Making Better Use of Population Health Data for Community Health Needs
Assessments
Authors: Stoto Michael A. , Davis Mary V. , Atkins Abby 
Published: August 2019

Research Objective: Non-profit hospitals are required to work with community
organizations to prepare a Community Health Needs Assessment (CHNA) and implementation
strategy (IS). In concert with the health care delivery system’s transformation from
volume to value and efforts to enhance multi-sector collaboration, such community health
improvement (CHI) processes have the potential to bridge efforts of the health care
delivery sector, public health agencies, and community organizations to improve
population health. Having a shared measurement system is critical to achieving
collective impact, yet despite the availability of community-level data from a variety
of sources, many CHI processes lack clear, measurable objectives and evaluation plans.
Through an in-depth analysis of ten exemplary CHI processes, we sought to identify best
practices for population health measurement with a focus on measures for needs
assessments and priority setting.Study Design: Based on a review of the scientific
literature, professional publications and presentations, and nominations from a national
advisory panel, we identified 10 exemplary CHI processes. Criteria of choice were
whether (1) the CHIs articulate a clear definition of intended outcomes; (2) clear,
focused, measurable objectives and expected outcomes, including health equity; (3)
expected outcomes are realistic and addressed with specific action plans; and (4)
whether the plans and their associated performance measures become fully integrated into
agencies and become a way of being for the agencies. We then conducted an in-depth
analysis of CHNA, IS, and related documents created by health departments and leading
hospitals in each process.Population Studied: U.S. hospitals.Principal Findings: Census,
American Community Survey, and similar data are available for smaller areas are used to
describe the populations covered, and, to a lesser extent, to identify health issues
where there are disparities and inequities.Common data sources for population health
profiles, including risk factors and population health outcomes, are vital statistics,
survey data including BRFSS, infectious disease surveillance data, hospital & ED
data, and registries. These data are typically available only at the county level, and
only occasionally are broken down by race, ethnicity, age, poverty.There is more
variability in format and content of ISs than CHNAs; the most developed models include
population-level goals/objectives and strategies with clear accountability and metrics.
Other hospital IS’s are less developed.Conclusions: The county is the unit of choice
because most population health profile data are not available for sub-county areas, but
when a hospital serves a population more broadly or narrowly defined, appropriate data
are not available to set priorities or monitor progress.Measure definitions are taken
from the original data sources, so comparisons across measures is difficult. Thus,
although CHNAs cover many of the same topics, the measures used vary markedly. Using the
same community health profile, e.g. County Health Rankings, would simplify benchmarking
and trend analysis.Implications for Policy or Practice: It is important to develop
population health data that can be disaggregated to the appropriate geographical level
and to groups defined by race and ethnicity, socioeconomic status, and other factors
associated with health outcomes.