Community Health Needs Assessment Toolkit Part I: Overview, Pre-Assessment, & Data Collection

Community Health Needs Assessment Toolkit Part I: Overview, Pre-Assessment, & Data Collection Kaiser Permanente National Community Benefit

Copyright 2015 Kaiser Foundation Hospitals This toolkit was developed by Kaiser Permanente, for use by Kaiser Foundation Hospitals for conducting their 2016 Community Health Needs Assessment (CHNA). Kaiser Permanente Community Benefit is the owner of the content within and must be acknowledged as such. The content may not be modified or used in other formats without prior permission from Kaiser Permanente Community Benefit. This toolkit may not be sold for revenue generation by those who have been granted permission to use or adapt it. For ques ons, please contact: Bri any Giles, MPH Na onal Community Benefit Kaiser Permanente Bri any. N. Giles@kp.org (510) 271 4685

Table of Contents Part I: Overview, Pre-Assessment, & Data Collection I. Introduction and Purpose Introduction... 4 Overview of Federal CHNA Requirement... 5 Changes to CHNA Requirements Since Last CHNA... 6 CHNA and Implementation Strategy Timeline: 2015-2017... 7 CHNA Pre-Assessment and Data Collection Checklist... 8 II. CHNA Pre-Assessment Definition of Community Served... 9 Working with Consultants... 10 Collaboration... 10 Tips and Considerations... 11 III. KP CHNA Process Map... 12 IV. Secondary Data Guidelines KP CHNA Common Indicators... 15 Common Indicator Categories... 16 Key Drivers... 17 Benchmarking... 18 Additional Secondary Data... 18 V. CHNA Data Platform... 19 Potential Health Need Categories... 20 VI. Primary Data Guidelines Primary Data Collection Overview... 21 Primary Data Collection Methods... 23 Primary Data Analysis... 25 Primary Data Collection Tracking... 26 VII. Other Data Considerations Community Assets......27 Data Limitations/Information Gaps......28 GLOSSARY... i APPENDICES A: KFH CHNA Report Review Checklist v B: Consultant Request for Proposals (RFP) Template... xvi C: KP CHNA Common Indicators... xxiii D: Healthy People 2020 Benchmarks... xxix E. Primary Data Tracking Form... xxxi

CHNA Toolkit Part I Introduction and Purpose I. INTRODUCTION AND PURPOSE Introduction Kaiser Permanente is committed to helping shape the future of health care. Founded in 1945, our mission is to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. Community Benefit is a central part of our mission. We understand that good health extends beyond the doctor s office and the hospital. To be healthy, people need access to healthy and nutritious foods in their neighborhood stores, clean air, successful schools, and safe parks and playgrounds. Good health for the entire community also requires a focus on equity as well as social and economic well-being. We ve committed our resources to help the most vulnerable people in our communities achieve good health. Community Health Needs Assessments (CHNAs) have been conducted by Kaiser Permanente Community Benefit for many years to understand the needs and resources within our communities and to guide our investment strategy. Our needs assessments have been conducted mostly at the facility level and frequently in partnership with local hospital collaboratives. Several environmental factors are driving the need to review our practices such as health reform, compliance, strategic planning, transparency and accountability, and emerging technologies. The recent passage of the health care reform law (the Patient Protection and Affordable Care Act), includes a provision for non-profit hospitals to conduct CHNAs and encourages us to consider more efficiency and rigor in our needs assessments and strategic planning. This toolkit was developed by Kaiser Permanente Community Benefit staff to support the implementation of CHNAs and to ensure compliance with the Federal CHNA requirements and guidelines. 4

Overview of Federal CHNA Requirement Enacted on March 23, 2010, the Patient Protection and Affordable Care Act (ACA) requires all nonprofit hospitals to comply with new regulations under section 501(r) of the Internal Revenue Code (the Code) in order to maintain their tax exempt status. Included in the new regulations is a requirement that all nonprofit hospitals must conduct a community health needs assessment (CHNA) and develop an implementation strategy (IS) every three years. On December 29, 2014 the Internal Revenue Service (IRS) issued final language that directs nonprofit hospitals on how to comply with the CHNA requirement (http://www.gpo.gov/fdsys/pkg/fr- 2014-12-31/pdf/2014-30525.pdf). CHNA Toolkit Part I Introduction and Purpose In this section: Overview of Federal CHNA Requirement Changes to Requirements Since Last CHNA CHNA and Implementation Strategy Timeline: 2015-2017 CHNA Pre-Assessment and Data Collections Checklist To conduct a CHNA the IRS requires non-profit hospitals to: Conduct a needs assessment at least once every three years Define the community it serves. 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 Identify and prioritize community health needs Document the CHNA in a written report that is adopted by an authorized body of the hospital facility. Make the CHNA report widely available to the public. Adopt an Implementation Strategy to address identified health needs Submit the Implementation Strategy with the annual Form 990 Pay a $50,000 excise tax for failure to meet CHNA requirements for any taxable year Appendix A includes a CHNA Report checklist that outlines the final CHNA requirements set forth by the IRS. Kaiser Foundation Hospital facilities and/or their consultants must complete the checklist to ensure that all CHNA requirements are met. KEY TERMS Community Health Needs Assessment A systematic process involving the community to identify and analyze community health needs and assets. Implementation Strategy The non-profit hospital s plan for addressing the health needs identified through the community health needs assessment (CHNA). Health Needs Issues and conditions that are disproportionately impacting the health of a particular population. They are identified through interpretation and analysis of secondary data as well as primary data. 5

CHNA Toolkit Part I Introduction and Purpose Changes to CHNA Requirements Since Last CHNA Since final language for the CHNA requirements was not issued until December 2014, hospitals were operating under proposed draft language for the last CHNA cycle. With only a few exceptions, the final regulations confirmed the original language proposed in the draft regulations. The table below describes the more significant changes made in the final regulations. For the purposes of this toolkit, and hereinafter, ACA and IRS requirements and regulations will be collectivity referred to as Federal CHNA Guidelines. Final Regulation Topic Defining health need Description The final regulations expand the definition of "health needs" to include what we would consider Social Determinants of Health and Prevention, e.g. (i) preventing illness, (ii) ensuring adequate nutrition; and (iii) addressing social, behavioral and environmental factors that influence health Community input The final regulations require a hospital facility to take into account community input not only in identifying significant health needs but also in prioritizing them and identifying resources available to meet the identified needs. Timing The final regulations allow hospital facilities an additional four and a half (4 1/2) months beyond the end of their fiscal year to have their Implementation Strategies adopted by an authorized body, allowing more time for the development of a thoughtful IS. Impact The final regulations add language requiring the CHNA report to include an evaluation of the impact of actions taken by the hospital to address the significant health needs identified in the hospital's previous CHNA/IS. 6

CHNA Toolkit Part I Introduction and Purpose National CB Role CHNA and Implementation Strategy Timeline: 2015-2017 The following timeline illustrates the current understanding of key milestones, dates, and National and Regional roles for KP s CHNA and IS process*. CHNA Pre-Assessment 2015 2016 2017 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Implement updates to KP CHNA platform (ongoing) Provide consultant RFP and contract templates (March) Update and release CHNA toolkits (April) Launch updated CHNA platform Secondary data analysis trainings (June) Data Collection & Analysis Provide updated CHNA Report template Develop approach to documenting evaluation of impact for CHNA Report Identify & Prioritize Needs Provide TA to Regions in drafting CHNA Reports Codify KP CHNA Community Engagement Guidance CHNA Report Writing National and California CB to review draft CHNA Reports for compliance and provide feedback (January/ February) Secure Board of Directors approval of CHNA Reports Update and release IS toolkits IS Development *Timeline subject to change Bold Text = CHNA/IS Reporting Deadline Finalize IS Report template IS Report Writing Post CHNA Reports to KP website Approve & Post IS Secure Board of Directors Approval of IS Reports Post IS Reports to KP website Regional CB Role Roles Engage and contract with consultants Share toolkits with consultants and stakeholders Conduct secondary data reports using KP CHNA platform Collect and analyze primary data Synthesize data findings and develop list of health needs Prioritize health needs Document evaluation of impact for CHNA Report Write draft CHNA Report (January) Finalize CHNA Report (March) Complete CHNA Report checklist Select health needs to address Research evidencebased practices to address health needs Identify opportunities for collective impact (optional) Develop Implementatio n Strategies to inform IS Report Write and Finalize IS Report Implement Community Engagement Guidance 7

CHNA Toolkit Part I Introduction and Purpose CHNA Pre-Assessment and Data Collection Checklist This checklist includes required information from the pre-assessment and data collection phase of CHNA. Documenting this information as you go will make it easier to populate the CHNA report at the end. For a complete checklist of CHNA requirements see Appendix A. Helpful Components for Completing CHNA Requirements: Community served (see page 9 of this toolkit) How the community was determined Description Map of service area Identity and qualifications of any consultant(s) used (see page 10 of this toolkit) Collaboration (see pages 11-12 of this toolkit) Description of collaborative (including list of all organizations and hospitals involved) Scope of work with the collaborative Data collection (see pages 15-26 of this toolkit) Sources and dates of secondary data used Analytical methods used for secondary data, for primary data, and for combined analysis Demonstrated input from public health professionals and representatives from the community (Appendix E) Description of assets and resources available to meet each community health need (see page 27 of this toolkit) Description of information gaps that impact the ability to assess health needs (see page 28 of this toolkit) 8

CHNA Toolkit Part I Introduction and Purpose II. CHNA PRE-ASSESSMENT Before beginning data collection and analysis, there are steps to consider in order to prepare for the community health needs assessment. The Federal CHNA Guidelines require non-profit hospitals to identify: The community served Definition of the community served Description of how the community was determined Any consultant used to assist with the CHNA Any organizations with whom the hospital collaborated on the CHNA Definition of Community Served Kaiser Permanente (KP) has determined each of the Region s hospital service areas by assigning zip codes based on primary care crossover and hospital affiliation of physicians. Standard language describing Kaiser Permanente s approach to defining hospital communities served will be included in the KP CHNA Report template. In addition to the standard language, each individual hospital will be required to list the major cities and towns included in that hospital service area as well as a map. Multiple hospital buildings that operate under a single state license are considered a single hospital facility for CHNA purposes, and the community served by the hospital facility is the aggregate of the hospital buildings areas or populations. If a CHNA report is developed for each hospital building that operates under a shared license, the reports must be combined into a single report to comply with the Federal CHNA Guidelines. In this section: Definition of Community Served Working with Consultants Collaboration Tips and considerations KEY TERMS Community Served According to the IRS regulations, when defining the community it serves, a hospital facility may take into account all of the relevant facts and circumstances, including the geographic area served by the hospital facility, target population(s) served (e.g., children), and principal functions (e.g., focus on cancer). However, a hospital facility may not define its community to exclude medically underserved, low income, or minority populations who live in the geographic areas from which the hospital facility draws its patients (unless such populations are not part of the hospital facility s target patient population(s) or affected by its principal functions) or otherwise should be included based on the method the hospital facility uses to define its community. In addition, a hospital facility must take into account all patients without regard to whether (or how much) they or their insurers pay for the care received or whether they are eligible for assistance under the hospital facility s financial assistance policy. 9

CHNA Toolkit Part I Introduction Pre-Assessment and Purpose Working with Consultants Many areas will find it useful to engage a consultant to help with some or all of the CHNA process. Each Community Benefit Manager and/or collaborative should decide the appropriate scope of work for a consultant for their area. Appendix B includes an RFP template that describes the elements required by Kaiser Permanente for successful implementation of a CHNA. Kaiser Foundation Hospital facilities may customize and use the RFP to recruit a consultant for the CHNA and, if needed, may add additional requirements based on the local context and circumstances. Collaboration Community Health Needs Assessments need to reflect the perspective of various stakeholders that are knowledgeable about the health needs in the community. Specifically, the IRS requires non-profit hospitals to report on input representing the broad interests of the community and identify all organizations with which the facility collaborated in preparing the CHNA. A collaborative can be defined as a group of organizations and/or individuals working together toward a shared purpose or goal with joint ownership of the work, risks, results, and rewards. Potential areas for collaboration on a CHNA include: Using a shared data platform as a robust source of secondary data Collection of comprehensive primary data to support interpretation of secondary data Identifying a single agreed upon list of prioritized health needs for the community Coordinating implementation strategies to maximize impact on a specific health need Coordinating coverage across prioritized health needs as rationale for an individual hospital not addressing all needs Why collaborate? While not specifically required by Federal CHNA guidelines, there are many advantages to working with a collaborative in order to meet the CHNA requirements, including: Sharing of expertise and resources Increased assessment quality Shared costs across all partners Shared accountability for outcomes Improved relationships among hospitals, local health departments, and members of the community 10

Introduction and Purpose CHNA Toolkit Part I Pre-Assessment Tips and Considerations The following considerations and information can assist with communication with collaborative partners about the CHNA: 11

CHNA Toolkit Part I Introduction Pre-Assessment Process Map and Purpose III. KP CHNA PROCESS MAP The KP CHNA Process Map represents Kaiser Permanente s agreed upon approach for implementing a Community Health Needs Assessment. The Process Map describes how all of the components of the CHNA process come together from data collection and analysis to identification of prioritized needs to the development, implementation and evaluation of an implementation strategy. 12

CHNA Toolkit Part I Introduction Pre-Assessment Process Map and Purpose KP CHNA Process Map: Steps 1. DATA COLLECTION Utilize KP s CHNA Data Platform Review Kaiser Permanente s common indicators to analyze the following: community demographics geographic areas of highest need using key drivers of health data health issues of residents and any disparities possible causes of health issues Compare KP s common indicators against benchmarks to identify a community s most critical health needs. Generate data analysis for community input. Link to Community Commons for additional data. Identify Supporting Data Supplement data analysis with additional primary and secondary data, including key informant interviews, focus groups, and/or surveys. Ask local public health professionals, community leaders, and residents to identify and prioritize the most pressing issues impacting the health of the community. Solicit their reaction to data analysis. Inventory community assets and resources. Consider any evaluation results available for strategies implemented since the last CHNA. 2. IDENTIFICATION & PRIORITIZATION OF HEALTH NEEDS Identify and Prioritize Using an agreed upon set of criteria, identify the health needs based on an analysis of the data and other community input. Prioritize the identified community health needs based on a second set of agreed upon criteria. Create CHNA Report Document the CHNA Include a description of: the collaborative (if applicable) and any consultants used secondary data sources and community input received methodology for identification and prioritization of community health needs the prioritized list of community health needs resources available to meet the health needs an evaluation of impact of strategies implemented since the previous CHNA Secure Board of Directors approval and post the CHNA Report on the hospital organization s website 13

KP CHNA Process Map: Steps (cont.) CHNA Toolkit Part I Introduction Pre-Assessment Process Map and Purpose 3. IMPLEMENTATION STRATEGY DEVELOPMENT Choose Needs to Address Determine which needs each KFH hospital will address in their implementation strategy by applying a third set of criteria to the prioritized health needs identified in the CHNA report. For health needs not being addressed at the current time, note the rationale for why they won t be addressed by the hospital. Develop Implementation Strategy Develop an implementation strategy for each health need selected by the hospital. Choose implementation strategies that build on evidence-based strategies, Kaiser Permanente assets and resources, and existing partnerships, whenever possible. Plan For Measuring Impact Identify anticipated outcomes for each implementation strategy. Finalize the Implementation Strategy Report Secure Board of Director s approval and post the IS Report on the organization s website. File the finalized, full implementation strategy with the Internal Revenue Service using Form 990 Schedule H. 4. IMPLEMENTATION, MONITORING & EVALUATION Implement, track and evaluate strategies Implement planned strategies and design a plan to track and evaluate each strategy Track progress and impact of implementation Document metrics and results for communication, reporting, and future planning purposes 14

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Map Data and Guidelines Purpose IV. SECONDARY DATA GUIDELINES Data collection, review, and interpretation are the foundation of the CHNA process. Each community health needs assessment needs to include a review of both secondary data as well as primary data that captures input from specific individuals. The Federal CHNA Guidelines require non-profit hospitals to: In this section: KP CHNA Common Indicators Common Indicator Categories Key Driver Indicators Benchmarking Additional Secondary Data Describe data collection Sources of secondary data used Methods used to analyze the data KEY TERMS KP CHNA Common Indicators In order to ensure a minimum level of consistency across the organization, Kaiser Permanente has identified a list of data indicators to be used by all Kaiser Permanente Regions for their Community Health Needs Assessment (Appendix C). The KP CHNA indicators list includes over 150 nationally available indicators that together help us understand the health of a community. In addition to the nationally available data, California (CA) data sources were identified for a handful of indicators. These CA sources were included because, compared to the national source, they either allowed for more granular data, they provided more recent data or the indicator was determined to be important but was not available through a national data source. The hospital region or service area selected in the CHNA Data Platform will determine whether the CA sources will be displayed in the report or not. The purpose of the common indicators is to provide both breadth and depth across multiple health needs, allowing hospitals to examine a comprehensive list of potential health needs in the community. This list includes data on both health outcomes as well as the social, environmental, and behavioral drivers of health. Primary Data New data that is collected or observed directly from first-hand experience. (Ex: Focus groups, key informant interviews, health surveys) Secondary Data Data that has already been collected and published by another party. (Ex: California Health Interview Survey (CHIS), Behavioral Risk Factor Surveillance System (BRFSS)) Health Indicator A characteristic of an individual, population, or environment which is subject to measurement and can be used to describe one or more aspects of the health of an individual or population. Drivers of Health Risk factors that may positively or negatively impact a health outcome. For the purposes of KP s CHNA they have been divided into four categories: social and economic factors, physical environment, health behaviors, and clinical care access and delivery. 15

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Map Data and Guidelines Purpose Common Indicator Categories The KP CHNA common indicators were selected using the following categories: Demographics: describes the population of interest by measuring its characteristics (e.g. total population, age breakdowns, linguistically isolated people). Unlike other categories, demographic indicators are purely descriptive and not generally compared to benchmarks or viewed as positive or negative. Health Outcomes: includes both morbidity (measures of disease burden and quality of life e.g., obesity rates, asthma incidence, etc.) and mortality (measures of rates and causes of death e.g., cancer mortality, motor vehicle deaths, etc.). Social and Economic Factors: includes measures of social status, educational attainment, and income, all of which have a significant impact on an individual s health. This category includes our Key Drivers (poverty, high school graduation and un-insurance), which are among the most predictive upstream indicators of community health. Health Behaviors: refers to the personal behaviors that influence an individual s health either positively or negatively (e.g. breastfeeding, smoking, eating fruits and vegetables). Physical Environment: measures characteristics of the built environment of a community that can impact the health of that community either positively or negatively (e.g. parks, grocery stores, walkability). Clinical Care: measures clinical care being delivered to the community (e.g. rate of preventative screenings, ambulatory care sensitive discharges) as well as factors that impact peoples access to timely, affordable clinical care (e.g. primary care physicians, number of FQHCs). With the exception of demographics, these categories closely mirror common themes found in other models of population health, including the County Health Rankings Model. MATCH Population Health Model 16

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Map Data and Guidelines Purpose Key Drivers Kaiser Permanente has identified three Key Drivers from the list of common indicators. These indicators are well-aligned with key driver indicators used in other initiatives. Key Driver Indicator Poverty High School Graduation Insurance Measure % of population below 100% FPL % of adults age 25+ without a high school diploma or equivalent % of population without health insurance coverage These indicators were differentiated from the other common indicators because: They are among the most predictive indicators of poor health outcomes. They are available at a sub-county geography, making it possible to examine and understand the specific neighborhoods and populations of greatest need within each hospital service area. Understanding the areas of highest need through these indicators can help communities target primary data collection with populations most at risk for poor health outcomes. 17

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Map Data and Guidelines Purpose Benchmarking Benchmarking is a critical component of the CHNA process. It provides a yardstick against which to measure the data to determine whether or not that data reveals a need in the community. Commonly used benchmarks are geographic averages and/or trends over time. Benchmarks might also include agreed upon targets such as Healthy People 2020 goals. The KP CHNA Data Platform uses state averages as the default benchmark for all indicators, however Healthy People 2020 targets and regional benchmarks are also available for use as a comparator in some cases. Common Benchmarks Geographic average (e.g. State, County)* Healthy People 2020 goals (when measures are comparable)* Time trends *included in the KP CHNA Data Pla orm Additional Secondary Data Areas may want to consider supplementing the KP common indicators with additional secondary data. Additional data can be particularly useful if any of the following is true: Local data sources provide more granular level data than the common indicator data sources (e.g. by zip code, census block level, school, etc.) Local data sources provide more recent data than the common indicator data sources (e.g. data collected in 2012 instead of 2008) Additional data would provide information for a health issue that is not included on the list of common indicators but is of interest to the local community Local data provides greater detail about the health of certain sub-populations of the community KEY TERMS Benchmark Something that serves as a standard by which others may be measured or judged. (Ex: State average) 18

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary CHNA Data Map Data Platform and Guidelines Purpose V. CHNA DATA PLATFORM Kaiser Permanente (KP) partnered with The Center for Applied Research and Environmental Systems (CARES) at the University of Missouri to develop a webbased data mapping platform. The platform is intended to facilitate and support CHNAs and community collaboration. It is designed to help users understand what is driving health in their communities and to prioritize those issues that require the most urgent attention. Users are able to view, map, and analyze the KP common indicators by hospital service area or Region and compare them against predefined benchmarks to determine which health needs exist. The indicators are grouped into meaningful categories that are intended to answer the following questions: The platform is able to generate customizable reports that can subsequently be used to guide primary data collection as well as inform the identification and prioritization of health needs. Users are able to save, export and share maps and reports. For additional information about the platform please visit www.chna.org/kp. KP CHNA Data Platform Logging in to the CHNA Data Platform: 1. Visit www.chna.org/kp and log in using your Community Commons password 2. If you don t have a Community Commons account, click the Log-In tab at the top of the page and create an account. 3. Once you ve logged in you will be redirected to the KP CHNA hub. 4. If this is your first time using the KP CHNA hub, you must click the Join Hub button. 5. You re now a member of the KP CHNA Hub and can start using the tools and features found on the home page. 6. If you have questions, click the Support tab in the top right corner of the page. Creating a Data Report in the CHNA Data Platform: 1. KP CHNA Hub members have the option to run various types of data reports. 2. From the home page, click the Create a CHNA Report box. 3. Read the How to Get Started instructions on the report page. Reports can be customized by KFH hospital area, KFH Region, county or custom service area. 4. Once a report area has been selected, users can click on Select Data to select various indicators or groups of indicators for the report. Data can be viewed as a Word/PDF report or an Excel spreadsheet. 5. Visit chna.org/kp for more information. 19

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Map Data and Guidelines Purpose Potential Health Need Categories In order to facilitate the identification of community health needs, the KP Data Platform allows users to run reports based on a predefined list of Potential Health Needs. This list includes the 14 most commonly identified health needs across KP communities during the last cycle of CHNA. With the exception of demographics, all of the KP common indicators have been mapped to one or more Potential Health Need. This allows platform users the ability to examine as a group a set of indicators that together impact a potential health need. The list of Potential Health Needs in the platform includes: Access to Care Asthma Cancers Climate and Health CVD/Stroke Economic Security HIV/AIDS/STDs Maternal and Infant Health Mental Health Obesity/HEAL/Diabetes Oral Health Overall Health Substance Abuse/Tobacco Violence/Injury Prevention 20

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Web-based Primary Data Map Data and Guidelines Platform Purpose VI. PRIMARY DATA GUIDELINES Primary Data Collection Overview The Federal CHNA Guidelines require non-profit hospitals to: Solicit and take into account input received from all of the following sources in identifying and prioritizing significant health needs and in identifying resources potentially available to address those health needs (Appendix E) At least one state, local, tribal, or regional governmental public health department (or equivalent department or agency), or a State Office of Rural Health with knowledge, information, or expertise relevant to the health needs of that community. Members of medically underserved, low-income, and minority populations in the community served by the hospital facility, or individuals or organizations serving or representing the interests of such populations. Written comments received on the hospital facility s most recently conducted CHNA and most recently adopted implementation strategy. Summarize any input provided by such persons and how and over what time period such input was provided (for example, whether through meetings, focus groups, interviews, surveys, or written comments and between what approximate dates) Provide the names of any organizations providing input and summarize the nature and extent of the organization's input; and describe the medically underserved, low-income, or minority populations being represented by organizations or individuals that provided input. In this section: Primary Data Collection Overview Primary Data Collection Methods Primary Data Collection Tips Primary Data Analysis Primary Data Tracking KEY TERMS Medically underserved For the purposes of CHNA, 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 barriers. Primary Data New data that is collected or observed directly from first-hand experience. (Ex: Focus groups, key informant interviews, health surveys) Secondary Data Data that has already been collected and published by another party. (Ex: California Health Interview Survey (CHIS), Behavioral Risk Factor Surveillance System (BRFSS)) 21

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Web-based Primary Data Map Data and Guidelines Platform Purpose Primary Data Collection Overview (cont.) Input required by the federal CHNA guidelines can be collected through primary data collection. Collecting primary data allows for more in-depth probing and can lead to a deeper understanding of the issues in a community. Combined with secondary data, primary data ensures a comprehensive picture of a community s health needs and can be used to: Purpose Validate health needs through the community s perspective Provide in-depth information about the causes of poor health in the community and for different sub-populations Determine a community s priorities among potential health needs Provide information about the assets available in a community or the appropriate strategies that might be used to address the identified health issues Example Data shows that obesity rates are higher here compared to other communities in California. Would you agree that obesity is an issue in this community? Why do you think obesity is a problem in this community? What is preventing community members from being physically active? Of the health needs we re identified here today, how would you rank them in terms of importance? From this list, what are the three most urgent health needs facing the community? What organizations or resources exist in the community to address high obesity rates? What do think might be an effective solution to addressing obesity in this community? How many individuals need to be consulted? The Federal CHNA Guidelines do not specify how many individuals need to be consulted. It is recommended that a hospital include at least two individuals from each specifically named category and a total of at least 6-10 key informants overall. Note that an individual may fall into more than one category. 22

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Web-based Primary Data Map Data and Guidelines Platform Purpose Primary Data Collection Methods Methods for primary data collection may include: surveys, focus groups, stakeholder or key-informant interviews, or focus groups. A. Surveys Surveys can be used to collect information from community members, stakeholders, providers, and public health experts for the purpose of understanding community perception of needs. Surveys can be administered in person, over the telephone, or using a web-based program. Surveys can consist of both forced-choice and open-ended questions. Surveys are generally targeted to a larger population than interviews or focus groups and may be used to collect both quantitative or qualitative information. Since it is very difficult and expensive to conduct surveys using scientific sampling methods, you are unlikely to produce statistically valid results. B. Community focus groups Community focus groups are group discussions with selected individuals. A skilled moderator is needed to lead focus group discussions. Members of a focus group can include hospital staff, community leaders, users of health services and/or members of minority or disadvantaged populations. The ACHI Community Health Assessment Toolkit recommends limiting each focus group to 8-15 individuals that share some specific characteristic (e.g., patients at a clinic, members of a community organization). Community focus groups can provide valuable information on where health problems lie and which problems are of the greatest importance to different populations. How recent should the primary data be? Guidance from IRS requirements: Section 501(r)(3)(A) provides that a hospital organization meets the CHNA requirements with respect to any taxable year only if it has conducted a CHNA in such taxable year or in either of the two immediately preceding taxable years." This means that the primary data needs to: Be conducted either in the year the CHNA is conducted or either of the previous two years; Be adequately tracked per the IRS requirements; AND When taken together with secondary data, ensure a complete scan of the needs of the community served with particular attention to the groups called out in the IRS requirements. C. Community forums Community forums are meetings that provide opportunities for community members to provide their thoughts on community problems. They can be targeted towards high need or priority populations. Community forums require a skilled facilitator. From Assessing & Addressing Community Health Needs, Catholic Health Association, February 2012. 23

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Web-based Primary Data Map Data and Guidelines Platform Purpose Primary Data Collection Methods (continued) D. Key Informant Interviews Key informant interviews are qualitative in-depth interviews with key stakeholders in the community. The purpose of key informant interviews is to collect information from a wide range of people including community leaders, professionals, or residents who have first hand knowledge about the community. These community experts, with their particular knowledge and understanding, can provide insight on the nature of problems and give recommendations for solutions. What are a few key questions to ask? 1. What are the community s most critical health needs? 2. What are the factors causing the health needs in the community? 3. How would you prioritize the health needs facing your community? 4. What do you see as the community s assets and resources? Advantages and Disadvantages of Key Informant Interviews Advantages Detailed and rich data can be gathered in a relatively easy and inexpensive way Allows interviewer to establish rapport with the respondent and clarify questions Provides an opportunity to build or strengthen relationships with important community informants and stakeholders Can raise awareness, interest, and enthusiasm around an issue Can contact informants to clarify issues as needed Disadvantages From Sec on 4: Key Informant Interviews, UCLA Center for Health Policy Research, Health DATA Program Data, Advocacy and Technical Assistance, Web: h p://www.healthpolicy.ucla.edu/healthdata/ t_prog24.pdf, no date. Selecting the right key informants that represent diverse backgrounds and viewpoints may be difficult May be challenging to reach and schedule interviews with busy and/or hard-to-reach respondents Difficult to generalize results to the larger population unless interviewing many key informants Tips for collecting primary data Ensure good representation across groups of individuals in the community Conduct data collection at convenient times (after work hours) and locations Clearly define the hospital s role: set expectations about what the hospital can and cannot do and be clear about how participants confidentiality will be maintained Take careful notes during interviews, focus groups or community forums, and also record them, if possible For discussions, explore multiple points of view; don t let a single issue dominate the discussion. Monitor the time, and use time efficiently Use a skilled facilitator for focus groups and community forums 24

Primary Data Analysis Regardless of the method used to collect primary data, the data should be analyzed and summarized to be most useful during the identification, prioritization and selection of health needs. The method for analysis will be dependent upon the method of data collection. If surveys are collected, data for close-ended questions should be analyzed quantitatively. Responses to any open-ended questions can be summarized based on any common themes (responses that are similar across multiple surveys). For interviews and/or focus groups, ideally there will be detailed notes and possibly even transcripts to work from. These should be reviewed and coded for common themes as well. Common themes are types of responses that occur across multiple interviews/groups. It is not a common theme if the same person continues to bring it up. Typically, the response would come up in at least a third to a half of the interviews. For focus groups, a theme is something multiple (again a third to half or more) people in the group identify. In order to accurately identify a theme versus a comment repeated by the same person in the group, it is important to indicate different speakers in notes and transcripts. Once data is analyzed and themes are identified, hospitals and/or collaboratives will have to determine whether the results validate, augment, or contradict findings from the CHNA Data Platform. In the case of contradictory findings a deeper review of the data may be necessary. Consider what the sources of information are and what limitations might exist. For example, is the secondary data several years old or is it only at the county level and maybe not representative of a particular community within the county. And/or was primary data collected from a subset of the population that has a particular perspective not shared by the broader community represented in the secondary data. CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Web-based Primary Data Map Data and Guidelines Platform Purpose 25

Primary Data Collection Tracking The following information about the individuals consulted during primary data collection should be tracked. Please see Appendix E for the complete tracking form. CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Web-based Primary Data Map Data and Guidelines Platform Purpose Resident or member of the community Name No No Title No Yes Affiliation No Yes Target Group Represented Yes Yes Data collection method Yes Yes Date input was gathered Yes Yes Leader or professional that represents or serves members of the community 26

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Web-based Other Data Map Considerations Data and Guidelines Platform Purpose VII. Other Data Considerations The IRS requires non-profit hospitals to: ACA requires non-profit hospitals to: Describe existing of information facilities and gaps resources that impact within the community ability to assess to meet the health identified needs health needs Describe information gaps that impact the ability to assess health needs Community Assets During the data collection phase of the CHNA, it is important to collect information about community assets and resources available to respond to the health needs of the community. Each hospital should explore assets included in the CHNA Data Platform as well as probe about community assets as part of their primary data collection. A community s assets include individual community members, programs, and institutions. Kretzmann and McKnight have developed the following asset map as a framework from which to consider your community s assets. In this section: Community Assets Data Limitations What are community assets? Examples include: Grocery stores Parks Primary care physicians Schools Hospitals, including specified Public Hospitals Federally Qualified Health Centers KEY TERMS Community Assets Those people, places and relationships that can conceivably be used in acting to bring about the most equitable functioning of a community. From Assessing & Addressing Community Health Needs, Catholic Health Association, February 2012. 27

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Web-based Other Data Map Considerations Data and Guidelines Platform Purpose Data Limitations/Information Gaps In order to describe information gaps that impact the ability to assess the community s health needs you may want to consider the following: Is the sample size large enough? Does it represent the broader population? How recent is the data? How granular is the data? Does the data allow you to examine health needs by subgroups? Is the data complete enough to allow an examination of all health needs? Are the data sources reliable? 28

GLOSSARY

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Web-based Primary APPENDICES GLOSSARY Data Map Data and Guidelines Platform Purpose The following table includes definitions of key CHNA terms referenced in this toolkit. In order to standardize the process and to ensure compliance with the ACA regulations a shared understanding of these terms is important. CONCEPT DEFINITION EXAMPLES Benchmark Something that serves as a standard by which others may be Healthy People 2020 measured or judged. 1 Affiliation The Federal, tribal, State or local health department, other departments, or other agencies an individual is associated with who provides current data or other relevant information. Department of Public Health Community Served Based on ACA regulations, the community served is to be determined by each individual hospital. It is generally defined by a geographical location such as a city, county or metropolitan region. A community may also take into consideration certain hospital focus areas (i.e., cancer, pediatrics) but should not be defined so narrowly as to intentionally exclude high need groups such as the elderly or low income individuals. Kaiser Permanente Northern California Region definition of hospital service area (pg. 7) Community Assets Those people, places and relationships that can conceivably be used in acting to bring about the most equitable functioning of a community. FQHCs Primary care physicians Parks Community Health Needs Assessment A systematic process involving the community to identify and The CHNA required by ACA analyze community health needs and assets. 2 Drivers of Health Risk factors that may positively or negatively impact a health outcome. For the purposes of KP s CHNA they have been divided into four categories: social and economic factors, physical environment, health behaviors, and clinical care access and delivery. High school graduation Smoking Access to parks Health insurance 1. Benchmark, Merriam Webster Dictionary, Web: http://www.merriam-webster.com/dictionary/benchmark. 2. World Health Organization, Web: http://www.who.int/hia/evidence/doh/en/. i

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Web-based Primary APPENDICES GLOSSARY Data Map Data and Guidelines Platform Purpose CONCEPT DEFINITION EXAMPLES Expertise Individuals with special knowledge in public health. Department of Public Health Health Indicator A characteristic of an individual, population, or environment which is subject to measurement (directly or indirectly) and can be used to describe one or more aspects of the health of an individual or population. 3 Percent of children overweight in SF Incidence of breast cancer in Santa Clara County Health Needs Health outcomes that are disproportionately impacting a particular population. They are identified through interpretation and analysis of secondary data as well as primary data. Breast cancer Obesity and overweight Asthma Health Outcomes Snapshots of diseases in a community that can be described in terms of both morbidity and mortality. They are measurable health indicators that may be used to identify and prioritize health needs. 4 Breast cancer prevalence Lung cancer mortality Homicide rate Implementation Strategy The non-profit hospital s plan for addressing the health needs identified through the community health needs assessment (CHNA). 5 Implementation strategy required by the ACA Incidence A measure of the occurrence of new disease in a population 1,000 new cases of breast of people at risk for the disease. 6 cancer in 2011 3. Health Promotion Glossary, World Health Organization, Division of Health Promotion, Education and Communications (HPR), Health Education and Health Promotion Unit (HEP), Geneva, Switzerland, 1998. 4. Catholic Health Association of the United States. (2011). Assessing & addressing community health needs Discussion draft: March 2011. http://www.chausa.org/ Assessing_and_Addressing_Community_Health_Needs.aspx 5. Adapted from: Assessing & Addressing Community Health Needs, Catholic Health Association of the United States, Discussion Draft: March 2011. 6. Aschengrau, Ann, Seage, George R., Essentials of Epidemiology in Public Health, Jones and Barlett Publishers, Sudbury, Massachusetts, 2008. ii

CHNA Toolkit Part I Introduction Pre-Assessment Process Secondary Web-based Primary APPENDICES GLOSSARY Data Map Data and Guidelines Platform Purpose CONCEPT DEFINITION EXAMPLES Prevalence Primary Data Qualitative Data Quantitative Data Risk Factor Secondary Data Target Group The proportion of total population that currently has a given 1,000 total cases of lung cancer disease. 7 in 2011. New data that is collected or observed directly from first-hand experience. Typically descriptive in nature and not numerical; however it can be coded into numeric categories for analysis. Qualitative data is considered to be more subjective than quantitative data but describes what is important to people who provide the information. Note: qualitative data can be primary or secondary data. 8 Data that has a numeric value. Quantitative data is considered to be more objective than qualitative data. Note: quantitative data can be primary or secondary. 9 Anything that increases an individual s chance of developing a disease or illness. Some risk factors can be changed (e.g., smoking) while others cannot (e.g., family history). 10 Data that has already been collected and published by another party. Leaders, representatives or members of groups from the following communities: individuals with chronic conditions; minorities; medically underserved; and low-income. Focus groups Key informant interviews Focus group responses Number of children diagnosed with asthma Smoking Genetics California Health Interview Survey (CHIS) data Behavioral Risk Factor Surveillance System (BRFSS) data Uninsured individual in service area 7. Aschengrau, Ann, Seage, George R., Essentials of Epidemiology in Public Health, Jones and Barlett Publishers, Sudbury, Massachusetts, 2008. 8. Adapted from: Assessing & Addressing Community Health Needs, Catholic Health Association of the United States, Discussion Draft: March 2011. 9. Adapted from: Assessing & Addressing Community Health Needs, Catholic Health Association of the United States, Discussion Draft: March 2011. 10. What are the risk factors of prostate cancer? American Cancer Society, Web: http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-risk-factors. iii

APPENDICES