Variation in Process and Priorities between Local Health Department Led Community Health Assessments/Improvement Plans and Hospital Led Community Health Needs Assessments, and Jointly Conducted Assessments Alexandria Drake, MPH Program Manager, Ohio Research Association for Public Health Improvement Sara Tillie, BA MPH Candidate, Case Western Reserve University Master of Public Health Program Scott Frank, MD, MS Director, Case Western Reserve University Master of Public Health Program Director, Shaker Heights Health Department 2015 PHSSR Keeneland Conference

No financial disclosures Acknowledgements  Robert Wood Johnson Foundation Public Health Practice Based Research Network Quick Strike  Health Policy Institute of Ohio (HPIO)

Purpose To compare and contrast the community health assessment process and health priorities identified by LHD led Community Health Assessments (CHA) or Community Health Improvement Plans (CHIP); and by hospital led Community Health Needs Assessment (CHNA) and Community Health Needs Improvement Strategy (CHNIS)

Objectives 1.Identify the variation in process between LHD led CHA/ CHIP and hospital led CHNA/ CHNIS 2.Identify the variation in priorities between LHD led CHA/ CHIP and hospital led CHNA/ CHNIS

Importance LHD Led CHA/CHIP Documents Recent state and national movement to require LHD accreditation Significant efforts are underway to enhance the quality and consistency of CHA/CHIP documents Hospital Led CHNA/ CHNIS Documents Under the Affordable Care Act IRS code section 501(r)(3), most nonprofit 501 (c)(3) hospitals are required to complete a CHNA/CHNIS document General Little has been done to examine variations in priorities of these documents and how community characteristics may influence these differences

Importance LHD Led CHA/CHIP Documents Recent state and national movement to require LHD accreditation Significant efforts are underway to enhance the quality and consistency of CHA/CHIP documents Hospital Led CHNA/ CHNIS Documents Under the Affordable Care Act IRS code section 501(r)(3), most nonprofit 501 (c)(3) hospitals are required to complete a CHNA/CHNIS document General Little has been done to examine variations in priorities of these documents and how community characteristics may influence these differences

Importance LHD Led CHA/CHIP Documents Recent state and national movement to require LHD accreditation Significant efforts are underway to enhance the quality and consistency of CHA/CHIP documents Hospital Led CHNA/ CHNIS Documents Under the Affordable Care Act IRS code section 501(r)(3), most nonprofit 501 (c)(3) hospitals are required to complete a CHNA/CHNIS document General Little has been done to examine variations in priorities of these documents and how community characteristics may influence these differences

Importance LHD Led CHA/CHIP Documents Recent state and national movement to require LHD accreditation Significant efforts are underway to enhance the quality and consistency of CHA/CHIP documents Hospital Led CHNA/ CHNIS Documents Under the Affordable Care Act IRS code section 501(r)(3), most nonprofit 501 (c)(3) hospitals are required to complete a CHNA/CHNIS document General Little has been done to examine variations in priorities of these documents and how community characteristics may influence these differences

Methods Comparative case study  Data abstracted from publicly available CHA/CHIP and CHNA/CHNIS documents  Ohio LHDs (n=110/124)  Ohio hospital systems (n=170/189)

Methods Adaptation of Wisconsin CHIPP (Community Health Improvement Plan and Process) Quality Measurement Tool Allow direct comparison between LHD and Hospital process  General  Working together  Assessment  Prioritization  Implementation  Evaluation

Methods Further adaptation to examine detailed priorities (35 items in 4 categories)  Medical conditions (11 items)  Health behaviors (9 items)  Community conditions affecting health (5 items)  Health systems factors (10 items)

Methods Data abstraction logged in REDCap and exported to SPSS V22.0 Analysis includes frequencies, Chi Square, and t-tests

LHD-Hospital Comparison of Process Quality Measurement Tool Section LHD Mean Hospital Mean General Working Together Assessment Prioritization Implementation Total Quality Measurement Tool

LHD Led CHA CHIP Significantly Higher than Hospital Led CHNA CHNIS (≤.05) General  The CHIP/CHNIS document(s) are electronically available to the public via a website.  The document acknowledges state priorities.  A formal model is used to guide the process.  Specific staff are designated to manage the process. Working Together  Sectors (stakeholders) participate in partnership to develop a comprehensive assessment (>4 sectors).  The stakeholders define a purpose, mission, vision, and/or core values.  Documentation of current collaborations that address specific public health issues or populations. Assessment  There is evidence of primary data collection.  Trends in local data are reported.

LHD Led CHA CHIP Significantly Higher than Hospital Led CHNA CHNIS (≤.05) General  The CHIP/CHNIS document(s) are electronically available to the public via a website.  The document acknowledges state priorities.  A formal model is used to guide the process.  Specific staff are designated to manage the process. Working Together  Sectors (stakeholders) participate in partnership to develop a comprehensive assessment (>4 sectors).  The stakeholders define a purpose, mission, vision, and/or core values.  Documentation of current collaborations that address specific public health issues or populations. Assessment  There is evidence of primary data collection.  Trends in local data are reported.

LHD Led CHA CHIP Significantly Higher than Hospital Led CHNA CHNIS (≤.05) General  The CHIP/CHNIS document(s) are electronically available to the public via a website.  The document acknowledges state priorities.  A formal model is used to guide the process.  Specific staff are designated to manage the process. Working Together  Sectors (stakeholders) participate in partnership to develop a comprehensive assessment (>4 sectors).  The stakeholders define a purpose, mission, vision, and/or core values.  Documentation of current collaborations that address specific public health issues or populations. Assessment  There is evidence of primary data collection.  Trends in local data are reported.

LHD Led CHA CHIP Significantly Higher than Hospital Led CHNA CHNIS (≤.05) General  The CHIP/CHNIS document(s) are electronically available to the public via a website.  The document acknowledges state priorities.  A formal model is used to guide the process.  Specific staff are designated to manage the process. Working Together  Sectors (stakeholders) participate in partnership to develop a comprehensive assessment of the population served by the health department (>4 sectors).  The stakeholders define a purpose, mission, vision, and/or core values for the process.  Documentation of current collaborations that address specific public health issues or populations. Assessment  There is evidence of primary data collection.  Trends in local data are reported.

LHD Led CHA CHIP Significantly Higher than Hospital Led CHNA CHNIS (≤.05) Implement  Data is used to inform public health policy, processes, programs, and/or interventions.  Identifies improvement strategies that are evidence-informed.  Contains measurable objectives with time-framed targets.  Activities that contribute to the development or modification of (public) health policy.  Detailed action plan exists or is under construction.  Identifies individuals and organizations that have accepted responsibility for implementing strategies.  Includes priorities and action plans for entities beyond just the local health department/hospital.  Seek resources to support implementation of the identified strategies.

LHD Led CHA CHIP Significantly Higher than Hospital Led CHNA CHNIS (≤.05) Implement  Data is used to inform public health policy, processes, programs, and/or interventions.  Identifies improvement strategies that are evidence-informed.  Contains measurable objectives with time-framed targets.  Activities that contribute to the development or modification of (public) health policy.  Detailed action plan exists or is under construction.  Identifies individuals and organizations that have accepted responsibility for implementing strategies.  Includes priorities and action plans for entities beyond just the local health department/hospital.  Seek resources to support implementation of the identified strategies.

LHD Led CHA CHIP Significantly Higher than Hospital Led CHNA CHNIS (≤.05) Implement  Data is used to inform public health policy, processes, programs, and/or interventions.  Identifies improvement strategies that are evidence-informed.  Contains measurable objectives with time-framed targets.  Activities that contribute to the development or modification of (public) health policy.  Detailed action plan exists or is under construction.  Identifies individuals and organizations that have accepted responsibility for implementing strategies.  Includes priorities and action plans for entities beyond just the local health department/hospital.  Seek resources to support implementation of the identified strategies.

Hospital Led CHNA CHNIS Significantly Higher than LHD Led CHA CHIP (≤.05) General  The CHA/CHNA document(s) are electronically available to the public via a website.  The document acknowledges national priorities. Assessment  Health issues and specific descriptions of population groups with specific health issues are described.  Health issues and specific descriptions of medically vulnerable population groups with specific health issues are described.  Health disparities and/or health equity are discussed.  A description of existing community assets and resources to address health issues is presented.  Sources of data are cited.

Hospital Led CHNA CHNIS Significantly Higher than LHD Led CHA CHIP (≤.05) General  The CHA/CHNA document(s) are electronically available to the public via a website.  The document acknowledges national priorities. Assessment  Health issues and specific descriptions of population groups with specific health issues are described.  Health issues and specific descriptions of medically vulnerable population groups with specific health issues are described.  Health disparities and/or health equity are discussed.  A description of existing community assets and resources to address health issues is presented.  Sources of data are cited.

Hospital Led CHNA CHNIS Significantly Higher than LHD Led CHA CHIP (≤.05) Prioritization  Information from the community health assessment is provided to the stakeholders who are setting priorities.  Document(s) include issues and themes identified by stakeholders in the community.  Community health priorities were selected using criteria established and agreed upon by the stakeholder group.  Priorities are easily located on a website and identifiable as priorities by the general public.

Hospital Led CHNA CHNIS Significantly Higher than LHD Led CHA CHIP (≤.05) Prioritization  Information from the community health assessment is provided to the stakeholders who are setting priorities.  Document(s) include issues and themes identified by stakeholders in the community.  Community health priorities were selected using criteria established and agreed upon by the stakeholder group.  Priorities are easily located on a website and identifiable as priorities by the general public.

Hospital Led CHNA CHNIS Significantly Higher than LHD Led CHA CHIP (≤.05) Implement  Documentation of implemented health promotion strategies.  Documentation that health promotion strategies are communicated to the public in your community.

Top Priorities LHD CHA/ CHIPHospital CHNA/CHNIS 1. Physical Activity (69.6%)1. Obesity (68.8%) 2. Obesity (69.1%)2. Access to Medical Care (58.8%) 3. Nutrition (63.8%)3. Mental Health (58.2%) 4. Substance Abuse Prevention (56.5%)4. Addiction (54.7%) 5. Access to Medical Care (55.1%)5. Heart Disease (52.4%) 6. Food Environment (49.3%)6. Diabetes (50.0%) 7. Addiction (49.3%)7. Cancer (47.1%) 8. Youth Development/ Schools (46.4%)8. Infant Mortality (42.4%) 9. Access to Behavioral Health (44.9%)9. Physical Activity (38.8%) 10. Mental Health (43.5%)10. Nutrition (37.1%)

Top Priorities LHD CHA/ CHIPHospital CHNA/CHNIS 1. Physical Activity (69.6%)1. Obesity (68.8%) 2. Obesity (69.1%)2. Access to Medical Care (58.8%) 3. Nutrition (63.8%)3. Mental Health (58.2%) 4. Substance Abuse Prevention (56.5%)4. Addiction (54.7%) 5. Access to Medical Care (55.1%)5. Heart Disease (52.4%) 6. Food Environment (49.3%)6. Diabetes (50.0%) 7. Addiction (49.3%)7. Cancer (47.1%) 8. Youth Development/ Schools (46.4%)8. Infant Mortality (42.4%) 9. Access to Behavioral Health (44.9%)9. Physical Activity (38.8%) 10. Mental Health (43.5%)10. Nutrition (37.1%)

Top Priorities Combined Priorities (Weighted) 1. Obesity (69.0%) 2. Access to Medical Care (57.0%) 3. Physical Activity (54.2%) 4. Addiction (52.0%) 5. Mental Health (50.9%) 6. Nutrition (50.5%) 7. Substance Abuse Prevention (40.3%) 8. Access to Behavioral Health (36.6%) 9. Diabetes (34.4%) 10. Heart Disease (34.2%)

Comparison of LHD and Hospital Priority Category Emphasis HospitalLocal Health Department CategoryMean% SelectedMean% Selected Medical Conditions % % Health Behaviors % % Community Conditions % % Health Systems % %

Key Process Findings LHD process more likely to:  Be grounded in theoretical and evidence based frameworks  Define a mission or vision  Include implementation planning  Have broad stakeholder participation  Conduct health policy activity

Key Process Findings Hospitals were more likely to:  Address community assets  Address health equity and vulnerable populations  Choose health priorities using criteria  Provide community health assessment information to the stakeholders who are setting priorities

Key Priority Findings Hospital based CHNA/ CHNIS priorities focused more on  Diagnostic conditions  Health system characteristics LHD based CHA/ CHIP priorities focused more on  Behavioral health  Community characteristics

Strengths Large, whole sample (n=110 and n=170) Comprehensive approach crossing health systems boundaries Mixed methods Utilized standard abstraction protocols from adaptation of a previously successful model

Limitations Based on information available in documents, not necessarily what was actually done Some items were not effective across LHD- Hospital boundaries and were therefore excluded Analysis based on current stage of assessment, therefore not final products

Implications for Public Health The variation between CHA/CHIP and CHNA/CHNIS identified priorities demonstrates important differences in perspective and experience. The differences appear complementary, implying the population needs would be more effectively served through a collaborative process.

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