1. Community Health Needs Assessment: Developing an Action Plan

2. Building Leaders – Transforming Hospitals – Improving Care
Speaker
Carolyn St. Charles, RN, BSN, MBA
Regional Chief Clinical Officer
Carolyn began her healthcare career as a staff nurse in Intensive Care.  She has worked in a variety of staff, administrative and consulting roles and has been in her current position as Regional Chief Clinical Officer with HealthTechS3 for the last fifteen years.   In her role as Regional Chief Clinical Officer, Carolyn St.Charles is the lead consultant for development of Community Health Needs Assessments. She also conducts mock surveys for Critical Access Hospitals, Acute Care Hospitals, Long Term Care, Rural Health Clinics, Home Health and Hospice.
Building Leaders – Transforming Hospitals – Improving Care

3. Building Leaders – Transforming Hospitals – Improving Care
Who We Are
Our Company
Our Team
Our Mission
Formerly known as Brim Healthcare we have a 45 year track record of delivering superior clinical & operating results for our clients
Our Executive Team has experience in managing hospitals from multi-billion $ healthcare systems to community hospitals
We believe that the combination of People, Process & Technology transforms healthcare & provides the required results
Management
Consulting
Placement
Technology
Turnaround Strategy
Financial
Operations
Corporate Compliance
Board Development
Regulatory Compliance and Accreditation Preparation
Lean Process Improvement
Community Health Needs Assessments
Execuitve Recruiting
Interim Executive Placements
Mid-level and Specialty Placements
Gaffey Revenue Cycle Management
CrossTX Population Health Platform
Optimum Productivity
Update Verbiage
Building Leaders – Transforming Hospitals – Improving Care

4. Instructions for Today’s Webinar
You may type a question in the text box if you have a question during the presentation
We will try to cover all of your questions – but if we don’t get to them during the webinar we will follow-up with you by
You may also send questions after the webinar to Carolyn St.Charles (contact information is included at the end of the presentation)
The webinar will be recorded and the recording will be available on the HealthTechS3 web site
HealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this information is not intended to be definitive.  HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof.  HealthTechS3 does not and shall not have any authority to develop substantive billing or coding policies for any hospital, clinic or their respective personnel, and any such final responsibility remains exclusively with the hospital, clinic or their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of this information consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare reimbursement and regulatory matters.

5. Requirement Affordable Care Act- 501(r) Addition
Requirement to maintain 501(c)(3)
Conduct a community health needs assessment (CHNA) and adopt an implementation strategy at least once every three years.
An authorized body of the hospital has adopted an implementation strategy to meet the needs identified in the CHNA on or before the 15th day of the fifth month after the end of such taxable year.
A $50,000 excise tax will be imposed on a hospital that fails to meet the CHNA requirements with respect to any taxable year
Let’s begin by discussing a little bit of background. The Affordable Care Act included IRS requirements for tax exempt hospitals, specifically section 501(r). The rule requires that facilities conduct a Community Health Needs Assessment and adopt an implementation strategy or action plan once every three years. The rules also require that you perform annual updates. So the rotation will look something like this, complete a CHNA in year one, within 4 ½ months (by the 15th of the fifth month following the adoption of the plan) have completed an action plan. Then for years two and three you will need to provide an update/progress report, and the cycle will repeat.
The rules indicate that a $50,000 excise tax will be imposed for failure to meet the requirements of any year. In this webinar we will be focusing on the development of the implementation strategy.
Source: 79 FR 79001

6. Implementation Strategy
Plan for addressing the health needs of the community
Identified by:
Completion of a CHNA
Documented Need
Request from a Public Agency
An implementation strategy as it relates to the IRS requirements is a plan that is developed to address the community health needs. These can needs can be identified in various different ways, however one of the main identification sources will be those needs prioritized in your CHNA. There are other needs which may become a priority and those include needs that may be identified through some other source of documentation or a request that may be received from a public agency.
Source: Catholic Health Association of the US: 2015 Guide for Planning & Reporting Community Benefit

7. Development Process Assess Readiness Identify Who
Develop Goals and Objectives
Select Interventions
Document the Plan
Adopt the Plan
Update as Needed and Annually
Using a process that contains the steps listed here is one way to ensure the successful development and implementation of a plan. The Catholic Health Association suggests that you begin by assessing your readiness and identify who will be involved in developing and implementing the plan. You will then be ready to proceed with developing goals, objectives and identifying the interventions that will help you achieve those goals. You’ll need to document your plan and ensure that it is adopted by the appropriate governing body and then update the plan as you move forward. We are going to look at each of these steps in more details as we move through the presentation.
Source: Catholic Health Association of the US: 2015 Guide for Planning & Reporting Community Benefit

8. Assess Readiness Staffing Budget Policies Leadership Support
Completed CHNA
Evaluate Community Connections
Review the Requirements
There are several things that you will need to take into consideration as you assess your readiness to develop your implementation strategy. Do you have the staff or community members available and willing to commit their time? Has the facility considered the budgetary needs of a plan. Do you have a procedure or policies that provide guidance? Is there support form leadership and are they committed to ensuring that the plan is successful. Make sure that a CHNA has been completed and that you have reviewed the community health needs that were prioritized through that assessment. Evaluate your facilities connections within the community. Are there individuals who are willing to participate, who are knowledgeable about certain health populations or knowledgeable about the community who can contribute to the plan? Consider public health experts or individuals who represent the various populations within your community. And finally be sure that you review the federal requirements and any state requirements that you may have as it relates to implementation strategies and community benefit planning.
Source: Catholic Health Association of the US: 2015 Guide for Planning & Reporting Community Benefit

9. Form a Team Determine the Number of Teams Identify Team Leaders
Identify Team Members
Identify Responsibilities
In forming your team decide whether you want one team or several teams. You may find it difficult to find team members who can commit the amount of time necessary to develop and oversee the implementation of multiple interventions. Each organization has different factors that will affect their implementation of the plan. These factors will need to be taken into account as you determine what format will be best for you. One option is to have a steering committee who assigns various teams for individual projects. Another option might be to start out with multiple teams who are assigned to one or more project without an overall steering committee. Once you have determined the structure of your team, then you will need to pick a team leader. This will need to be someone who has the time available to commit to the project and who will actively oversee the process. When considering who will be on the team, identify those individuals who are knowledgeable about the subject. Teams can and should include both internal and external members. When identifying external members, look for those individuals who are knowledgeable about the community or the subject at hand. Consider public health officials, business owners, school officials, school faculty, community service organization members, city or county officials, law enforcement, health agency employees, representatives of high priority populations among others.
Another important step is to identify the responsibilities of the team and make sure the team is made aware of their responsibilities. Those responsibilities may include identifying interventions and goals, establishing a budget, establishing timelines, identifying community resources, overseeing the implementation of various strategies and documenting progress and annual updates
Source: Catholic Health Association of the US: 2015 Guide for Planning & Reporting Community Benefit

10. Goals and Objectives- Root Cause
Root Cause Analysis
Limited Access
Available but not Accessible
Contributing Public policies
Contributing Social Factors
Contributing Economic Factors
Contributing Environmental Factors
Before you can identify goals, objectives or interventions, you need to understand what factors contribute to the prioritized need and the approach that can be taken in order to have an impact on that need.
A good way to understand the need is to perform a root cause analysis. Ask yourself is the problem stems from a problem with access to a service or a resource? Is the service available but not accessible by a priority population? Are there public policies that are contributing to the problem? What are the social, economic or environmental factors such as a low living wage, poverty, lack of housing, lack of food access etc. Additional information may need to be collected if sufficient data is not available.
Source: Catholic Health Association of the US: 2015 Guide for Planning & Reporting Community Benefit

11. Start with Root Cause Analysis
What is the problem?
Why is it happening – What are the causes? 1.
Why is that?
Why is that? 2.
Why is that? 3.
Why is that? 4.
Why is that? 5.
What should be done to prevent it?
Caution: If your last answer is
something you cannot control,
go back up to previous answer.

12. Fishbone – Cause and Effect Analysis

13. Goals and Objectives-Collective Impact
Common Agenda
Shared Measurement
Mutually Reinforcing Activities
Continuous Communication
Backbone Support
Consider using the Collective Impact Framework. This is a framework developed by the Collective Impact Forum. Collective Impact is a process of bringing different groups together to share experience and knowledge in order to solve a problem. This is a good method to use when bringing groups together to solve a problem that can not be solved by one group or organization. The Collective Impact Forum describes five conditions of Collective Impact core approach. The first being a common agenda with a common understanding of the problem that needs to be solved, the group agrees on the goals and there is a joint approach taken to solve the problem. Next is a form of measurement that all groups agree upon to ensure that all efforts by each organization are aligned and support the same goal.
Each person or team member focuses on the activities specifically in their area of expertise and are coordinated in a way to support each other.
Having regular meetings of the groups provides for continuous communication and helps to build relationships and trust.
And finally there should be one organization that is the backbone. This group should be separate from the participating groups and according to the Collective Impact Forum, this groups activities would include facilitation and mediation, technology and communication support, data collection and reporting as well as logistical and administrative activities.
Source: Brady, S. & Juster, J. (2016) Collective Impact Principles of Practice: Putting Collective Impact into Action

14. Collective Impact Framework

16. Goals and Objectives- Levels of Prevention
Primary Prevention
Preventing from occurring
Secondary Prevention
Finding and treating early
Tertiary Prevention
Making healthy again
The Catholic Health Association also suggests that you look at the various levels of prevention as you develop your interventions and focus on one, two or all three. The first level is primary prevention, in this stage the goal is to prevent something from occurring. Examples of this type of prevention include health education or immunizations. Secondary prevention is a focus on finding and treating a disease early. Examples here would be screening for various diseases, once identified focusing on early intervention in order to stop or minimize the progress. The last type of prevention is tertiary. In this case and individual already has a disease and your focus is to make them health again. Helping someone who is diabetic learn how to adjust their diet, or someone who has asthma prevent attacks.
Be sure that whatever type of intervention you select that you look at those that are evidenced-based.
Source: Catholic Health Association of the US: 2015 Guide for Planning & Reporting Community Benefit

17. Goals and Objectives- Other Considerations
Community Assets
Existing Programs
Feasibility
Community Support
Actions that need to be taken
Time-Frames
Staff
Infrastructure
Budget
Knowledge and expertise needed
Partnerships
Need for outside experts and consultants
Be sure to collect information about the assets that already exist in your community. You can start by looking at the resources that were identified in the CHNA. This will provide you with an initial list that you can build upon. What programs are already out there that you could build upon. It will not be very productive to try to create an new intervention along side one that is already in place. This will only serve to confuse the community and divide resources. Be sure to evaluate the feasibility of your goals and objectives. Do you have the support needed to meet the objective, what are the actions that need to be taken and can those be done? Is there staff available to assist, do we have the infrastructure built to support the goal long term, can the goal be accomplished in the time allowed? Do we have the knowledge and expertise needed on the team, do we need to develop additional partnerships or need outside experts or consultants? All of these things need to be considered in order to make sure that the goals and objectives can be realistically accomplished.
Source: Catholic Health Association of the US: 2015 Guide for Planning & Reporting Community Benefit

18. Select Interventions Reach Impact Evidenced-Based
Culturally appropriate Interventions
Once you have decided what your goals are you will need to develop the interventions that you believe will accomplish the set goals. Consider how many people that the identified intervention will be effected or influenced. Will the intervention be designed to reach an entire community or a specific population. Evaluate the intervention to determine if it has the potential to have an impact to change behavior. Evidenced-based interventions have already proven themselves as having the ability to be successful but you must consider the barriers within your targeted population and if those barriers can be overcome. Also make sure that the interventions that you pick are culturally appropriate for the group that is targeted. Selecting an intervention that conflicts with the cultural beliefs of a group will be destined for failure.
Source: Catholic Health Association of the US: 2015 Guide for Planning & Reporting Community Benefit

19. Written Strategy Describe how the need will be addressed
Describe the intended actions to address the health need
Describe the anticipated impact of the actions
Identify resources that will be committed
Describe planned collaborations
Describe the reasons for not addressing any of the significant health needs
Sample template available at
Once you have identified your goals and selected the interventions that you believe will accomplish those goals you will need to document your plan. According to the xxx you will need to document the actions you plan to take to address each health need. For each need describe the impact that you believe your actions will have and what resources you plan to commit. Any collaborations that will occur for the planned intervention will also need to be identified. The rules also indicate that if there was a health priority previously identified that you do not plan to address then you must document what your reasons are for not addressing that specific need. Some reasons for not addressing a specific need might include financial constraints, lack of expertise, lack of community support or the needs is being address by another group.
The Catholic Health Association provides a template that you can use to develop your written plan. They suggest that you also include your organizations mission statement and the community served in your written plan. I have included a link to their suggested template.
Source: 79 FR 79002

20. Joint Implementation Strategy
May developed a strategy with;
Other hospital facilities or organizations for example
Related and Unrelated Facilities
For-profit Organizations
Nonprofit Organizations
Governmental Hospitals
Governmental Departments
Hospitals can develop joint strategies with other organizations. These organizations can be either related to the facility or totally unrelated. They may include both for-profit or nonprofit organizations and it may also include governmental entities. However, you are still required to document your implementation strategy in a separate document that is tailored to your facility and takes into account your specific resources.
Source: 79 FR 79003

21. Joint Implementation Strategy Requirements
Clearly identified as apply to the hospital facility
Clearly identify the hospital’s role, responsibilities, and resources it plans to commit
Include a summary or tool that helps the reader easily locate the portions that relate to the hospital
Hospital governing body must adopt
Source: 79 FR 79003

22. Adopting the Plan
Hospital required to adopt an implementation strategy to meet the needs identified through the CHNA
Must be approved on or before the 15th day of the fifth month after the end of the taxable year in which the hospital completes the final step for the CHNA
Source: 79 FR 78970

23. Reporting Requirements
Non-governmental Hospitals
Attach to Form 990 most recently adopted implementation strategy for each hospital it operates OR
On the Form 990 provide the URL(s)of the Web Page where the implementation strategy is widely available
Governmental Hospitals
Exempt from filling Form 990
Make CHNA reports widely available on a Web Site
However, to be treated as described in section 501(c)(3), government hospital organizations still must meet all section 501(r) requirements that do not involve disclosure on or with the Form 990, including making their CHNA reports widely available on a Web site.
Source: 79 FR 78995

24. Enforcement
Section 4959
Imposes $50,000 excise tax on a hospital organization that fails to meet the CHNA
May be imposed for each taxable year
Not imposed for MINOR omissions or errors
Hospital organizations liable for the excise tax in any taxable year must file Form 4720 by the 15th day of the fifth month after the end of the taxable year.
Revoke 501(c)(3) status
Section 4959 indicates that a hospital facility WILL be subject to an excise tax and this tax can be imposed for each year that the facility doesn’t meet the requirements. So for example if you complete a CHNA and an implementation strategy but you don’t provide annual updates then you could still receive the penalty for the two years following the CHNA. The rules do indicate that if there is an omission or error and it is minor and either inadvertent or due to a reasonable cause and if corrected in accordance with the regulations that the excise tax would not apply.
Hospitals who are liable for the excise tax as a result of failing to meet the CHNA requirements are required to report that tax on Form 4720
The regulation indicate that the IRS will consider all facts in determining whether or not to revoke their 501(C)(3) status. These facts include the size, scope, nature and significance of the failure, the reason for the failure and whether or not the same failure has occurred before. Another factor that is considered is if the hospital had established practices or procedures in place that were designed to promote and facility overall compliance with the requirements, if they were being followed and if the failure was corrected promptly.
Source: 79 FR 78961

25. Example Goal: Improve Nutrition

26. Goal: Provide Nutrition Education BEFORE YOU START
Vulnerable or At-Risk Population(s) Communities or Neighborhoods Focus
Hospital and Clinic Employees Clinic Patients All communities in primary service area where employees and patients live Education to improve healthy food choices

27. Assess Readiness Internal Team Budget Leadership Support
Hospital Dietitian
Community Relations Director
Budget
$10,000 budgeted for initiative and approved by governing board to include staff costs and any materials that may be developed
Leadership Support
Board Steering Committee
CEO

28. Identify WHO – Form a Team
Internal – WHO has knowledge / information about nutrition and about education?
Dietitian
Clinic Director
Human Resources
Marketing
External – WHO is working on / addressing this issue – or may be interested in working on this from the community?
Public Health Dietitian
YMCA (Healthy Choices Program)

29. Root Cause Analysis – very simplistic
Problem:
25% of employees meet the CDC definition of obesity.
15% of employees meet the CDC definition of overweight
(75% of employees eat at least one meal at work)
1. Employees make poor health choices – eat unhealthy food that are high in sugar, carbs and fat.
2. Access: Lack of access to healthy food at work.
3. Environmental Factor: Food in cafeteria is pre-packaged with high salt, cholesterol and fat. Multiple vending machines with chips, soda, etc.
4. Economic Factor: Hospital makes money on vending machines. Budgetary constraints for purchasing and cooking healthier foods.

30. Goals – Objectives - Interventions
Goal: Reduce percent of employees who are overweight by 10% within the next 12 months.
Objective: Provide healthier food choices while at work along with incentives for eating healthier.
Interventions:
Remove items with high sugar and high fat from vending machines
Provide employee meal vouchers at a 50% discount good for “healthy food choices”
Change menu in cafeteria to add at least 50% more healthy choices
Eliminate pre-prepared food in cafeteria that is high in salt or fat
Implement Food cart with fresh fruits and vegetables once per week with one free item for each employee
Provide adult and kid cooking classes once per month

31. Provide adult and kid cooking classes once per month
Action Plan
Provide adult and kid cooking classes once per month
WHAT
WHO
WHEN
Identify place and time for classes
Hospital Dietitian
Public Health Dietitian
By February 2017
Develop class content for adults
By March 2017
Develop class content for kids
Develop marketing campaign for classes
Marketing
By April 2017
Begin providing classes
By June 2017

32. Questions?

33. If you would like to talk about your CHNA Please contact me
Carolyn St.Charles
Regional Chief Clinical Officer

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Upcoming Webinars
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