Supporting Nonprofit Hospitals with CHNA and Implementation of Community Benefit

1. Supporting Nonprofit Hospitals with CHNA and Implementation of Community Benefit

2. Learning Objectives • Participants will have… • Increased understanding of the IRS requirements and recommendations for CHNAs • Methods and guidance for assisting hospitals in defining “community” for their CHNA and implementation plans • New ideas and success stories for engaging public health (including systemically) and other stakeholders with hospitals for assessment and planning • Capacity building activities and tools for moving hospitals from Community Benefit activities to Effective Community Health Interventions.

3. Opportunities for Partnership Local Health Departments (PHAB) Nonprofit Hospitals (ACA) ACA = Affordable Care Act PHAB = Public Health Accreditation Board

4. Affordable Care Act, Section 9007 • Requirements for nonprofit hospitals: • conduct a Community Health Needs Assessment (CHNA) at least every 3 years; • adopt implementation strategies to meet the community health needs identified through the assessment; • take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health; and • make the community health needs assessment and implementation plan widely available to the public.

5. IRS Guidance on Community Health Needs Assessment • July 2011 - IRS Notice 2011-52 • April 2013 - Notice of Proposed Rule Making • (NPRM REG-106499-12) – Comments due July 5, 2013 • Important clarifications/additions in new proposed rule: • Hospital may define its community to include geographic areas outside of those in which its patient populations reside. • Hospitals may work collaboratively on CHNA • A joint CHNA report may be issued if : • Joint report adopted by each collaborating hospital. • Collaborating hospitals define their community to be the same

6. IRS Guidance on Community Health Needs Assessment • Important clarifications/additions in new proposed rule: • Description of how hospital takes community input into account: • Summarize input and how and over what time period such input was provided. • Provide names of organizations providing input and summarize nature and extent of organization’s input. • Describe the medically underserved, low-income, or minority populations being represented by organizations or individuals providing input. • CHNA report must include description of the potential measures and resources identified through the CHNA to address the significant health needs. • Implementation plan must include plan to evaluate impact

7. IRS Guidance on Community Health Needs Assessment • Important clarifications/additions in new proposed rule: • Implementation plan must include plan to evaluate impact • • Collaborating hospitals may adopt joint implementation strategy if: • Clearly identifies the hospital facility’s particular role and responsibilities in taking the actions described in the implementation strategy and programs and resources the hospital plans to commit • Include a summary or other tool that helps the reader easily locate those portions of the joint implementation strategy that relates to the hospital facility.

8. IRS Guidance on Community Health Needs Assessment • Important clarifications/additions in new proposed rule: • Penalties: • IRS can revoke the tax exemption of the hospital organization depending on “relevant facts and circumstance” including organization’s history of compliance, scope of the failure to comply, and whether policies and safeguards were in place. • Minor and inadvertent omissions and errors will not be considered failure to meet requirements if the hospital facility corrects after discovery. • $50,000 excise tax for failure of a hospital to meet 501(r)(3)

9. Local Health Depts Nonprofit Hospitals (PHAB) (Affordable Care Act) • Community Health Assessment (CHA) every 5 years • Engage Community Stakeholders • Document partnerships, primary data collection, and community input • Variety of data sources to identify needs • Identify Priority Issues using criteria • Description of assets and resources • Community Health Improvement Plan (CHIP) and implementation • Documents available to the public • Community Health Needs Assessment (CHNA) every 3 years • Must report community benefit activities yearly on Form 990 • Engage Community Stakeholders • public health experts • medically underserved, low-income and minority populations • Analytical methods applied to identify needs • Identify Priority Issues using criteria • Description of assets and resources • Implementation Strategies for Community Benefit • Must be widely available to the public Thanks to KHI and KY PHI for sharing their crosswalk!

10. Other Opportunities for Partnership • Required Assessments: • Federally Qualified Health Centers (FQHCs): • HRSA requires: “Needs Assessment: Health center demonstrates and documents the needs of its target population, updating its service area, when appropriate.” (Section 330(k)(2) and Section 330(k)(3)(J) of the PHS Act) • Community Reinvestment Act (CRA): Performance Context • Other groups doing community health assessment and planning: • United Way, local/regional planning departments, community foundations, community based organizations, etc.

11. Where to find more information on CHNA and Community Benefit • Catholic Health Association • www.chausa.org • Hilltop Institute • www.hilltopinstitute.org/hcbp.cfm • Association for Community Health Improvement • Advancing the State of the Art in Community Benefit • www.communityhlth.org/ • IRS Guidance • www.irs.gov/pub/irs-drop/n-11-52.pdf • www.gpo.gov/fdsys/pkg/FR-2013-04-05/pdf/2013-07959.pdf

12. Will County, Illinois Will County is part of the Chicago Metropolitan Area, located south of Cook County in northeastern Illinois. The county has become increasingly suburban, with the population increasing 35% between 2000 and 2010 (2010 pop: 677,560) In 2008, the Will County Health Department, United Way & Presence St. Joseph’s hospital came together to partner on a MAPP process (shared planning, funding, ownership)

13. Will County, Illinois • Lead community health staff from health department and one hospital attended MAPP (Mobilizing for Action through Planning and Partnerships) training together • They became co-coordinators of the project • Formed a 20-member executive committee including a range of community partners • Now, four nonprofit hospitals and the health department are equal partners, and provide funding for MAPP, with the United Way acting as fiscal agent

14. Will County, Illinois Key learnings • All partners benefit from a coordinated, collaborative approach; Easier to engage more community partners • The Will County partnership has found it important to formalize participation on the executive committee with letters of commitment • Other counties in Illinois see this success and are adapting this model

15. Challenges/Barriers to initiating these partnerships • Different motivations • Resource intensive on the front end • Aligning assessments’ frequency and time cycle • Ownership of data • Choosing and interpreting indicators • Overlapping jurisdictions • Scope of assessment can vary • Different reporting needs and audiences

16. Communicating the Benefits of Hospital-Health Department Collaborations on Assessment, Planning and Implementation Understand the strategic and mission motivators for different partners! • Collective action results in more collective impact • Economies of scale • Improved system efficiencies and less redundancies • One comprehensive assessment can meet several types of requirements • No one entity can fully address issues identified by assessments • Funders reward effective partnerships • For health care, changes in payment/reimbursement will drive more focus on population health; community benefit needs to be tied into hospitals’ overall strategy • Need to continue to develop a shared vision for working on social determinants of health

17. Challenges for a coordinated systems approach • Paradigm Shift – moving toward population health interventions and addressing social determinants of health • Defining Community • Engaging hospitals and community partners for effective collaboration and sustainable community health improvement • Maximizing levels of partnership and engagement through regional and systems approaches

18. Need for Paradigm Shift • Hospitals’ community benefit has been mostly charity care and uncompensated care • As of 2009, • 72% of community benefit $$ used to help pay for care for the uninsured or underinsured (charity care, uncompensated care, means-tested payer discounted care and Medicare shortfalls) • only 5% of community benefit $$ went to community health improvement and community building activities • Local Health Departments often also find it difficult to move toward addressing population health and social determinants of health Source: Trust for America’s Health, A Healthier America 2013 - analysis of AHA/Ernst & Young data report

19. Roles for PHIs • - Project Management, consulting, and capacity building • for CHA/CHIP/Implementation • for community engagement • - Facilitate collaborative processes • - Create linkages between partners and help develop a shared vision • - Policy development, analysis, and implementation • - local, regional, state, federal • - Thought leadership on strategic approaches to integrating • population health in CHNA/community benefit and broader • implementation of the Affordable Care Act • - Convene stakeholders for systems approaches • - Evaluate processes, systems, and impact • - develop and/or implement metrics and methods

20. Panel Discussion

21. Wrap Up • Key Takeaways • PHIs have an important role to play both as consultant/technical assistance provider but also in building systems and relationships for partnership • Need to communicate the value to each partner in a way that speaks to their motivations, mission, strategy • There is a wealth of experience and expertise within our network of PHIs and we should continue to find ways to share • Different places and contexts call for different approaches. As we continue to confront and overcome challenges, it is essential that we share lessons learned in the field. • There are many untapped opportunities, and we should be open to thinking outside the box. • Other reflections?

22. Contact Information Jess Lynch Illinois Public Health Institute Jessica.Lynch@iphionline.org 312-850-4744 ReenaChudgar NACCHO rchudgar@naccho.org Kevin Barnett Public Health Institute kpb@pacbell.net Sarah Hurd Kansas Health Institute shurd@khi.org Steve Ridini sridini@hria.org