Assessing Community Health Needs

Assessing Community Health Needs

Why This Skill Exists

Community Health Needs Assessments (CHNAs) are both a public health best practice and a legal requirement. IRS Section 501(r)(3) mandates that nonprofit hospitals conduct a CHNA every three years. PHAB accreditation requires health departments to complete a Community Health Assessment (CHA) as a prerequisite for Domain 1 compliance. The MAPP (Mobilizing for Action through Planning and Partnerships) framework — developed by NACCHO and CDC — provides the structured methodology most widely adopted by local health departments. Without a rigorous CHNA, communities cannot identify priority health needs, justify funding requests, or align interventions with actual population burden. This skill guides the complete CHNA process from planning through implementation strategy development.

The CHNA process has evolved significantly since the ACA's 501(r)(3) mandate. Best practices now emphasize genuine community co-ownership (not just community input), explicit health equity analysis, integration with state health improvement plans (SHIPs), and alignment with Healthy People 2030 objectives. ASTHO's and NACCHO's updated MAPP 2.0 framework (2022) reflects these shifts, moving from community consultation to community partnership.

Checkpoint A — Intake and Scoping

Intake Questions

1. Who is the lead entity — health department, nonprofit hospital, or collaborative? (Determines regulatory framework: PHAB vs. IRS 501(r)(3).)
2. What is the geographic scope — county, multi-county region, city, tribal area, or hospital service area?
3. Is this an update to a prior CHNA or a first-time assessment?
4. What community engagement infrastructure exists — advisory boards, coalitions, community health workers?
5. What quantitative data sources are available — BRFSS, YRBSS, vital records, hospital discharge, claims data, CDC WONDER, County Health Rankings?
6. What is the timeline and budget for primary data collection (surveys, focus groups, key informant interviews)?
7. Will the CHNA feed directly into a Community Health Improvement Plan (CHIP)?
8. Are there Healthy People 2030 objectives or state health improvement plan (SHIP) priorities that must be addressed?

Required Documents

• Prior CHNA report and CHIP (if existing)
• County Health Rankings & Roadmaps data profile for the target geography
• BRFSS prevalence estimates for key health behaviors and chronic conditions
• Vital records data: birth, death, and fetal death files for the jurisdiction
• Hospital discharge and ED visit data by diagnosis (if accessible)
• Census Bureau demographic profiles (American Community Survey 5-year estimates)
• Community input from prior assessments, town halls, or listening sessions
• Healthy People 2030 Leading Health Indicators relevant to the jurisdiction

Step 1 — Convene Stakeholders and Define the Assessment Framework

• Identify and recruit a steering committee that includes: health department leadership, hospital community benefit staff, community-based organizations, elected officials or their designees, and community residents (especially from populations experiencing health disparities).
• Select the assessment framework:
  • MAPP 2.0 (NACCHO/CDC): Four assessments — Community Health Status Assessment, Community Themes and Strengths Assessment, Forces of Change Assessment, and Local Public Health System Assessment.
  • CHNA for 501(r)(3) compliance: Must include input from persons representing the broad interests of the community, including underserved populations, and public health expertise.
• Define the health topics to be assessed. At minimum, address: chronic disease, infectious disease, maternal and child health, behavioral health (mental health and substance use), injury and violence, environmental health, and access to care.
• Establish a community engagement plan with specific strategies for reaching priority populations (non-English speakers, rural residents, persons experiencing homelessness, tribal communities).

Step 2 — Collect and Compile Quantitative Data

Assemble a community health profile using standardized data sources:

• Demographics: Population size, age distribution, race/ethnicity, poverty rate, educational attainment, unemployment, uninsured rate (ACS 5-year estimates).
• Mortality: Leading causes of death, age-adjusted death rates, years of potential life lost (YPLL), premature mortality (deaths before age 75). Source: NCHS/vital records.
• Morbidity: Prevalence of diabetes, hypertension, asthma, obesity, cancer incidence (state cancer registry), STI rates, TB incidence. Source: BRFSS, state surveillance, NCI SEER.
• Maternal/child health: Infant mortality rate, low birth weight rate, preterm birth rate, teen birth rate, prenatal care initiation. Source: vital records, Title V data.
• Behavioral risk factors: Smoking prevalence, binge drinking, physical inactivity, fruit/vegetable consumption. Source: BRFSS, YRBSS (for youth).
• Healthcare access: Primary care provider-to-population ratio, mental health provider shortage, preventable hospitalization rate (PQI composites from AHRQ), uninsured rate. Source: HRSA Area Health Resource File, ACS.
• Social determinants: Food insecurity rate (Feeding America Map the Meal Gap), housing cost burden, broadband access, Social Vulnerability Index (CDC/ATSDR SVI).

Benchmark all indicators against state averages, national averages, and Healthy People 2030 targets.

Key Data Source Reference

Step 3 — Collect Qualitative Data from the Community

Primary data collection gives voice to community members and surfaces needs not visible in administrative datasets:

• Key informant interviews (15-25 interviews): Target healthcare providers, social service leaders, school administrators, faith leaders, and public safety officials. Use a semi-structured guide aligned with CHNA health topics.
• Focus groups (4-8 groups): Recruit from priority populations (racial/ethnic minorities, low-income, uninsured, persons with disabilities, LGBTQ+ community). Conduct in appropriate languages with trained facilitators.
• Community survey: Deploy online and paper-based survey covering perceived health priorities, barriers to care, and community strengths. Use validated instruments (e.g., PROMIS, PHQ-2 for mental health screening). Target a sample that reflects the community's demographic composition.
• Community forum/listening sessions: Open public meetings in accessible locations (libraries, churches, community centers) to gather broad input.

Analyze qualitative data using thematic coding. Identify convergent and divergent themes between quantitative findings and community perception.

Step 4 — Synthesize Findings and Prioritize Health Needs

Merge quantitative and qualitative findings into a prioritization process:

• Present compiled data to the steering committee and community stakeholders.

• Apply a structured prioritization method:

  • Hanlon Method: Score each health issue on Size (magnitude), Seriousness (severity, urgency, economic impact), and Effectiveness of interventions (PEARL feasibility: Propriety, Economics, Acceptability, Resources, Legality).
  • Multi-voting or nominal group technique: Stakeholders rank top priorities.
  • Dot voting: Community members allocate priority dots to health issues at public meetings.

• Select 3-5 priority health needs based on: magnitude of the problem, severity of consequences, health equity impact (disproportionate burden on underserved populations), availability of effective interventions, community readiness, and alignment with state/national priorities.

• Document the prioritization rationale, including the criteria used and the stakeholder input that informed selection.

• For each selected priority, document: the quantitative burden (prevalence, rate, trend), the qualitative burden (community voice, lived experience), the equity dimension (which populations are disproportionately affected), the evidence base for intervention (what works), and the community capacity to address it (existing assets, organizations, programs).

Step 5 — Document the CHNA and Develop the Implementation Strategy

• Write the CHNA report including: executive summary, community description, methods, data findings by health topic, community input summary, priority health needs, and resources available to address them.

• For 501(r)(3) hospitals: prepare the accompanying Implementation Strategy (IS) that describes how the hospital plans to address each identified priority need, or explains why a need will not be addressed. The IS must be adopted by the hospital's governing body.

• For health departments: the CHNA feeds directly into the Community Health Improvement Plan (CHIP), which specifies measurable objectives, evidence-based strategies, responsible partners, and timelines for each priority.

• Post the CHNA report publicly (required for 501(r)(3); best practice for health departments per PHAB standards).

• Plan for continuous monitoring: establish lead indicators for each priority that will be tracked annually between CHNA cycles.

• Cross-sector alignment --- Align CHNA priorities with other planning processes in the community: hospital community benefit plans, United Way priorities, school district health plans, local government strategic plans, and Federally Qualified Health Center (FQHC) needs assessments. Shared priorities enable shared resources.

Checkpoint B — CHNA Completion Review

• Steering committee included representation from underserved populations and public health expertise

• Quantitative data compiled for all required health topics with sources documented

• Qualitative data collected from at least 3 distinct methods (interviews, focus groups, surveys)

• Data benchmarked against state, national, and Healthy People 2030 targets

• Prioritization process documented with criteria and stakeholder participation

• 3-5 priority health needs selected with documented rationale

• CHNA report written and formatted for public posting

• Implementation Strategy or CHIP drafted with measurable objectives

• Cross-sector alignment assessed with other community planning processes

• Health equity analysis documented for each priority need with disparity ratios

• Community asset inventory completed alongside need identification

Quality Audit

• CHNA meets IRS 501(r)(3) requirements if conducted by a nonprofit hospital (community input, public health expertise, public availability)

• CHNA aligns with PHAB Standards and Measures Version 2022 Domain 1 if conducted by an accredited health department

• MAPP 2.0 four-assessment framework applied (or equivalent methodology documented)

• Data sources cited with year, geography, and methodology notes

• Health equity lens applied — disparities by race/ethnicity, income, geography, and other SDOH factors highlighted for each priority

• Community engagement was inclusive, not just advisory — community members had decision-making power in prioritization

• SVI or equivalent composite index used to identify populations at greatest risk

• Report reviewed by steering committee and community stakeholders before finalization

• MAPP 2.0 (or equivalent) framework applied with all four assessments completed

• Priority selection process documented with explicit equity criteria applied

• Cross-sector alignment with hospital, government, and nonprofit planning processes documented

• Community asset mapping completed to complement needs identification

Guidelines

• The CHNA is a community document, not just a hospital or health department document. Genuine community ownership increases the likelihood that priorities translate into action.

• Avoid data dumps. The CHNA should tell a story about community health — not merely present tables. Contextualize every data point with community voice and local relevance.

• Prioritization must be transparent and inclusive. A process that produces priorities without meaningful community input will lack legitimacy and political support for implementation.

• For 501(r)(3) compliance, the IRS requires that the CHNA be conducted in the tax year it is adopted, be approved by an authorized body, and be made widely available to the public. Failure to comply results in an excise tax of $50,000 per year.

• When data for small populations is unavailable (e.g., tribal nations, specific immigrant communities), document the data gap explicitly and describe steps taken to gather primary data from those communities.

• Update the CHNA on a three-year cycle at minimum. In rapidly changing communities (pandemic impact, economic disruption, population migration), consider interim updates.

• Escalate to steering committee leadership when: community stakeholders disagree on priorities, data reveals a previously unrecognized health crisis, or available resources are insufficient to address any of the top priorities.

• A CHNA that identifies needs without identifying assets is incomplete. Every community has strengths — organizations, leaders, cultural assets, natural resources — that should be mapped alongside health needs. Asset-based community development (ABCD) principles complement needs-based assessment.

• Data presentation matters as much as data collection. Use data visualization (maps, infographics, comparison charts) to make findings accessible to community members, elected officials, and non-technical stakeholders. A CHNA report that only data analysts can interpret fails its primary audience.