Following passage of the Affordable Care Act, the U.S. Internal Revenue Service (IRS) began requiring that non-profit hospitals conduct a Community Health Needs Assessment (CHNA) every three years and adopt implementation strategies to address identified needs. Together with other developments, the CHNA requirement offers an extraordinary promise to refocus hospital “community benefits” spending upstream to address the social and behavioral determinants of health and to catalyze community health improvement (CHI) processes that address health equity through multi-sector assessment, prioritization, planning, implementation, along with monitoring and evaluation. 

However, although some hospitals and communities have adopted promising approaches, hospitals vary markedly in how they receive input from community members, the methods they use to set priorities, their collaboration with other organizations, and in how they measure performance and evaluate strategies to improve population health. CHI processes focus more on conducting CHNAs than on implementing strategies, monitoring these efforts, and evaluating the results. Consequently, the IRS CHNA regulations so far do not seem to have catalyzed multisector community health improvement efforts to the degree that some hoped. 

Fulfilling the promise of CHNAs requires building on two major trends:

  • A transformation in healthcare towards reimbursement based on value rather than the volume of services provided, meaning that healthcare systems are increasingly held accountable for improving health outcomes, which requires collaboration with others in their communities.
  • The emergence in many communities of collaborations involving healthcare providers, public health agencies, and many other organizations, along with data systems to support them.

Within the context described above, our environmental scan suggests five strategies to facilitate population health improvement within the context of the needs, will, and capacity of community partners.

Community benefit requirements and expectations. The IRS or state agencies could make clear that hospitals’ community benefits requirements should encourage population health improvement using a collaborative approach, such as Kania and Kramer’s concept of “collective impact.”  Rosenbaum and colleagues suggest that to improve population health hospital collaborations be proactive, broad, and include diverse community engagement. 

States, as in New York, could also tie CHNA’s and implementation strategies directly to other population health initiatives. More specifically, the IRS could clarify which “community building” investments aimed at promoting community-wide interventions such as affordable housing and environmental improvements that address the “upstream” social determinants of health qualify as community benefits. Allowing these expenditures could facilitate a transformation from hospitals as medical care providers to partners in community health improvement.

Definition of community. The IRS regulations require CHNAs to include the definition of community served by the hospital and a description of how it was determined, but the regulations do not say specifically how the community should be defined. Not surprisingly, great variability exists in how hospitals define the community they serve, and the result is a patchwork of overlapping populations defined by geographic, demographic, and other factors.  Moving forward, the hospitals in a city or county might agree on a common community definition that allows for population-wide interventions and priority setting.  Individual hospitals could choose target areas for their own implementation strategies reflecting a targeted focus to address disparities. 

Priority setting. Deciding which community health priorities to address is a central part of the community health improvement process, but hospitals and other organizations conducting CHNAs have taken very different approaches to selecting them. Most commonly, hospitals focus their attention on clinical priorities and activities that are already underway. One option to consider is changing the IRS or related state requirements and expectations to more strongly encourage hospitals to use their CHNAs as a guide to address upstream factors such as housing and food insecurity in their community benefits programs.   

Collaboration in implementation strategies. Collaboration between the healthcare delivery system, public health agencies, and many other community organizations, is critical to population health improvement. Yet many hospitals’ community health improvement processes are limited in scope. One way to address this problem would be to change the expectations set by the IRS and state agencies to encourage multisector collaborations that support shared ownership of all phases of community health improvement, including assessment, planning, investment, implementation, and evaluation. Collaboration does not mean that every hospital, health department, and other organization in a region undertake the same community health improvement activities. Rather, organizations could identify common population health goals and each undertake specific programs consistent within their capabilities and resources. The IRS regulations or related state requirements also could be clarified to recognize and encourage hospitals’ financial contributions to other organizations addressing the same goals as appropriate community benefit expenditures. For example, the Massachusetts Attorney General’s Office encourages hospitals to collaborate with other hospitals, health plans, local health departments, and other organizations in developing their Implementation Strategies. A joint Implementation Strategy should describe how organizations intend to collaborate to address the identified needs in their community, clearly identify each hospital’s role and responsibility in taking the actions described in the Implementation Strategy, and identify the resources each hospital plans to commit to such actions. 

Evaluation and performance measurement. As noted by Kania and Kramer, agreement on a common agenda is illusory without agreement on the ways success will be measured and reported. Community health improvement processes benefit from a shared measurement system that indicate accountability for specific activities. Despite the importance of measurement and evaluation, existing community health improvement efforts often fall short in these areas. Strengthening the CHNA regulations to require that hospitals report the evaluation measures they intend to monitor based on an established community health improvement model could help communities demonstrate impact. 

This analysis is part of a larger project, conducted with support from the Robert Wood Johnson Foundation, aimed at increasing our understanding of the characteristics of CHI processes, employed by hospitals and their community partners, that have promise (via evidence) to improve health equity and outcomes. 

Michael Stoto

Michael A. Stoto, Ph.D.

Professor - Georgetown University

Dr. Stoto, a Professor of Health Systems Administration and Population Health at Georgetown University, is a s... Read Bio


Mary Davis

Senior Evaluation Lead - Health Resources in Action

Mary Davis, DrPH, MSPH, is a Senior Evaluation Lead with Health Resources in Action and an evaluation consulta... Read Bio

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