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Completing an Actionable — and Compliant — Community Health Needs Assessment

By , VP of Planning March 19, 2024 CHNA and Implementation Plans

Since not-for-profit 501(c)(3) hospitals began conducting federally mandated Community Health Needs Assessments (CHNAs), the process has brought to light various health concerns affecting communities across the country, including those in rural areas. Depending on geographic region, demographics and other factors, identified health issues include hindered access to care, high rates of obesity and diabetes, food insecurity, and mental and behavioral health. 

To make sure CHNA reports address community health issues and meet government requirements, not-for-profit hospitals might now consider shining a light on the CHNA process itself to make sure their methodology, documentation and action plan can withstand IRS scrutiny. CHNA plans are subject to be audited. Failure to meet all the requirements could result in a financial penalty of $50,000 per year and potential loss of tax-exempt status.

Not-for-profit hospitals must conduct a CHNA every three years and use the findings to develop and implement an intervention plan. While 2021 research found that 99 percent of 500 randomly selected hospitals completed a CHNA, less than half of them (40 percent) made the results and action plan publicly available online as required by the Affordable Care Act.

Many hospitals’ well-intended but noncompliant CHNAs have issues such as a missing action plan; failure to present their findings to their board or another authorized body; missing community input to identify health needs; or lacking sufficient data or documentation to demonstrate progress from one CHNA reporting period to the next. 

Other types of noncompliance include posting it deep within the hospital website or requiring individuals to fill out an online form to access a hospital’s two most recent CHNA reports. 

Even a bare-bones outline of the IRS requirements for CHNAs gives a sense of the amount of legwork, data crunching and documentation involved. 

Conducting a CHNA 

A compliant CHNA must:

  1. Define the community your organization serves, paying special attention to medically underserved, low-income and minority populations.
  2. Assess the health needs of the community. In doing so, solicit input from people, organizations and agencies who represent the broad interests of that community. CHC conducts one-on-one interviews, collects surveys and convenes focus groups to identify and prioritize health needs. 
  3. Document the CHNA and corresponding implementation plan in a report and submit it for adoption by the authorized body of the hospital. Each document has a deadline for adoption and must be noted in board meeting minutes.
  4. Make the CHNA report widely and readily available to the public, online and as a hard copy available on request. A means of accepting written feedback is also required.

CHNA Documentation

Regulations also define the content CHNA reports must present, including: 

  • A definition of the community served and a description of how the community was determined.
  • The process and methods used to conduct the CHNA.
  • How community input was solicited and taken into account.
  • The significant health needs of the community identified through the CHNA. 
  • A description of resources available to address those health needs.
  • An evaluation of the impact of any actions that were taken to address the health needs identified in the preceding CHNA.

A comprehensive, compliant CHNA report describes the data and other information used in the assessment, as well as the methods of collecting and analyzing this information. The report must also identify any parties with whom the hospital collaborated or contracted for assistance in conducting the CHNA.

CHC’s Approach

In completing CHNAs and implementation plans for healthcare facilities, CHC checks all the boxes. We also provide guidance to hospitals regarding necessary updates to existing reports to come into compliance with federal regulations, as well as various levels of support toward completing CHNA reports.

CHC has helped more than 100 healthcare organizations conduct CHNAs. Some hospital clients come to us to review existing CHNA documents and ensure requirements are met while others bring in CHC to lead the entire process. 

By , VP of Planning March 19, 2024 CHNA and Implementation Plans
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