss of exemption for the entire organization, a “facility-level tax” would be imposed. The tax would calculated as if the hospital was a taxable corporation and the amount of the income tax it would have owed would be the amount owed.

Final Rule

Comments on the proposed rule due July 5 No firm date on final rule (estimate

October 2013) Rely on proposed rule for guidance until

October 5, 2013.

The Community Health Needs Assessment Process

Steps To Conducting A CHNA

1. Define the community2. Identify internal and external partners3. Collect secondary data4. Develop and conduct primary data collection5. Analyze and prioritize primary and secondary data6. Identify and prioritize community health issues 7. Develop and widely disseminate the CHNA report8. Develop and implement a strategy to address

the priority health issues

CAUTION: Conserve EnergyCommit to Three

Stakeholders/partners Secondary data sources Formats for primary survey At-risk population groups Routes to disseminate findings Priorities to address Strategies for each priority Three indicators per priority Three year plan

Keep in Mind:

The hard work begins with

implementation.

Population-based model for improving health outcomes

CHNA question

s and data

Categories for

analysis and

prioritiesImplementation Plan

Strategies and

process measures

Outcome

measures

Step One: Define the Community

The community definition must include Geographical service area Population served Specialty services provided At-risk populations Unique community characteristics Federal designation for medically

underserved Other hospitals in same “community”

Rationale for PartnershipsMany health care and community organizations benefit from assessmentsMany health care organizations are required or encouraged to conduct assessments

Step Two: Identify Partners

BenefitsCollective wisdomCollective impactEfficiency

Step Three: Collect Secondary Data

Definition: existing data collected for another purpose Data are available from local, state and

national resources Data provide the foundation for the quantitative information Establish a baseline Reveal health issues

Secondary Data Categories

Demographics Health outcomes

Mortality Morbidity

Health factors Health behaviors Clinical care, including access

Social and economic factors Physical environment

Step Four: Primary Data Collection

Primary data: data collected specifically for the purpose of answering project-specific questions.

After review of secondary data, development of a survey tool should be used to Validate secondary information Fill gaps in data not provided by secondary sources Provide more depth and information about a

specific health issue identified through secondary data review

Provide qualitative information

Primary Data Collection (cont’d)

Planning considerations: More resource intensive; requires

development, testing and implementation prior to review of results

Collect exactly what you want and need, keep your questions focused (e.g. chronic disease)

Process can be simplified by using existing questions

Individual versus group response

Community Forums Varied size – can be

large Diverse composition Open invitation Broad-based, open-

ended questions Less formal

Data Collection: Group Responses

Focus Groups Small Homogeneity Invitation-only Specific topic and

focus Requires strong

facilitation

Step Five: Analyze and Prioritize

Begin with dialogue….

The Community’s Focus

Primary research Significant community issues

Non-health related Health related

Current programs Failed programs

Comparison – SAMPLE DATA

HEALTH BEHAVIORS

Data Local Trend

Compare – Peer/ Region

Compare – State

Compare – Nation

Healthy People 2020 Goal

Adult smoking

27 % 28% 24% 20% 12%

Youth smoking

29% na 25.5% 26% 21%

Adult obesity

30% 30% 31.4% 34% 30.6%

Childhood Obesity

na na 14.4% 17.9% 16.1%

Fruits and Vegetables

na 20.6 19.3 24% Volume per calories consumed

HEALTH BEHAVIORS

Available Data

Population Affected

Importance Score

Adult smoking

Youth smoking

Adult obesity

Childhood Obesity

Fruits and Vegetable Consumption - all

Prioritization Matrix

Prioritization Score – Available Data

Is measurable and historical data available? No data “0” Perception/anecdotal “1” Perceptions and counts “2” Perceptions and baseline “3” Perceptions and trend “4”

Source: Adapted from Thruston County Public Health and Social Services. Retrieved from http://www.countyhealthrankings.org/take-action/pick-priorities

Prioritization Score – Size of Issue

What percentage of the population does this health issue affect? Less than 1% “1-2” 1.0 – 9.9% “3-4” 10 – 24.9% “5-7” 25% or greater “8-10”

Note: because the size of the problem is considered more critical that data, this score is multiplied x 2.

Source: Adapted from Thruston County Public Health and Social Services. Retrieved from http://www.countyhealthrankings.org/take-action/pick-priorities

Prioritization Score - Importance What is the seriousness of this issue?

Urgency – high death rate– hospitalization – premature death rate – economic burden – impact on others? Not serious/little impact “1-2” Moderate – illness “3-5” Serious – some death, impact “6-8” Very serious – high death “9-10”

Note: because the size of the problem is considered more critical that data or population affected, this score is multiplied x 3.

Source: Adapted from Thruston County Public Health and Social Services. Retrieved from http://www.countyhealthrankings.org/take-action/pick-priorities

HEALTH BEHAVIORS

Available Data

Population

Affected(x2)

Importance

(x3)

Score

Adult smoking 4 (4)

6 (12)

8 (24)

40

Youth smoking 3 (3)

10 (20)

9 (27)

50

Adult obesity 4 (4)

10 (20)

8 (24)

40

Childhood obesity 3 (3)

6 (12)

9 (27)

42

Fruits and Vegetables - all

3 (3)

10 (20)

5 (15)

37

Prioritization Matrix

Step Six: Review, Reflectand Select

Final Report Format - sample Community description

Demographics Socioeconomic Health resources

Community health strengths and risks Quality of life Behavioral risk factors environment

Health status Social and mental health maternal and child health Death, illness, injury Infectious disease Sentinel events

Step Seven: Disseminate ResultsCollecting Data Demographics Health outcomes

Mortality Morbidity

Health factors Health behaviors Clinical care, including

access

Social and economic factors

Physical environment

Develop and Implement a Strategy

Step Eight

Keep in Mind:

The hard work begins with

implementation.

Collaboration: Art and Science

Every organization may have different reasons for collaboration – that is okay – but you need a common goal

Ensure those with authority for resource allocation support the goals and objectives

Find an inspired champion Time is required to build trust and innovate Measure, evaluate

Sample Ground Rules

Innovation and creativity are encouraged Challenge assumptions Be respectful Be engaged Are you being quiet? Speak Are you talking a lot? Pause Avoid side conversations Keep technology use to a minimum

Determine Your Strategy

Document Your Intent and Progress

Community Health Improvement Implementation PlanHEALTH ISSUE # 1 (very specific):

Contributing FACTORS to Health Issue #1 (including social determinants):

Three Year GOAL for Improvement (written as a SMART objective):

BUDGET for health issue #1 (consider direct and indirect costs):

Strategies to Achieve Goal

Specific Partners and Roles for each

StrategySpecific Actions to Achieve Strategies

Specific 3-year Process Measure(s) for Each

Strategy

Specific 3-year Outcome Measures for Strategies (should align with SMART

Goal for Health Issue)

Strategy #1 ( may

include specific budget allocation for each strategy)

 

Partners and Roles for Strategy #1

*NEW*Action 1 Process Measure for Strategy

#1 Outcome Measure for

Strategy #1

 

*NEW*Action 2 Process Measure for Strategy

#1

Collective Impact

Common agenda Shared measurement

system Mutually reinforcing

activities Continuous

communication Backbone support

organization

Source: Kramer, M. & Kania, J. (2011). Social innovation. Stanford Review. Retrieved from http://www.fsg.org/tabid/191/ArticleId/211

Leslie Porth, MPH, R.N.Vice President of Health

Planning573-893-3700 x 1305

lporth@mail.mhanet.com

Staff Contact

Mary BeckerSenior Vice President of

Strategic Communications

573-893-3700 x 1303mbecker@mail.mhanet.c

om