Rural Arizona Hospital Community Health Needs Assessment Status Report May 2013 Prepared by Benjamin Brady In Collaboration with Joyce Hospodar CPH 594B Rural Health Policy and Management Practicum Mel and Enid Zuckerman College of Public Health University of Arizona For more information, please contact Joyce Hospodar at hospodar@email.arizona.edu!
Table of Contents Introduction*...*3! Methods*...*3! Results*...*4! Objective*1*...*4! Objective*2*...*4! Objective*3*...*5! Objective*4*...*5! Table*1* *AZ*Rural*Hospitals*CHNA*Phone*Questionnaire*Results*...*6! Recommendations*...*8! Acknowledgements*...*9! Appendix*A* *Questionnaire*...*10! Appendix*B* *Introductory*Letter*...*15!!
Introduction In July 2011, the IRS issued a mandate stating that all rural and critical access hospitals are required by Federal Law, as a condition of their not-for-profit status, to complete a community health needs assessment (CHNA). In an effort to better understand the status of Arizona s critical access and rural hospitals in planning and executing CHNAs, the University of Arizona s Center for Rural Health (CRH) commissioned a brief survey of these hospitals. For many, this is the first time they have been asked to direct such a broad, community-based data collection effort. The results of the study are included in this report. In addition to outlining the hospitals current status, this report also details each hospital s strategy and potential interest in receiving assistance from the CRH to complete its CHNA. In April and May of 2013, all of Arizona s rural and critical access hospitals were contacted and asked to respond to a brief questionnaire. The questionnaire was designed around four primary questions: 1. What is the current status of Arizona s rural and critical access hospitals in completing their respective CHNAs? 2. How are hospitals conducting CHNAs? 3. Did the hospital coordinate with the other community partners, including their local County Health Department or nearby hospitals? 4. What types of assistance might rural hospitals need in completing their CHNA? The findings from this study will be used by the CRH to orient future service planning and outreach efforts towards these hospitals. An equivalent version of this report, with nonidentifiable data, was also prepared and sent to all participating hospitals. Methods All of Arizona s non-tribal, critical access hospitals (11 ea.), and not-for-profit rural hospitals (2 ea.) were contacted to participate in the study. Using the structured questionnaire provided in Appendix A, a MPH student conducted phone interviews with executive administrators, in most cases the CEO, at 9 of the 13 hospitals. A CRH staff member interviewed an administrator at one hospital. Before beginning the study, the CRH was already aware that two critical access hospitals had participated in and completed a CHNA. After the study began, a preliminary website and hospital newsletter search was conducted and it was discovered that a third hospital had already completed its CHNA as well. These three hospitals were not asked to participate in the survey. CRH staff, Mel and Enid Zuckerman College of Public Health (MEZCOPH) faculty members, and a MPH student contributed to developing the questionnaire. Once created, an introductory email (provided in Appendix B) was sent to the remaining ten hospitals. The email was directed to hospital CEOs informing them of the CRH s intentions to administer a CHNA-related! 3!
questionnaire, to notify them of a forthcoming phone call, and to invite them to participate in the study. Results The results from the study have been analyzed and divided into the study s four primary objectives. Objective 1 Number of Hospitals Stratified by Status in Completing a CHNA t Yet Begun Just Started Almost Done Complete 2 3 2 6 All ten hospitals identified that they are aware of the IRS requirement, including the two that have not yet begun their CHNAs. These two hospitals report that they are already considering timelines for when their hospital might begin the planning process. They have not yet begun, however, due to financial and staffing constraints. One executive commented that the hospital s preference would be to hire out the assessment to an external contractor, except the hospital s budget will not allow for this option. The executive, therefore, will wait as long as possible before beginning the assessment and will likely conduct the assessment alone, as no staff is available to assist. The second hospital reports that other, more time-sensitive priorities limit its ability to begin planning for a CHNA. The remaining five hospitals that report having just started or being almost done do not have significant concerns regarding their ability to complete CHNAs. Of the three that just started, one plans to hire the entire process out to an external contractor. A second has already organized a team of 6 internal staff members to conduct the assessment process. The third will also use inhouse staff, and feels confident in their data collection and analytical capacity. In the case of this hospital, accessing resources such as a CHNA guide or checklist that defines necessary steps for completing an assessment is the team s biggest concern. The two hospitals that are almost done used in-house staff. They report no significant barriers. One CEO did express concern about the quality of the final report, however. Objective 2 Number of Hospitals (Excluding Those t Yet Begun) Stratified by Human Resources Used in Completing a CHNA In-house Staff Contractors or Hospital Group Manager Combination 5 4 1 For Arizona s hospitals, the decision of whether to use internal staff or external help seems like an either/or question. The one hospital that reports using a combined approach is working with its hospital group managers. This hospital, however, only expects its managing group to provide assistance in accessing secondary data. The group managers who worked with two other hospitals, on the other hand, directed and oversaw the entire assessment process. One additional hospital reported searching for and receiving bids from a private contracting firm to complete its CHNA. The remaining four hospitals directed their CHNAs using only in-house staff.! 4!
Objective 3 Number of Hospitals (Excluding Those t Yet Begun) Stratified by Partnerships ne County Health Department Contractors Other Hospitals Hospital Group Managers Combination of Partners 3 5 1 1 3 3 Five hospitals have worked on their CHNA through alliances with one or more partners. The County Health Department was identified as the most commonly used partner. While one hospital worked with its county health department to complete a single, shared CHNA, the other four hospitals are using the results from their counties reports in their own, separate assessments. This form of data piggybacking seemed to be the most widely shared strategy. One hospital that has not yet begun its CHNA mentioned that it would have liked to partner with another hospital, but did not contact it soon enough. The other hospital was already at the end of completing its own CHNA. The two CEOs individually commented that they felt this was a missed opportunity. They intend to coordinate better on future assessments. Objective 4 Number of Hospitals Interested in CRH Assistance to Complete Specific CHNA Steps Locating Collecting Obtaining Developing Existing Data New Data Community Action Plan Assessment Planning Documenting & Presenting Results Input 1 3 1 2 2 3 1 3 2 1 1 2 Most hospitals report that they had enough outside assistance or were confident enough in their staff that they do not anticipate needing CRH resources to complete their CHNA. Looking across all hospitals, no single category of assistance stands out as a key assistance concern. The hospitals that indicated being unsure about CRH assistance pointed out that they are not far enough along in the process to identify subsequent needs. Hospitals with CHNAs that are being directed by outside contractors or group managers described limited interest in CRH assistance. Additionally, of the hospitals using its own staff, only the CEO who lacks outside or internal staff resources expressed interest in all six categories high interest for all six. Beyond this one case, only two other hospitals indicated high interest for any of the recommended CHNA steps.! 5!
Name of Hospital Hospital A Hospital B Hospital C Hospital D Hospital E ne & Complete wo assessment ports) NA ement group HNA as well as ty Health. County health department & management The hospital s staff has not participated in the CHNA process; they are unaware of barriers. The hospital would not be interested in any assistance from CRH Almost Done In-house staff County health department NA NA NA NA Unsure Unsure Need to see what working group finds in the data. Will know more after the next meeting. t yet Begun "More important priorities" are the hospital's #1 barrier. They have superseded the hospital's ability to begin planning a CHNA. The hospital anticipates completing a CHNA, but without beginning the process yet, it is unclear what barriers may exist. The hospital may be interested in receiving technical assistance. It is not at the point now to begin identifying barriers. When the planning process begins, CEO believes the hospital will identify assistance needs and will likely contact the RHC at that time. Complete Management group County health department, another hospital, and management group Minor Minor Invited but did not receive participation or input from community leaders. NA - CHNA already complete t yet Begun In-house staff Intends to partner with County health department, another hospital, MEZCOPH Major Major Major Major Minor Barriers are all financial. If had money would hire help Affordable service - no $ in budget for CHNA. CEO will begin CHNA alone Intention to complete CHNA Stage of Planning Complying with IRS requirements Using In-house staff or outside contractor Collaborators Financial Trained Personnel Locating Existing Data Collecting New Data Analyze Data Additional Barriers Assessment Planning Locating Existing Data Collecting New Data Obtaining Community Input Developing Action Plan Documenting & Presenting Results to Community Other Assistance Interests Hospital s Strategy for Completing a CHNA Barriers to Hospital in Completing a CHNA Interest in Assistance from MEZCOPH Center for Rural Health (CRH) Table 1 AZ Rural Hospitals CHNA Phone Questionnaire Results Believe that CHNA Will Be a Valuable Resource? - Will use CHNA to use available resources to address needs, or to refocus resources to be used better, by knowing community needs. - Increase communication with reservation hospitals that share same patients t sure - Need to see what results come back. CEO would like to see the report before he will know what actions are possible. - but not sure how yet. This is hospital s the first CHNA. Administrators are not sure how the use the
Hospital M CRH already aware that CHNA was complete. Did not administer questionnaire Hospital L CRH already aware that CHNA was complete. Did not administer questionnaire Hospital K CRH already aware that CHNA was complete. Did not administer questionnaire Hospital J Almost Done In-house Staff ne But executive felt that it should have been Minor Minor ne Hospital I Just Started In-house staff & Group Manager County health department & managing group is providing data Minor - one more hat everyone has to wear Minor - depends on how costly it becomes Medium (low) Hospital H Complete In-house staff ne Minor Minor Major Major Biggest challenges: identifying whom the hospital serves, inaccurate census data in rural areas & seasonal influx of winter visitors. Hospital G Just Started In-house staff: 6 member team ne Major Because of the remoteness of the area and demographics, CHNA team anticipates difficulty in coordinating with the community and translating communication with non-english speakers NO (moderate) (moderate) Hospital F Just Started Contractor - firm not yet identified County CHNA will provide secondary data - one staff member will coordinate proccess with contractor - borrow data from county health dept.'s report ne assistance needed from CRH - Contractor will be expected to produce a final report with recommendation implementation strategies! t at this time. Once the team gets into the assessment, and survey questions begin coming in, may know better where team can use assistance. CRH can help hospital identify what resources or directives federal and state sources provide regarding CHNA It would be nice to train staff by using a template of studies and checklist of what would be a good study. CEO has never seen a completed study Would welcome the idea to partner with CRH to pay for staff travel expenses - beneficial in identifying position recruiting and determining service area needs (e.g., pain management, radiation, etc.) - community members have contacted the hospital asking for this information/data. Only census data is available for this area. Need to update data to see better community's health needs and know what services to expand. - Next steps include organizing the hospital into teams that can consider how to convert the assessment findings into action steps. - IRS requirement is overkill. The hospital is already involved in the community the CHNA requirement is wasteful and redundant. But would attend a workshop to learn how to utilize the CHNA going forward! 7!
Recommendations In examining the above findings, four recommendations have been identified. First, the CRH s role in assisting Arizona s rural and critical access hospital should focus on instruction and advisement. The CRH will best serve the hospitals by assisting them in establishing CHNA partnerships, identifying and recommending process steps for completing key aspects of the CHNA process. Overall, the hospitals expressed a lack of interest in contracting with the CRH as a service consultant. Instead, most believe that the CRH could contribute by clarifying the CHNA process and offering instructional tips for translating CHNA results into actionable improvement strategies. Second, for the CRH to succeed in the first point, CHNAs need to become one of the Center s regular, periodic points of communication with Arizona s rural hospitals. To do this, it will be necessary for the CRH to remain more informed about each hospital s assessment and implementation timelines and practices. Though many of the hospitals are new to the CHNA process and the barriers and concerns they report in this survey might be expected in their first CHNA experience, the CRH s ability to provide a big picture view for the hospitals will always remain necessary. Leadership personnel will eventually turnover and hospitals will inevitably develop and pursue new approaches to completing CHNAs. Because CHNA reports come due every three years, the CRH will continue to hold an important leadership role in providing general direction to new hospital leaders while mediating a productive information exchange between all hospitals. Hospitals will benefit from the CRH s ability to host a collaborative exchange of ideas and cost saving practices. Third, although most hospitals indicated that they are fine to complete their assessments using their own or independently contracted resources, it is important to note that at least one hospital in the study reported high interest in receiving assistance from the CRH. Where this hospital is not able to pay for professional CHNA services, nor does it have available internal staff, the hospital would likely benefit from student internship support. Though this option would not be possible to offer to all 13 hospitals, it is clear that the majority of hospitals are already comfortable completing a CHNA with established partnerships and trained staff. MEZCOPH s internship program, therefore, may be in a position to fill this need for one or two hospitals. The CRH is certainly in a position to facilitate this type of intern-based partnership. An obvious benefit to conducting this and future CHNA, status surveys, lies in the CRH s ability to identify those few hospitals that may require more direct forms of assistance. Fourth, there is much more room for partnering between hospitals and health departments, MEZCOPH students, and faculty. The CRH may make the most impact in assisting these hospitals by outlining principles of partnership, including how hospitals can coordinate future CHNA deadlines and work with strategic partners in completing the CHNA process steps. In the questionnaire, the final question asked hospitals to indicate their interest in using the findings from their CHNA reports. The CRH was curious to know whether the hospitals view CHNAs as valuable resources. All but two executives responded positively. One executive! 8!
reported that the CHNA process is too prescribed and burdensome. It imposes regulations on similar actions that the hospital was already taking. The other mentioned interest in learning more how to utilize CHNA findings. While initially optimistic about the possible actions the CHNA report makes possible, other administrators offered similar opinions. It remains unclear to many hospital leaders whether the CHNA process, at least as realized by their staff or consultants, is structured in such a way that the results will provide an effective resource the hospitals can use to enact discernible improvements. Thus, to fulfill its mission of improving the quality of Arizona s rural hospitals, the CRH should see the CHNA as a core service area where it can assist hospitals in producing a quality product that it will know how to use. Otherwise, there is a risk that conducting a CHNA will provide a poor return on investment, an investment that rural and critical access hospitals are already financially limited to make. Acknowledgements The report was created by the University of Arizona s Center for Rural Health and faculty in Mel and Enid Zuckerman College of Public Health. Joyce Hospodar, Dr. Kevin Driesen, Dr. Lynda Bergsma, Dr. Neil MacKinnon and Benjamin Brady contributed to the questionnaire and summary report.! 9!
Appendix A Questionnaire AZ Rural Hospital Community Health Needs Assessment (CHNA) Phone Questionnaire Date: Name of Hospital: Respondent s Name: Introduction The purpose of this questionnaire is to help the University of Arizona s Center for Rural Health answer four broad questions: What is the current status of Arizona s rural and critical access hospitals in completing CHNAs? How are hospitals conducting CHNAs? Did the hospital coordinate with the other community partners, including a County Health Department? What types of assistance might be needed in conducting a CHNA? Statement of Confidentiality Personalized answers to these questions will not be made available to any individual or organization outside of the University of Arizona s Center for Rural Health. If published, personal or hospital specific identifiers will not be used.! 10
SECTION 1 HOSPITAL S STRATEGY IN COMPLETING A CHNA 1. Does your hospital plan on completing a CHNA? a. If no, are you aware of the IRS mandate and noncompliance fine? 2. In what phase is your hospital in planning a CHNA? t Yet Begun Just Started Almost Done Completed a. If not yet begun, please indicate when you plan to begin the process? b. If completed, has the CHNA been posted to your website? 3. Is your hospital following the IRS specified steps and requirements for completing a CHNA? The hospital has a copy of IRS requirements The hospital is aware of, but unfamiliar with, IRS requirements The hospital is unaware that the IRS published specific guidelines 4. To perform your CHNA, does your hospital plan to use: (check all that apply) In-house staff Outside contractor 5. In conducting a CHNA, is your hospital working in collaboration with: (check all that apply) County Health Department University of Arizona College of Public Health Another hospital Consulting group Other a. If other, please indicate the name of the organization(s)! 11
SECTION 2 BARRIERS TO YOUR HOSPITAL IN COMPLETING A CHNA 6. Is a lack of financial resources a barrier to completing a CHNA? Major barrier Minor barrier barrier 7. Is a lack of staff or trained personnel a barrier to completing a CHNA? Major barrier Minor barrier barrier 8. Is your hospital s ability to locate existing data a barrier to completing a CHNA? Major barrier Minor barrier barrier 9. Is your hospital s ability to collect new data a barrier to completing a CHNA? Major barrier Minor barrier barrier 10. Is your hospital s ability to interpret or analyze data a barrier to completing a CHNA? Major barrier Minor barrier barrier 11. Are you aware of any additional barriers that might impede your hospital in completing a CHNA? SECTION 3 INTEREST IN RECEIVING ASSISTANCE FROM THE U OF ARIZONA At the Center for Rural Health, we are interested in identifying ways we might be able to assist your hospital in completing a CHNA. Experts indicate that the CHNA process can be divided into six interrelated, yet distinguishable steps. Below, the six steps are briefly outlined to assess your interest in contracting with the Center to complete any or all of them. For each step, please indicate your level of interest as being high, low or none. 12. Facilitate needs assessment planning that would involve working with the hospital needs assessment leadership group to: a. Develop a logic model for the needs assessment (project roadmap) b. Identify community partners to be involved c. Establish needs assessment goals, objectives, and work plan interest interest interest! 12
13. Work with the hospital needs assessment leadership group and identified community partners (e.g., county health department) to: d. Identify existing data e. Collect and analyze the data f. Prepare reports, such as a demographic profile of the hospital service area interest interest interest 14. Collect new data by conducting key informant interviews, focus groups, and surveys, analyze the data, and prepare report for the hospital. interest interest interest 15. Work with the hospital needs assessment leadership group to design and facilitate community conversations (meetings) to: g. Assess needs h. Collect ideas for resolution of needs i. Present the needs assessment final report j. Obtain community input for, and investment in, the hospital action plan interest interest interest 16. Assist with development of your hospital s action plan, including measures for monitoring progress. interest interest interest 17. Assist with documenting results and communicating them to your hospital service area population. interest interest interest 18. Is there any other way you believe that the Center for Rural Health might contribute to your hospital s ability to complete a CHNA?! 13
19. Do you believe that a CHNA will be a valuable resource to your hospital? a. If yes, what actions do you anticipate taking once it is complete? b. If no, would you or members of your staff be interested in attending a workshop (webinar) that addresses strategies for utilizing CHNAs to plan future services? QUESTIONNAIRE COMPLETE THANK YOU! In a few weeks, a summary report will be posted on the Center for Rural Health website. For more information please contact Joyce Hospodar or Kevin Driesen.! 14
Appendix B Introductory Letter Hello everyone, Over the next few weeks, the Center for Rural Health (CRH) will be contacting each of you to assess your hospital s progress in completing and implementing the IRS mandated community health needs assessment (CHNA) required under Schedule H Form 990. Benjamin Brady, a graduate student here at the University of Arizona s College of Public Health who is taking a 1 credit course with me will be calling each of you this Thursday, April 11 th or Friday, April 12 th to schedule a time over the next few weeks to answer a brief, 10 to 15 minute questionnaire reviewing your hospital s current status and/or possible assistance needed to complete the CHNA. Of course, the information we receive from each of you will be kept confidential. The CRH s goal is to develop a better understanding on how we might be able to support your hospital in planning, completing, and/or utilizing the results from conducting the CHNA. Thank you in advance for your time and willingness to speak with Benjamin. Regards, Joyce and Kevin! 15