1. Community Health: From Assessment to Action June 5, 2013

2. The Affordable Care Act New IRS Requirements for Tax-Exempt Hospitals

3. Hospitals Required to Comply  All hospitals recognized as a 501(c)(3), including governmental hospitals.  Must complete a CHNA and adopt an implementation strategy, but are not required to file a form 990. Hospitals with this status should make their assessments and implementation strategies widely available.  If more than one hospital is operated by an organization, each hospital is required to complete a CHNA and adopt an implementation strategy.

4. Timing and Frequency of CHNAs  The CHNA must be conducted once every three years, beginning in the hospital’s first taxable year after March 23, 2012.  To be considered conducted, the written report must also be made widely available to the public. Posted “conspicuously.”*

5. Conducting and Documenting

6. Collaboration – New Hospitals may collaborate to conduct a CHNA if:  the collaborating hospitals define their community to be the same  the report clearly identifies that it applies to the hospital  the governing body of each hospital adopts the joint report

7. Defining Community – New  Hospitals have flexibility in defining the community they serve. The proposed facts and circumstances approach recognizes variance in defining community (e.g. geographic area, target populations, principal function)  Community may be defined by a particular area of specialty or disease.  Medically underserved, low-income or minority populations may not be excluded.

8. Identifying Health Needs – New  Hospitals must identify the “significant” health needs of the community rather than “all” needs.  Prioritize needs and identify potential measures, resources and facilities to address them. Hospitals have flexibility for determining what is significant and setting priorities.

9. Broad Community Input  Two categories of persons must have input taken into account in conducting the assessment.  one nonfederal governmental public health department  members of medically underserved, low- income and minority populations (or organizations representing their interests)

10. Broad Community Input – New  When subsequent CHNAs are conducted, written input received on a hospital’s existing CHNA or implementation strategy must be taken into account.  This requires a hospital’s most recent CHNA remain widely available until its two subsequent CHNAs are adopted and made widely available.

11. Implementation

12. Collaboration  Hospitals that collaborate on a CHNA may collaborate on an implementation strategy but must clearly identify that it:  applies to each hospital  outlines and identifies each hospital’s particular role and responsibilities, including programs and resources it will commit  provides a summary or tool to help the reader locate the strategies that relate to each hospital

13. Addressing Significant Needs  Every significant need identified must include a description of how the hospital will address the need or why it will not be addressed. For needs to be addressed, include:  the actions the hospital will take  the anticipated impact  a plan to evaluate the impact  identification of the programs and resources the hospital will commit

14. Transition Relief – New  The implementation strategy must be adopted by the hospital’s governing body in the same tax year as the hospital finishes the CHNA.  Recognizing that many hospitals will not be able to meet this initial requirement, the proposed rule adds four and a half months to the original three-year period for adoption of the first implementation strategy.

15. Noncompliance – New Proposed penalties for non-compliance.  Excused noncompliance. Forgives immaterial failures to comply as well as those that were corrected under two circumstances:  if the infraction is minor, inadvertent and due to reasonable cause and the hospital promptly takes remedial steps  if the infraction is more serious, but is neither willful nor egregious and is corrected by the hospital and disclosed to the IRS  Willful and Egregious Noncompliance that may result in revocation of a hospital’s tax-exempt status.  determined after a review of all facts and circumstances including prior infractions, magnitude and reasons for noncompliance, size and functions of the noncompliant facilities, policies and procedures implemented and followed to comply

16. Noncompliance  Facility-level tax  If one organization in a multi-hospital system egregiously or willfully fails to comply, but does not warrant loss of exemption for the entire organization, a “facility-level tax” would be imposed. The tax would calculated as if the hospital was a taxable corporation and the amount of the income tax it would have owed would be the amount owed.

17. Final Rule  Comments on the proposed rule due July 5  No firm date on final rule (estimate October 2013)  Rely on proposed rule for guidance until October 5, 2013.

18. The Community Health Needs Assessment Process

19. Steps To Conducting A CHNA 1. Define the community 2. Identify internal and external partners 3. Collect secondary data 4. Develop and conduct primary data collection 5. Analyze and prioritize primary and secondary data 6. Identify and prioritize community health issues 7. Develop and widely disseminate the CHNA report 8. Develop and implement a strategy to address the priority health issues

20. CAUTION: Conserve Energy Commit to Three  Stakeholders/partners  Secondary data sources  Formats for primary survey  At-risk population groups  Routes to disseminate findings  Priorities to address  Strategies for each priority  Three indicators per priority  Three year plan Keep in Mind: The hard work begins with implementation.

21. Population- based model for improving health outcomes CHNA questions and data Categories for analysis and priorities Implementation Plan Strategies and process measures Outcome measures

22. Step One: Define the Community The community definition must include  Geographical service area  Population served  Specialty services provided  At-risk populations  Unique community characteristics  Federal designation for medically underserved  Other hospitals in same “community”

23. Rationale for Partnerships  Many health care and community organizations benefit from assessments  Many health care organizations are required or encouraged to conduct assessments Step Two: Identify Partners Benefits  Collective wisdom  Collective impact  Efficiency

24. Step Three: Collect Secondary Data  Definition: existing data collected for another purpose  Data are available from local, state and national resources  Data provide the foundation for the quantitative information  Establish a baseline  Reveal health issues

25. Secondary Data Categories  Demographics  Health outcomes  Mortality  Morbidity  Health factors  Health behaviors  Clinical care, including access  Social and economic factors  Physical environment

26. Step Four: Primary Data Collection  Primary data: data collected specifically for the purpose of answering project-specific questions.  After review of secondary data, development of a survey tool should be used to  Validate secondary information  Fill gaps in data not provided by secondary sources  Provide more depth and information about a specific health issue identified through secondary data review  Provide qualitative information

27. Primary Data Collection (cont’d)  Planning considerations:  More resource intensive; requires development, testing and implementation prior to review of results  Collect exactly what you want and need, keep your questions focused (e.g. chronic disease)  Process can be simplified by using existing questions  Individual versus group response

28. Community Forums  Varied size – can be large  Diverse composition  Open invitation  Broad-based, open-ended questions  Less formal Data Collection: Group Responses Focus Groups  Small  Homogeneity  Invitation-only  Specific topic and focus  Requires strong facilitation

29. Step Five: Analyze and Prioritize Begin with dialogue…. Mission and Vision Priorities Patients Services and Programs Influence Successes

30. The Community’s Focus  Primary research  Significant community issues  Non-health related  Health related  Current programs  Failed programs Focus Primary Research Significant Issues Existing Programs

31. Comparison – SAMPLE DATA HEALTH BEHAVIORS DataLocal Trend Compare – Peer/ Region Compare – State Compare – Nation Healthy People 2020 Goal Adult smoking 27 %28%24%20%12% Youth smoking 29%na25.5%26%21% Adult obesity30% 31.4%34%30.6% Childhood Obesity na 14.4%17.9%16.1% Fruits and Vegetables na20.619.324%Volume per calories consumed

32. HEALTH BEHAVIORS Available Data Population Affected ImportanceScore Adult smoking Youth smoking Adult obesity Childhood Obesity Fruits and Vegetable Consumption - all Prioritization Matrix

33. Prioritization Score – Available Data  Is measurable and historical data available?  No data“0”  Perception/anecdotal“1”  Perceptions and counts“2”  Perceptions and baseline“3”  Perceptions and trend“4” Source: Adapted from Thruston County Public Health and Social Services. Retrieved from http://www.countyhealthrankings.org/take-action/pick-priorities

34. Prioritization Score – Size of Issue  What percentage of the population does this health issue affect?  Less than 1%“1-2”  1.0 – 9.9%“3-4”  10 – 24.9%“5-7”  25% or greater“8-10” Note: because the size of the problem is considered more critical that data, this score is multiplied x 2. Source: Adapted from Thruston County Public Health and Social Services. Retrieved from http://www.countyhealthrankings.org/take-action/pick-priorities

35. Prioritization Score - Importance  What is the seriousness of this issue? Urgency – high death rate– hospitalization – premature death rate – economic burden – impact on others?  Not serious/little impact“1-2”  Moderate – illness“3-5”  Serious – some death, impact“6-8”  Very serious – high death“9-10” Note: because the size of the problem is considered more critical that data or population affected, this score is multiplied x 3. Source: Adapted from Thruston County Public Health and Social Services. Retrieved from http://www.countyhealthrankings.org/take-action/pick-priorities

36. HEALTH BEHAVIORS Available Data Population Affected (x2) Importance (x3) Score Adult smoking4 (4)6 (12)8 (24)40 Youth smoking3 (3)10 (20)9 (27)50 Adult obesity4 (4)10 (20)8 (24)40 Childhood obesity3 (3)6 (12)9 (27)42 Fruits and Vegetables - all 3 (3)10 (20)5 (15)37 Prioritization Matrix

37. Mission Priorities Patients Influence Focus Primary Research Significant Issues Existing Programs Step Six: Review, Reflect and Select

38. Final Report Format - sample  Community description  Demographics  Socioeconomic  Health resources  Community health strengths and risks  Quality of life  Behavioral risk factors  environment  Health status  Social and mental health  maternal and child health  Death, illness, injury  Infectious disease  Sentinel events Step Seven: Disseminate Results Collecting Data  Demographics  Health outcomes  Mortality  Morbidity  Health factors  Health behaviors  Clinical care, including access  Social and economic factors  Physical environment

39. Develop and Implement a Strategy Step Eight Keep in Mind: The hard work begins with implementation.

40. Collaboration: Art and Science  Every organization may have different reasons for collaboration – that is okay – but you need a common goal  Ensure those with authority for resource allocation support the goals and objectives  Find an inspired champion  Time is required to build trust and innovate  Measure, evaluate

41. Sample Ground Rules  Innovation and creativity are encouraged  Challenge assumptions  Be respectful  Be engaged  Are you being quiet? Speak  Are you talking a lot? Pause  Avoid side conversations  Keep technology use to a minimum

42. Determine Your Strategy Contribut e Align

43. Document Your Intent and Progress Community Health Improvement Implementation Plan HEALTH ISSUE # 1 (very specific): Contributing FACTORS to Health Issue #1 (including social determinants): Three Year GOAL for Improvement (written as a SMART objective): BUDGET for health issue #1 (consider direct and indirect costs): Strategies to Achieve Goal Specific Partners and Roles for each Strategy Specific Actions to Achieve Strategies Specific 3-year Process Measure(s) for Each Strategy Specific 3-year Outcome Measures for Strategies (should align with SMART Goal for Health Issue) Strategy #1 ( may include specific budget allocation for each strategy) Partners and Roles for Strategy #1 *NEW* Action 1 Process Measure for Strategy #1 Outcome Measure for Strategy #1 *NEW* Action 2 Process Measure for Strategy #1

44. Collective Impact  Common agenda  Shared measurement system  Mutually reinforcing activities  Continuous communication  Backbone support organization Source: Kramer, M. & Kania, J. (2011). Social innovation. Stanford Review. Retrieved from http://www.fsg.org/tabid/191/ArticleId/211http://www.fsg.org/tabid/191/ArticleId/211

45. Leslie Porth, MPH, R.N. Vice President of Health Planning 573-893-3700 x 1305 lporth@mail.mhanet.com Staff Contact Mary Becker Senior Vice President of Strategic Communications 573-893-3700 x 1303 mbecker@mail.mhanet.com