From CHNA to population health: Moving from your needs assessment to population health management

Your Community Health Needs Assessment (CHNA) can be seen as a compliance exercise: a project to be completed, filed, and forgotten until the next requirement. Or it can be a strategic document that outlines how an organization can better use its resources, better serve the community, and maximize its return on investment (ROI).

Recognizing the value of a CHNA on your concurrent Population Health Management (PHM) strategies will allow you to realize a significant return from the time, effort, and expense invested in a CHNA.

"A strategically focused CHNA can benefit both the community and the bottom line. It can also help an organization plan and prepare for future healthcare delivery by identifying high-risk populations and predicting health needs that will affect future programs and resources."

The value of a CHNA

In short, a strategic CHNA can help:

• Maximize resources by focusing on priority health issues
• Understand healthcare utilization patterns and identify underserved populations
• Create an action plan that captures measurable outcomes
• Compare local communities and organizations to others across the state and nation
• Develop and strengthen long-term, collaborative partnerships
• Enhance care models to improve quality and value
• Inform patient engagement and other population health management initiatives

Data and analysis

To gather a full picture of community health needs and maximize the value of your CHNA, healthcare providers should integrate patient utilization data into the CHNA to show the intersection between service delivery gaps and community health needs. 

CHNA quantitative data typically incudes:

• Demographic information, including age, gender, race, and ethnicity
• Socio-economic measures, including education, poverty, and housing
• Public health statistics, like morbidity and mortality rates
• Health behavior trends, such as smoking rates, physical activity levels, and nutrition

These public data can be augmented with internal data, including:

• Emergency department (ED) utilization
• Inpatient and outpatient volumes and readmission rates for chronic diseases
• Behavioral health and comorbidity factors

Combining these data sources helps healthcare providers gain a deeper understanding of:

• Barriers to achieving optimal health
• Service delivery gaps
• Socio-economic trends that will determine future healthcare needs
• Healthcare delivery preferences among different population segments
• Partnership opportunities to improve patient outcomes

Correlating internal and external data points can demonstrate ROI to support community health programs and guide resource allocation. For example, examining utilization trends may reveal whether a school-based asthma initiative in a low-income neighborhood reduced ED visits.

To further understand behaviors behind health statistics, qualitative research can be gathered through discussions, surveys, focus groups, and interviews with healthcare consumers and other community stakeholders. Focus groups with diabetic patients, for instance, can pinpoint challenges and motivational factors that can inform patient engagement initiatives that ultimately improve chronic disease management and patient outcomes.

A model for the future

As healthcare providers move toward value-based payment models and away from fee for service, CHNA research helps decision-makers determine what population risks they are exposed to and identify potentially beneficial partners in a risk-sharing model.

Strategic community partnerships allow hospitals to better manage high-risk populations by meeting patients’ social needs in addition to their healthcare needs. No single healthcare organization has the capacity and expertise to meet all the demands of high-risk populations; collectively, healthcare partnerships can ensure positive outcomes for patients.

Questions a strategic CHNA should answer

 

• How effective are your ongoing community health improvement efforts?
• What internal data would be valuable to your CHNA; what external data will be valuable to internal PHM strategies?
• How will your health system align priorities, strategies, and measurement to maximize resources and coordination?
• What is your ROI for community health improvement efforts? 

How Baker Tilly can help

Baker Tilly’s CHNA team has conducted CHNAs for more than 100 hospital and health systems, from standalone hospitals to multi-state systems. We’ll ensure that your CHNA research aligns with your strategic initiatives and that findings support ongoing PHM planning. 

Even if you’ve already begun or completed your CHNA, Baker Tilly can help your organization use CHNA findings to evaluate internal capacity and processes to predict and meet the future needs of your community to improve population health and your bottom line.

Though implementation of a population health strategy is complex, Baker Tilly brings the depth of experience necessary to guide organizations through this process with services that include:

• Financial planning and feasibility studies
• Operational and organizational assessments
• Revenue cycle optimization
• Transaction advisory services
• Value-based managed care contracting services

Your previous CHNA may have been a “check the box” compliance task, with hundreds of pages of data and only a few pages of strategic planning; Baker Tilly can help you integrate your data into a robust, ongoing PHM strategy.