A Review of Tools to Assist Hospitals in Meeting Community Health Assessment and Implementation Strategy Requirements

EXECUTIVE SUMMARY

Recent changes in U.S. national policies and regulations have created an opportunity for meaningful collaborations to take place between health systems, public health departments, and social service organizations. For medical systems, and particularly tax-exempt hospitals, new requirements include community health assessments (CHAs) and implementation strategies to address identified health needs. Individuals and groups responsible for meeting the new CHA and implementation strategy requirements may be unsure about the best ways to achieve specific aspects of the CHA process. In this report, we provide an in-depth review and rating of tools developed by public health and community experts that cover the steps necessary to meet the new requirements. A team of three community and public health experts and the authors developed a rating sheet based on a well-known community health improvement process model and on the steps in the new requirements to identify and systematically rate nine comprehensive tools. The ratings and recommendations provide a guide for hospitals in choosing tools that will best assist them in meeting the new requirements.

INTRODUCTION

Over the past 25 years, medical, public health, and social service organizations have collaborated in efforts to improve the health of communities and populations (Koo, Felix, Dankwa-Mullan, Miller, & Waalen, 2012; Lasker & Committee on Medicine and Public Health, 1997; Ockene et al., 2007). Among those who have called for collaboration are the Institute of Medicine (IOM, 2012) and Kania and Kramer (2011). Unfortunately, these efforts have yielded mixed results because of challenges associated with incentives, finances, regulations, and time, as well as a lack of shared knowledge, skills, purpose, and goals (Gale, Coburn, & Newton, 2014; Jones & Wells, 2007; Porterfield et al., 2012).

Recent changes in U.S. national policies and regulations have created an opportunity for meaningful collaborations to take place between health systems, public health departments, and social service organizations that result in shared goals and interventions for population health improvement (Chok-shi, Singh, & Stine, 2014; Stoto, 2013). For medical systems, and particularly tax-exempt hospitals, these changes include the 2010 Affordable Care Act’s (ACA) requirement that “tax-exempt hospitals conduct triennial community health needs assessments (CHNAs) with input from public health experts and other community stakeholders” (Gale et al., 2014), as well as adopt an implementation strategy to address identified population health needs (Berkery, 2013). These requirements are not trivial; hospitals failing to meet the CHA requirements can incur a $50,000 excise tax (Berkery, 2013).

Although many U.S. hospitals conduct community needs assessments and develop implementation plans and have partnered with community stake-holders (Gale et al., 2014), a recent review of the community benefits provided by tax-exempt U.S. hospitals revealed that little is being spent on community health improvement (Young, Chou, Alexander, Lee, & Raver, 2013). This finding suggests that many hospitals will need to make significant investments of time and resources to meet the new requirements and provide evidence of meaningful partnerships and commitments to the communities they serve.

Because medical practice has traditionally focused on the health of individuals rather than entire populations, individuals and groups in hospital settings responsible for meeting the new CHA and implementation strategy requirements may not know how to best achieve specific aspects of the CHA process, which include

• defining the community, and ensuring that medically underserved, low-income, and/or minority populations are included;

• identifying and prioritizing the significant health needs of the community;

• obtaining community input;

• documenting the process and findings in a CHA report that is “available to the public via a hospital facility’s website” (Berkery, 2013);

• developing an implementation strategy that describes how a hospital plans to address the health needs, including “the actions the hospital facility intends to take, the anticipated impacts of the actions, and a plan to evaluate the impacts” (Berkery, 2013).

Fortunately, community and public health efforts that have focused on the health of populations have resulted in the development of models and tools from which to understand and organize the work required by the CHA and implementation strategy requirements. Public health and community experts have applied and tested these models and tools over many years, as evidenced by numerous examples of high-quality assessments and plans (Community Preventive Services Task Force, 2015; National Association of County and City Health Officials, 2015a).

Our aim is to assist groups and individuals in hospital settings charged with meeting the new CHA and implementation strategy requirements by providing an in-depth review and rating of tools that can assist in this process. Specifically we (1) provide an overview of an existing health promotion model to identify common process steps important for meeting CHA and implementation strategy requirements; (2) systematically identify and rate population health tools on these process steps and their availability and usability (e.g., features, applicability, and accompanying resources); and (3) provide specific recommendations to hospitals as they embark on community health assessments and improvement work. We believe this review will assist hospitals in efficiently choosing tools that have been carefully developed over time.

BACKGROUND

Health improvement models can be thought of as representations of various theories of health promotion. One of the most well-known is the IOM’s community health improvement process (CHIP) model (Durch, Bailey, & Stoto, 1997), which has been used as the basis for development of other models, such as the evidence-driven CHIP (Layde et al., 2012). Two cycles of the improvement process are depicted in this model: (1) the problem identification and prioritization cycle and (2) the analysis and implementation cycle. The CHIP model is dynamic and iterative, with an emphasis on continuous redefinition and prioritization of health issues over time. Community health improvement models based on CHIP exhibit the following core processes developed through the healthy cities movement (Hancock & Duhl, 1988):

1. Gathering together a diverse group of community members

2. Developing a shared vision of community health

3. Assessing the current realities and trends

4. Planning action

5. Performing strategically

6. Monitoring and evaluation

Given its prominence and wide-spread use, we adopted the CHIP model as the framework for identifying overall process steps essential to meeting the new CHA and implementation strategy requirements. These steps include the following: form a community health coalition, prepare and analyze community health profiles, identify critical health issues, analyze the health issue, inventory resources, develop a health improvement strategy, identify accountability, develop process and performance indicator sets, implement the strategy, and monitor the process and outcomes (Durch et al., 1997). We then looked for guides, which we defined as tools that provide information and resources for completing each of these steps. We describe our process of conducting a systematic review of these tools.

METHODS

Identification of Tools

We located tools based on the CHIP model that included practical information for operationalizing the steps in the model. We conducted a comprehensive search in both peer-reviewed and open-source outlets, including electronic journal databases (MEDLINE, Cochrane Library, Google Scholar, PsycINFO), citations of published reviews, and recommendations from colleagues in public health and community medicine. The review included published guidebooks, toolkits, and other instructive resources related to the following: community health and quality improvement, community-based participatory research and action initiatives, collaborative partnerships in public health and community medicine, and action learning collaboratives in which “multiple teams with a shared aim work together over a fixed period of time using quality improvement tools and methods to bring about organizational or systemic change” (Bazos et al., 2013, p. 62). We also required that the tool be available electronically, consist of at least one version in English, and be free of charge.

Development of Rating Sheet

We convened a review panel consisting of four researchers (K.E.S., D.A.B., K.A.S., L.R.A.L.) and three community and public health leaders (a division head of chronic disease prevention and neighborhood health for a city public health department, a physician directing community health improvement efforts between a regional healthcare system and community-based organizations, and a vice president of marketing and community health improvement at a rural critical access hospital). The makeup of this panel ensured representation of medicine, public health, hospital, academic, and community perspectives. The researchers developed a rating sheet based on the CHIP model and focused on key requirements (e.g., obtaining community input) from the CHA along with other features indicative of the tool’s usefulness (e.g., ease of access, accompanying resources). We shared the draft rating sheet with community leaders for comments and revisions. Two researchers (D.A.B., L.R.A.L.) and two community leaders (L.R., R.F.) then tested it on three tools.

The final rating sheet, which was approved by the review panel, consisted of the four main process steps (Assessment, Planning, Implementation, and Monitoring and Evaluation) and subcategories (Table 1). The rating sheet also listed specific features of each tool (e.g., case examples, sample PowerPoint [Microsoft] slides, sample surveys).

TABLE 1.

Final Rating Sheet With Process Steps and Subcategories

Process Step	Subcategory
Assessment	Establish a rationale for improvement Identify potential partners and stakeholders Engage stakeholders Form community health coalition (e.g., team-building, meeting tips) Prepare and analyze community health profiles Identify and analyze critical health issues
Planning	Prioritize health issues and set goals Inventory resources: What do the coalition and community have available to address issues? Explore evidence and effective programs Develop a health improvement strategy (define the intervention and methods or steps) Identify accountability: Who will be responsible for each piece of the strategy?
Implementation	Implement the strategy Test the strategy (e.g., Plan, Do, Study, Act cycles) Plan strategies for dissemination and tips for executing dissemination Maintain gains
Monitoring/ Evaluation	Develop process and outcomes indicator sets and measures Develop instruments and strategy for collecting evaluation data Monitor the process and outcomes

Rating Process

One researcher (K.A.S.) from the review panel rated the tools on the basis of the final rating sheet parameters. To ensure reliability of the ratings, a second researcher (K.E.S.) then reviewed and rated the tools independently.

RESULTS

Our initial search yielded 23 tools that included most of the characteristics of interest. On the basis of our inclusion criteria, we selected nine of these tools for a full review. The most common reasons for excluding tools were that they focused on one or a few of the four primary process steps, and the content was specific to the state in which the tool originated, limiting the generalizability to other geographical areas and state health systems.

Table 2 provides a list of the nine tools, as well as a brief summary of their distinctive features, structures, and focus areas.

TABLE 2.

Final Selected Tools and Summary of Focus and Features

Tool (Author, Year)	Summary of Focus and Features
CHANGE (Community Health Assessment and Group Evaluation)   (Centers for Disease Control and Prevention, 2010)	The CHANGE tool centers on a method of assessment that helps communities identify strengths and weaknesses in the areas of policy, systems, and environmental change strategies.
Community Readiness   (Tri-Ethnic Center for Prevention Research, 2014)	The Community Readiness tool helps users assess a community’s readiness to address a particular health issue. This tool guides the user through an evaluative process that ranks community readiness across six key dimensions.
Community Tool Box   (University of Kansas Work Group for Community Health and Development, 2015)	The Community Tool Box is organized into units, chapters, sections, and subsections, and is accessible for a wide variety of audiences.
County Health Rankings and Road Maps   (University of Wisconsin Population Health Institute, 2015)	The County Health Rankings and Road Maps tool combines step-by-step guidelines with the County Health Rankings database resources to plan a community health initiative.
MAP-IT (Mobilize, Assess, Plan, Implement, Track)   (U.S. Department of Health & Human Services, 2015a)	The MAP-IT tool is designed around Healthy People 2020 objectives and resources and is intended to help communities plan and evaluate public health interventions that aim to address Healthy People 2020 objectives.
MAPP (Mobilizing for Action through Planning and Partnerships)   (National Association of County and City Health Officials, 2015b)	The MAPP tool includes four community assessments (Community Themes and Strengths Assessment, Local Public Health System Assessment, Community Health Status Assessment, and Forces of Change Assessment), the results of which inform strategic planning and action. MAPP has a distinctly systems-level focus.
PATCH (Planned Approach to Community Health)   (U.S. Department of Health & Human Services, 2015b)	The PATCH tool was created as a resource for individuals designated as PATCH local coordinators, leaders who guide every step of a community health initiative. This tool is a rich resource for those who hold positions of leadership in an initiative, but it may not be widely accessible to a broader audience.
Practical Playbook   (de Beaumont Foundation, Duke Department of Community and Family Medicine, & Centers for Disease Control and Prevention, 2014)	The Practical Playbook tool is designed to assist in efforts to integrate the activities of public health and primary care groups. Resources focus on facilitating integrative efforts and encouraging collaboration as key to successful population health efforts.
SPF (Strategic Prevention Framework)   (Substance Abuse and Mental Health Services Administration, 2009, 2015)	The SPF tool is intended for use in creating interventions targeting substance abuse, and it is specifically designed for states, tribes, and jurisdictions seeking funding through the Center for Substance Abuse Prevention structures.

Table 3 presents a summary of the rating results for each of the nine tools across the four main process steps (Assessment, Planning, Implementation, Monitoring and Evaluation). For each subcategory, we assigned a rating of 0 (none), 1 (some), or 2 (a lot) on the basis of the extent to which the tool provided applicable information or resources. We averaged the numerical ratings for each of the four main steps and translated these averages into overall ratings of low, mid, or high. We also rated each tool on the basis of whether it included specific attributes that may affect its usability and utility. Table 4 provides a summary of these ratings (i.e., none, some, many), as well as information about language, navigability, and format.

TABLE 3.

Ratings of Tool Process Steps

Process Step	CHANGE	Community Readiness	Community Tool Box	County Health Rankings and Road Maps	MAP-IT	MAPP	PATCH	Practical Playbook	SPF
Assessment	Mid	Mid	High	High	Mid	High	High	High	High
Planning	Low	Low	High	High	Mid	High	High	Mid	High
Implementation	Mid	Mid	High	Mid	Low	Mid	Mid	Mid	Mid
Monitoring/ Evaluation	Low	Mid	High	High	Mid	High	Mid	Mid	High

Note. CHANGE = Community Health Assessment and Group Evaluation; MAP-IT = Mobilize, Assess, Plan, Implement, Track; MAPP = Mobilizing for Action through Planning and Partnerships; PATCH = Planned Approach to Community Health; SPF = Strategic Prevention Framework; low = a small amount of information related to the process step; mid = a moderate amount of information, instructions, and resources related to the process step; high = a large amount of information, instructions, and resources related to the process step.

TABLE 4.

Ratings of Tool Features

Features	CHANGE	Community Readiness	Community Tool Box	County Health Rankings and Road Maps	MAP-IT	MAPP	PATCH	Practical Playbook	SPF
Toolkit Legend, Icons	Many	None	Some	Some	None	Some	None	Some	None
Call-out Boxes (e.g., Tips for Use)	Some	None	Some	Some	None	Many	Some	Some	None
Pictures, Diagrams, Figures, Graphic Organizers	Some	Some	Some	Some	Some	Many	Some	Some	Some
Case Examples	Some	Some	Many	Many	Some	Many	Some	Many	Many
Meeting Agendas or Session Plans	None	Some	Some	Many	None	Many	Many	Some	None
Sample Handouts or Slide Presentations	Some	Some	Many	Many	Some	Many	Many	None	Some
Sample Data Collection Sheets, Surveys	Many	Many	Some	Some	Some	Many	Many	Some	Some
Exercises or Learning Activities	None	Some	Some	Many	Some	Many	Many	Some	Some
Linked Resources, Research Evidence, or Bibliography	Some	Many	Many	Many	Some	Many	Many	Many	Many
Glossary of Terms Languages Available	Many English, Partial Spanish	None English	Some English, Spanish, Arabic	None English	None English	Many English	Many English	Many English	Some English
No. of External Links	Low	Low	High	High	Mid	Low	Low	High	High
Format	Primarily PDF/ some web	Primarily PDF/some web	Web	Web	Primarily web/some PDF	Primarily PDF/some web	PDF	Primarily web/some PDF	Primarily web/some PDF

Note. CHANGE = Community Health Assessment and Group Evaluation; MAP-IT = Mobilize, Assess, Plan, Implement, Track; MAPP = Mobilizing for Action through Planning and Partnerships; PATCH = Planned Approach to Community Health; SPF = Strategic Prevention Framework; PDF = portable document format.

The nine tools vary with respect to specific process steps and features and formats. All of the tools can be helpful to hospitals as they embark on CHAs and project implementation. However, we offer these considerations for individuals in hospital settings.

Community Tool Box

The Community Tool Box is the most comprehensive of the nine tools. Each process step is covered in depth, and numerous resources and references are provided to guide users in even the most specific aspects of an initiative. However, the navigability and, thus, usability of the Community Tool Box is limited by the large volume of information provided and the number of external links. Because of its size and the time required to navigate it, we do not recommend the Community Tool Box for hospitals just starting to conduct CHAs or that have limited experience in navigating the process steps. However, for hospitals already engaged in these activities or looking for particular resources in one area, we highly recommend the Community Tool Box.

County Health Rankings and Road Maps Tool

The County Health Rankings and Road Maps tool is comprehensive and accessible. The instructions and resources are extensive enough to provide a strong project foundation, and the format is manageable for a wide range of users. We recommend that hospitals just beginning to explore these resources and those with limited experience first review the road maps tool to determine if it meets their needs.

Some hospital employees working on the CHA and implementation requirements may have expertise related to one or more of the four main process steps (e.g., evaluation) and do not require as much information in those areas. We recommend that they use the ratings tables (Table 3 and 4) to determine which tools most effectively address the process steps for which they need assistance.

Practical Playbook

Organizations interested in solidifying long-term partnerships with public health and community organizations that include and extend beyond the CHA and implementation planning requirements will benefit from the Practical Playbook. The Playbook was developed with healthcare providers in mind and outlines a process for creating sustained partnerships with public health departments on community health efforts.

DISCUSSION AND RECOMMENDATIONS

The ACA’ s CHA and implementation strategy requirements provide an opportunity for hospitals to begin or build on population health efforts for the communities they serve by partnering strategically with public health and social service agencies. Fortunately for hospitals, public health and community health experts have developed a solid platform of models and tools to jump-start the work related to these requirements. In addition, by understanding and using these tools, hospital leaders acknowledge the expertise of community and public health partners, which provides an opportunity to establish or enhance collaborative relationships.

Limitations of Review

The list of tools in this review was comprehensive, but we excluded some tools that may be helpful for certain users. For instance, we omitted some tools because they focused only on one of the four primary process steps. These less-comprehensive tools do not include the resources necessary to guide a user through the entire community health initiative process, but some may find such tools helpful for obtaining in-depth information about a particular step (e.g., assessment).

Other excluded tools were from statewide public health agencies and departments. These tools include content that is particular to the state in which they originated and to the state-specific health system structures and regulations. However, individuals responsible for conducting a CHA can contact their state or county health departments to inquire about tools designed for their particular contexts.

Finally, we included only those tools that are available electronically, so we may not have captured some that would be helpful. However, given the depth and breadth of the tools located, we feel confident that users will find them more than adequate for meeting their needs.

CONCLUSION

Collaborative partnerships between public health, community stakeholders, and medicine are essential for healthcare reform. The models and tools reviewed in this report give those tasked with meeting the new CHA and implementation strategy requirements a portfolio of resources to use. We also hope that use of these tools brings health systems closer to realizing the opportunities and rewards that come with sustained, collaborative partnerships with public health departments and community agencies. As the IOM (2012) noted:

By working together, primary care and public health can each achieve their own goals and simultaneously have a greater impact on the health of populations than either of them would have working independently. Each has knowledge, resources, and skills that can be used to assist the other in carrying out its roles (p. 5).