community health needs assessment round 2...building leaders – transforming hospitals –...

Building Leaders – Transforming Hospitals – Improving Care


Community Health Needs Assessment

Round 2


45 Years of Delivering Superior Results

Strategy – Solutions – Support


• Turnaround

Strategy

• Financial

•Operations

•Corporate

Compliance

• Board

Development

•Regulatory Compliance and Accreditation Preparation

• Lean Process

Improvement

•CHNA

•Gaffey Revenue Cycle Management

•CrossTX Population Health Platform

•Optimum Productivity

• Execuitve Recruiting

• Interim Executive Placements

•Mid-level and Specialty Placements

Formerly known as Brim

Healthcare we have a

45 year track record of

delivering superior

clinical & operating

results for our clients.

We believe that the combination of People, Process & Technology transforms healthcare & provides the required results

Our Company

Our Executive Team

has experience in

managing hospitals

from multi-billion $

healthcare systems to

community hospitals

Our Team Our Mission

Management Placement Consulting Technology



Opex Categories

%

Revenue Cumulative

Salaries and Wages 41%

Fringe Benefits 10%

Contract Labor 2%

Total Labor Expense 53% 53%

Supply Expense 14% 67%

Purchased Services 9% 76%

Physicians Fees 4% 80%

* Data from HealthTechS3 Comparative Financial Benchmark Database

80% of Hospital Operating Expenses Fall into 4 Categories

Executive Search

Productivity

Management

Software

Benchmarking

Lean Projects

GPO Services

Cost Benchmarking

Lean SC Consulting

GPO Services

PPM Consulting

Physician Comp

Consulting

Increasing Efficiency/Reducing Waste Our Mission



HealthTechS3 is a trusted partner our hospitals. We are fair, honest, professional, and provide ongoing support. Integrity

HealthTechS3 has been around for 45 years and successfully navigated many hospitals through an ever changing healthcare market. Longevity

HealthTechS3 knows how to work with community hospitals and health systems to best leverage their assets and resources to serve their market and maintain independence.

Market

HealthTechS3 is flexible and affordable relative to many large national consulting firms who focus on strategic work and ideas rather than implementation and impact.

Value

HealthTechS3 is an award winning healthcare services company. We are a renowned management company with award winning hospitals, health systems and physician practices with CEOs of long tenure.

Performance

HealthTechS3 only has consultants with deep experience; Consultants are former hospital leaders and executives, clinical resources are best in the

industry. Expertise

Who we are and what drives us?


• HealthTechS3 – currently provides hospital management,

consulting, turnaround, supply chain management, and

professional and physician recruitment services to:

– More than 50 hospitals and health systems

nationwide

– Community hospitals, Critical Access hospitals,

district hospitals, non-profit hospitals

– Most operate physician clinics

– Net Revenue between $20M and $400M

– Business Partner Illinois Critical Access Hospital

Network (ICAHN)

– Preferred vendor with California Critical Access

Hospital Network and Texas Organization of

Rural and Community Hospitals

A Nationwide Client Base Management


January 2015 Becker’s 50 Rural CEOs to Know • Nicole Clapp, Grant Regional Health Center

• John Gallagher, Sunnyside Community Hospital

• Chandler Ralph, Adirondack Health

• Phil Stuart, Tomah Memorial Hospital

April 2015 HealthStrong Top 100 Hospitals (iVantage Health Analytics)

• Barrett Hospital & Healthcare

• Carlinville Area Hospital

• Grant Regional Health Center

• Hammond-Henry Hospital

• Hillsboro Area Hospital

• Tomah Memorial Hospital

May 2015 Becker’s Top Hospitals for Physician Communication (scored 92% or higher) • Spooner Health System – score 94%

• Tri Valley Health System – score 93% • Grant Regional Health Center - score 92%

June 2015 Becker’s 100 Great Community Hospitals • Adirondack Health

• Grant Regional Health Center


June 2015 Top 100 Critical Access Hospitals (iVantage Health Analytics)

• Barrett Hospital & Healthcare

• Hillsboro Area Hospital

• Tomah Memorial Hospital

July 2015 Most Wired Hospitals – Small & Rural (published H&HN magazine)


• Sunnyside Community Hospital

September 2015 Becker’s 50 CAH CEOs to Know • Nicole Clapp, Grant Regional Health Center

• Florence Spyrow, Hammond-Henry Hospital

• Ken Westman, Barrett Memorial Hospital

Client Recognition and Awards Management


Strategy

Growth Strategy Market Positioning

Network Collaboration and Development

Physician Relations and Integration

Turnaround Strategy Financial and Operational

Restructuring

Risk Advisory

Creditor Consultancy

Transaction Advisory Merger Integration

Deal Structuring

Contract Analysis and Negotiations

ACO Transition Analysis

Payment Strategy

Transitions

Financial Modeling

Capital Sourcing

Operations

Financial Budgeting/Financial

Planning

Capital Programs

Supply Chain

Labor Productivity

Managed Care Negotiations

Risk Advisory

Revenue Cycle

Business Office Consolidation

Clinical Documentation and Coding Reviews

Operations Lean Workflow Analysis and

Redesign

Patient Access, Throughput,

Level of Care

Corporate Compliance

Clinical & Quality

Quality Improvement Quality Program Development

Clinical Process Redesign

Care and case Management Process

Benchmarking and Reporting

Regulatory Compliance and Accreditation Preparation

Survey Readiness

Plans of Correction

Public Reporting of Quality and safety Indicators

Evidence Bases care

Population Health Management

Care Coordination

Transitional Care Management

Governance &

Leadership

Board Advisory Education

Retreats

Hospital Governance Management

Licensing Advisory Services

Regulatory Strategy Development

Annual Report Preparation

Expert Led Solutions Consulting


Community Health Needs Assessment Consulting

Phase 1

Strategy and Planning

Phase 2

Research and Analysis of Community

Phase 3

Identification and Prioritization

of Community Health Needs

Phase 4

Multi-Year Implementation

Plan

Phase 5

Annual Review of

Implementation Plan

In consultation with your governing board, steering committee and community partners, HealthTechS3 consultants facilitate development and documentation of your Community Health Needs Assessment –

and we assist with development of a multi-year implementation plan that is actionable and measurable.


Your Solution for Continuous Survey Readiness and Development of Effective Plans of Correction

Critical Access Hospitals PPS Hospitals SNF

Long Term Care

Home Health

Hospice Rural Health Centers

Surveys based on your

accreditation status

CMS Conditions of Participation

State Regulations

The Joint Commission DNV

HFAP

Continuous Survey Readiness Consulting


Finding The Right Leader

Peter Goodspeed leads our Executive Placement Services group.

With over 30 years experience Peter understands the unique

challenges of today’s hospitals. Whether finding a candidate for a

rural hospital or searching for a multi-hospital system, we focus on

your desired qualifications and specific needs. Services include:

Interim

Permanent

Executive Search Process

45 Years of Excellence

• HTS3 has been recruiting Senior

Executives for over 45 Years

• Our extensive understanding of

hospitals & healthcare helps us

find the right candidates for you.

Placement



Technology Solutions that Target Key Areas of Pain

Revenue Attrition / Automation & Efficiency / Closed Loop Learning

Increase in Clean &

Complete Claims

Claims Management

Lack of Collection

Automation

AutoStatus

Poor Workflow &

Task Efficiency

AlphaCollector

Under Payment &

Revenue Integrity

Contract Calculator

Correct Patient

Information

Integrated Eligibility

Integrated Reporting

&

Process Insight

AlphaAnalytics

Revenue Cycle - GAFFEY Technology


The Complete Solution.

The Optimum Productivity Enhancer program

provides you with the tools and support

services necessary to ensure your success in

addressing today’s productivity challenges.

For over 40 years, our experienced

Consulting Staff have been assisting hospitals

in developing sustainable financial

improvement solutions.

Optimize Productivity

Performance.

HealthTechS3 provides your managers,

supervisors and C-suite the

confirmation needed to accurately

calculate workload staffing and

appropriately adjust staffing on a

timely basis.

Productivity– Optimum Technology


The estimated average approximate reimbursement is $42.60* per patient per month, which amounts to over $500 per year that your primary care providers are eligible to be

paid. With an average patient panel size of 3,2791 this can add substantial revenue to

your organization’s bottom line.

Patient Panel Size1 3,279

% of Panel on Medicare1 21.85%

Medicare Patients 716

% of Medicare patients CCM Eligible2 68.6%

Number of CCM Eligible Patients 491

Annual Billing for CCM Patient $511.20

Annual CCM Revenue Potential $250,999

Population Health : CrossTX Technology

Community Connect Platform


Carolyn St. Charles, RN, BSN, MBA

Regional Chief Clinical Officer Carolyn began her healthcare career as a staff nurse in Intensive Care. She has worked in a variety of staff, administrative and consulting roles and has been in her current position as Regional Chief Clinical Officer with HealthTechS3 for the last fifteen years. In her role as Regional Chief Clinical Officer, Carolyn St.Charles is the lead consultant for

development of Community Health Needs Assessments and conducts mock surveys for Critical Access Hospitals, Acute Care Hospitals, Long Term Care, Rural Health Clinics, Home Health and Hospice. Carolyn also provides assistance in developing strategies for continuous survey readiness and developing plans of correction.

Sara Stanton Vice President Marketing and Business Development Sara Stanton is responsible for marketing and business growth for both new and existing clients. She is a business development leader with over 15 years of experience in healthcare strategy, consulting, data analytics, and patient communications. Sara has worked with large provider organizations, community hospitals, regional health systems, national ASCs and specialty providers, and the largest IDN’s in the nation. This experience and exposure has given her a broad understanding of the American healthcare market and the initiatives, challenges, and mandates that hospital executives are facing. Stanton earned a BA in Communication Studies from Baylor University.





Round 2


Instructions

• You may type a question in the text box if you have a question during the presentation

• We will try to cover all of your questions – but if we don’t get to them during the webinar we will follow-up with you by e-mail

• You may also send questions after the webinar to Carolyn St.Charles (contact information is included at the end of the presentation)

• The webinar will be recorded and the recording will be available on the HealthTechS3 web site

www.healthtechs3.com

HealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this information is not intended to be definitive. HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof. HealthTechS3 does not have responsibility for nor does it develop or provide policies intended for direct use by any hospital, clinic or their respective personnel. Any and all responsibility for such and for compliance with state and federal requirements remains exclusively with the hospital, clinic or their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of this information consult original source materials and qualified healthcare regulatory counsel for

specific guidance in adopting and customizing policies for your particular healthcare entity’s use.

http://www.healthtechs3.com/




The Affordable Care Act added 501(r) to the Internal Revenue Code. This provided that hospital organizations will not be treated as tax-exempt under 501(c)(3) unless they meet certain requirements. All of the provisions apply to taxable years beginning after March 23, 2010, except the Community Health Needs Assessment (CHNA).

1. Establish written financial assistance and emergency medical care policies.

2. Limit amounts charged for emergency or other medically necessary care to

individuals eligible for assistance under the hospital's financial assistance policy.

3. Make reasonable efforts to determine whether an individual is eligible for assistance under the hospital’s financial assistance policy before engaging in extraordinary collection actions against the individual.

4. Conduct a community health needs assessment (CHNA) and adopt an implementation strategy at least once every three years. – A $50,000 excise tax will be imposed on a hospital that fails to meet the

CHNA requirements with respect to any taxable year.

Page | 20

http://www.irs.gov/


Final Regulations December 2014

The final rules issued December of 2014 are consistent with earlier guidance issued by the IRS in April of 2013. However, they include the following clarifications:

1. Expands examples of health needs to include preventing illness and addressing the social determinants of health

2. Gives hospitals flexibility if they are unable to obtain required community input

3. Adds requirement to use community input in setting priorities as well as in the assessment process

4. Requires that CHNA documentation must include evaluation of impact of any actions that were taken to address significant health needs since the previous assessment

5. The requirement that implementation strategies include a plan to evaluate planned actions was deleted from the final rule but the strategy still must include anticipated impact of planned actions

Sources:

• “Additional Requirements for Charitable Hospitals; Community Health Needs Assessments for Charitable Hospitals; Requirement of a Section 4959 Excise Tax Return and Time for Filing the Return; Final Rule,” 79 FR 78953 [December 31, 2014], pp. 78953-79016)

• “Community Health Needs Assessments for Charitable Hospitals,”78 FR 20523 [April 2, 2013], pp. 20523-20544

• Catholic Health Association: Assessing & Addressing Community Health Needs 2015 EDITION I I


Who is required to complete a CHNA?

The IRS takes the position that §501(r) applies to all

hospitals exempt under §501(c)(3), whether or not

they may be owned by government or political

subdivisions. Accordingly, the IRS intends to apply the

CHNA requirements to every hospital that is been

recognized as an organization under §501(c)(3).

Critical Access Hospitals are NOT excluded IF they are

a §501(c)(3)

Government or District Hospitals are NOT excluded IF

they are a §501(c)(3)


WHY~


Community Health Needs

Assessment Definitions

“A community health needs assessment is a systematic process involving the community to identify and analyze community health needs and assets in order to prioritize these needs, and to plan and act upon significant unmet community health needs.”

“An implementation strategy is the hospital’s plan for addressing community

health needs, including significant health needs identified in the community health needs assessment. The implementation strategy is also known as the hospital’s overall community benefit plan.”

Source: Catholic Health Association: Assessing & Addressing Community Health Needs 2015 EDITION I I


CHNA Basic Requirements

Conduct a community health needs assessment every three years. The assessment must:

1. Take into account input from persons who represent the broad interests the community served by the hospital facility, including those with special knowledge of or expertise in public health

2. Document the CHNA in a written report that is adopted by an authorized body of the facility

3. Make the CHNA report widely available to the public

4. Adopt an implementation strategy to meet the community health needs identified through the assessment

5. Report how the hospital is addressing the needs identified in the community health needs assessment … and a description of needs that are not being addressed with the reasons why such needs are not being addressed

Page | 25


Catholic Health Association

Guiding Principles

• Health care organizations must demonstrate the value of their community service.

– Government (at all levels), community members, funders and others committed to improving community health want to know that tax-exempt hospitals are aware of the major needs of the community and that their community benefit planning takes into account these needs.

• Community benefit programs must be integrated into the organization’s overall planning.

– The results of the assessment and the community benefit plan should be integrated with the strategic and operational plans of the organization. This will ensure that the organization allocates the necessary resources to carry out these processes effectively.

• Leadership commitment is required for successful community benefit programs.

– As leaders of charitable organizations, hospital board members, chief executive officers and senior managers should view access to health care and improved community health as important concerns of their organizations. Leadership commitment helps ensure that assessment and planning processes are viewed as organizational priorities and the results are used to implement programs that will improve community health.



Catholic Health Association

Guiding Principles

• Those who live in poverty and at the margins of our society have a

moral priority for services. – While assessments will look at the health needs of the overall community, low-income

and other disadvantaged people deserve special attention and priority. Their needs should be a top priority and implementation strategies should include interventions to address these needs.

• Not-for-profit health care has a responsibility to work toward improved

health in the communities they serve. – While assessment and planning are key steps in the overall process to improve

community health, they are not ends in themselves. Assessment results and the implementation strategy must be put into action and these actions should be evaluated and refined, as needed, to ensure that the community and community partners are achieving their ultimate goal – improved community health.

• Health care facilities should actively involve community members,

organizations and agencies in their community benefit programs. – Collaboration among providers and community partners expands the community’s

capacity to address health needs through a shared vision, shared resources and skills, and creates a foundation for coordinated efforts to improve community health.



HealthTechS3


In consultation with your governing board, steering committee

and community partners, HealthTechS3 consultants facilitate

development and documentation of your initial or subsequent

Community Health Needs Assessment.

Our process includes five phases:

Phase 1

Strategy and Planning

Phase 2

Research and Analysis of Community

Phase 3

Identification and Prioritization

of Community Health Needs

Phase 4

Multi-Year Implementation

Plan

Phase 5

Annual Review of

Implementation Plan


Phase 1: Strategy and Planning

Questions Thoughts and Ideas

1. Will the CHNA be for the hospital only –

or – will this be a multi-organization

CHNA?

2. Are there other organizations conducing

or planning to conduct a community

health needs assessment?

Multi-organization CHNAs can be very powerful in both

identifying community health needs and developing

strategies.

3. Who will facilitate the CHNA process?

• Internally developed

• Consultant

If internal, determine if there sufficient expertise and

resources to complete the CHNA and meet the IRS

requirements.

4. Will there be a CHNA steering

committee?

It is very important to identify an individual and/or group to

guide the process. A steering committee that includes

community stakeholders including public health, can help

ensure the CHNA is not hospital-centric.

5. Who will function as staff support to the

process?

Regardless of if you develop the CHNA internally or hire a

consultant, there should be staff identified to assist with the

logistics such as advertising, etc.

6. How will the governing board and senior

leadership be involved? How will you

provide education and regular updates

about the process?

The governing board is vitally important to the process.

They represent the community and can provide important

insights. They also are required to approve the final CHNA.


Phase 1: Strategy and Planning continued


7. What is the impact of any actions that

were taken to address significant health

needs since the previous assessment?

Utilize a multi-disciplinary team, including community

representatives.

Consider including questions about the impact if you conduct a

community survey and/or include a question for key community

stakeholders.

8. What is the service area for the CHNA? The IRS states that hospitals should define community taking into

account, “all of the relevant facts and circumstances”

concerning the service area including geographic area served,

target populations and principal functions”.

Hospitals may not define their communities in a way that

excludes certain populations served by the hospital (for

example medically underserved, low-income or minority

populations). Medically underserved populations include

populations experiencing health disparities or at risk of not

receiving adequate medical care as a result of being uninsured

or underinsured or due to geographic, language, financial or

other barrier.


Phase 1: Strategy and Planning continued


9. Are there specific / targeted

populations to be included in the

CHNA?

Your previous CHNA, secondary data and your patient

population are good sources.

10. What is the timeline for the CHNA

completion?

The CHNA must be approved by the governing board by

the end of the fiscal year in which it is due.

11. What is the budget for the CHNA? When constructing a budget ensure you include:

• Consultant Fees, if applicable

• Staff time

• Advertising to community to solicit input

• Focus Groups

• Editing and Publication


Phase 2: Research and Analysis of the

Community


1. What are the existing healthcare facilities and

resources within the community that are

available to respond to the health needs of

the community?

• Inventory existing healthcare facilities and

services

• Identify demand for services

• Review internal supply with demand

Hospital Social Services is a good source of information as are

community resource guides.

2. What secondary data will be collected and

what are the sources?

• Population demographics by Age/Race

• Socioeconomic characteristics

• Income

• Unemployment

• Poverty

• Uninsured - Underinsured

• Mortality and Morbidity

• Communicable diseases

• Access to healthcare

• Community safety

• Health behaviors

• Maternal and Child Health

• Mental Health

• Chronic Disease

• Other focused populations

Review prior CHNA for sources that were used. Examples:

• Proprietary Data Bases

• American Community Survey (ACS)

• Centers for Disease Control – Behavioral Risk Factor Surveillance

• National Health and Nutrition Examination Survey (NHANES)

• Center for Disease Control – Morbidity and Mortality Report

(MMWR)

• Community Health Status Indicators Report (U.S. Department of

Health and Human Services)

• Healthy People 2020

• Health Indicators Warehouse

• Local, County and State Health Departments

• Hospital information

• Hospital and Emergency Dept.

• Charity Care


IMPORTANT

Access the most current data available! Look carefully at dates of

data!

Comparison: Healthy People 2020

State - 2011 69

County - 2005-2009 76.5

Goal/Target 83.9



3. Who are the individuals with special

knowledge of public health? Who are key

stakeholders?

IRS regulations require

• Input from persons who represent the broad interests

of the community serviced by the hospital, including

those with special knowledge of public health

• At least one state, local, tribal, or regional

governmental public health department with

knowledge, information, or expertise relevant to the

health needs of the community

• Leaders, representatives, or members of medically

underserved, low-income and minority populations &

populations with chronic disease needs

4. How will you gather community input?

• Key informant interviews in person or by

phone

• Focus groups

• Surveys

• Social media

Key informants may include leaders of community

organizations, service providers, healthcare providers,

rural health clinics or federally qualified rural health

clinics, government, school administrators, etc.

Involve individuals who are aware of health needs in your

community.

5. What format will you use for interviews / focus

groups / surveys?

Consider including questions from last CHNA priorities

and/or target specific issues.

• Standardize formats so they are consistent and

address health issues of uninsured persons, low-income

persons, minority groups and those with chronic disease.

Phase 2: Research and Analysis of the

Community continued


IMPORTANT

You are not required to collect reliable, statistically valid and

comparable health data! The best sources for health data are federal

and other public health agencies.

“Hospitals and those working with them on community health

needs assessment should focus their time and resources on

validating and supplementing public health data findings

through interviews and forums with community members and

key informants.”

“Some hospitals may think “conduct a community health needs

assessment” means “conduct a population survey to learn

about the health of the community.” This is not usually

advisable, and in many situations resources will be spent

collecting data that is not statistically valid because the

population sample is not representative or the survey questions

are not validated.”


Source: Florence Reinishch, Healthy Communities Institute


IMPORTANT

Internal data is a vital source of information such as:

• Discharge data by MS-DRG

• Discharge data by payor

• Readmissions by MS-DRG and Payor

• Emergency department visits

• Emergency department “frequent flyers”

• Emergency departments visits by payor

• Prenatal Care

• Low Birth Weight Babies

• Medicaid

• Charity Care


Phase 3: Analyze

Primary and Secondary Data


1. How does your community compare to other

communities / counties / state and the U.S.?

Most secondary data sources have comparative

data.

2. Are the indicators getting better, staying the

same or getting worse?

Review external data as well as your previous CHNA.

3. Is the community meeting external

benchmarks?

Secondary data sources such as Healthy People 2020

have established benchmarks.

4. What are the disparities based on race,

income, age, chronic disease, etc.?

Ensure that you drill down in the data to see if there

are disparities for specific populations.

5. Are there causal factors? Does the secondary data show causal factors that

can be identified? If so, include those factors in the

analysis.


Phase 4: Identify and Prioritize

Community Health Needs


1. Based on the analysis, what are the most significant

health needs?

Develop a list of all of the significant health needs based

on primary and secondary data.

Categorize the health needs by type. Separate health

needs from causal factors if possible.

2. What criteria will be used to establish priority health

needs? Consider:

• Magnitude

• Severity

• Historical Trends

• Ability to impact problem

• Impact on vulnerable populations

• Available resources

• Feasibility

The Hospital may develop their own criteria for establishing

priority health needs.

3. Who will be involved in determining priorities?

How will you include community input in setting

priorities?

The IRS requires community input in setting priorities as well

as in the assessment process.

Include a question about priorities if you conduct a

community survey.

Include community representatives to assist in developing

priorities.


Phase 5: Develop a

Multi-Year Implementation Strategy

The implementation strategy is adopted on the date it is

approved by the governing body

The implementation strategy must be adopted on or before the

15th day of the fifth month after the end of the same taxable year

in which the hospital conducts the CHNA.

The additional time after the end of the fiscal year for

development of the implementation plan was intended to

provide time to collaborate with community partners.

“Collaborating across the community allows the hospital to:

1. Leverage existing assets in the community creating the opportunity for broader impact

2. Avoid unnecessary duplication of programs or services thereby maximizing the use of scarce resource; and

3. Help build the capacity of community members to engage in civic dialog an collaborative problem solving, positioning the community to build upon and sustain health improvement activities.”



Phase 5: Develop a

Multi-Year Implementation Strategy Questions Thoughts and Ideas

1. Who will be involved in developing the

implementation plan?

Consider community partners / key stake-holders

who participated in the CHNA development.

Include other providers of healthcare to avoid

duplication of effort.

2. How will you ensure that the implementation

plan is comprehensive and includes goals –

objectives – accountability – impact of actions?

Develop a template.

3. Who will be responsible for implementing the

strategy?

Consider the same group that developed the

Implementation Strategy with regular meetings and

updates.

4. Who will be responsible for evaluating the

strategy at least annually?

Assign one individual to ensure there is an annual

evaluation.

Note: The requirement that implementation strategies include a plan to evaluate planned actions was deleted

from the final rule but the strategy still must include anticipated impact of planned actions


Make the CHNA

“Widely Available”

• The written CHNA report must be "conspicuously posted" on the

hospital facility's website, or the hospital organization's website

• The definition of "widely available" contains detailed

requirements for website posting and document accessibility,

including the following:

– Hospitals must provide individuals who ask how to access a copy with

the direct website address or URL of the web page on which the CHNA

Report is posted

– Website must clearly inform reader how to download the report

– Download may not require special equipment or fee

– Report must be maintained on the website until two subsequent CHNA

reports are made available

– Paper copies must be available for public inspection without charge



Make it work for you! Find value in the process

– Great marketing opportunity

– Integrate findings in your Strategic Plan

– Increase reimbursement by reducing readmissions, lower LOS, etc.

Improve Population Health – It’s your community too!


It Takes a Community


Questions?


Contact Information

If you would like us to send you a proposal for a

Community Health Needs Assessment,

please contact:

Carolyn St.Charles

Regional Chief Clinical Officer

Email: [email protected]

Phone: 360-584-9868

mailto:[email protected]

© HTS3 2016 | Page 46

Documentation - Self-Assessment 990 Y N Page

1 Description of the community served by the facility (geographic area, populations etc.) X

2 Description of how the community served was determined

3 Description of community demographics X

4 List of existing healthcare facilities and resources within the community that are available

to respond to the health needs of the community

X

5 Description of sources of data and other information used in the CHNA. X

6 Information gaps that impact the faculties ability to assess the community X

7 List of all organizations with which facility collaborated in conducting the CHNA X

8 Identification of any third parties with which facility contracted to assist in conducting

CHNA, including qualifications

9 Description of how the facility took into account input from persons who represent the

broad interests of the community it serves (At least one state, local, tribal or regional

governmental public health department (or equivalent department or agency) with

knowledge, information, or expertise relevant to the health needs of the community

X

10 Description of how the facility took into account input from persons who represent the

broad interests of the community it serves : Members of medically underserved, low-

income, and minority populations in the community, or individuals or organizations serving

or representing the interests of such populations.

X

11 Description and process for taking into account input from persons who represent the

broad interests of the community it serves: Written comments received on the most

recently conducted CHNA and most recently adopted implementation strategy.

X

© HTS3 2016 | Page 47

Documentation - Self-Assessment continued

Y N Page

12 Description of when and how facility conducted with these persons (focus groups,

interviews, surveys

13 If input from an organization, name and title of at least one individual in each organization,

with whom the hospital consulted.

X

14 Description of primary and chronic disease needs and other health issues of uninsured persons, low income

persons and minority groups X

15 Process and criteria used in identifying certain health needs as significant X

16 Process and criteria for prioritizing significant health needs X

17 Prioritized description of ALL of the significant health needs of the community X

18 Description of existing health care facilities and other resources in the community to meet

the needs identified.in the CHNA

X

19 Actions facility intends to take to address each significant health needs X

20 Provide explanation of reason for not addressing significant health needs, including resource

constraints or lack of expertise

X

21 Evaluation of impact and effectiveness of any actions taken in prior CHNA X

22 Implementation strategy approved by governing board

23 CHNA available on web site and/or information on how to download report X

24 Report on website until two subsequent CHNA reports are made available X

25 Paper copies available without charge X

community health needs assessment round 2...building leaders – transforming hospitals –...

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