Assessing Community Health Needs in a Rural Area: Determining Best Practices to Meet New Affordable Care Act Requirements

We conducted a review of the peer-reviewed literature focused on conducting community health needs assessments and highlighted the necessary steps to conduct a community health needs assessment in a rural community. From the literature review, we identified three steps necessary— establishing partnerships, using a mixed methods approach, and disseminating results—to successfully conduct a needs assessment that fitted the definition of the Affordable Care Act. These three steps have been used as a guide for developing a protocol for conducting a community health needs assessment in Meadville, PA. We detail our preliminary project protocol here.


Introduction
The Affordable Care Act (ACA) requires that all 501(c) (3) hospitals conduct a community health needs assessment (CHNA) and adopt an implementation strategy to meet identified community health needs at least once every three years [1] [2].Determining an effective and sustainable methodology, especifically for a small hospital in a rural community, to meet the community health needs assessment requirement of the ACA is the focus of our research.Our project goal is twofold: 1) to develop a mixed-methods protocol and conduct a community health needs assessment in accordance with the ACA guidelines; 2) to improve the health in our community.
Here we present a set of principles and practices to guide the development of protocol for a CHNA that will be conducted in Meadville, PA.In order to establish the principles and practices for our CHNA, we conducted a systematic review of the literature in MEDLINE focused on articles that discussed the methods and approaches of conducting a CHNA.We specifically used "community health needs assessment" or "health needs assessment" as our search terms (through May 2014).A total of 270 articles were identified.From the articles that met our search criteria for methods for conducting a CHNA (n = 27), we developed a set of three common themes: 1) Developing community partnerships; 2) Developing a mixed methods protocol; and 3) Disseminating valid and reliable results.These themes were used to guide the development of our multi-year CHNA protocol.

Developing Community Partnerships
Establishing partnerships and effective ways of communicating with partner organizations and community members should be the first step of a community health needs assessment.Community partners-both individuals and organizations-need to be invited to participate in the process of assessing the community, prioritizing needs, developing strategies for meeting those needs, and assessing the impact of those strategies.Community partners participating in the process should be expected to provide information (both qualitative and quantitative) about the health needs of the community; additionally, they should be able to identify where gaps in knowledge and data exist.Once the health needs of the community are identified, programs and policies to meet the needs of the community may be executed by community organizations.Rooting all partnerships in trust and mutual respect at the beginning of the project will ensure community buy-in and support for changes that need to be made to improve the community's health.
The CHNA that we will be conducting is a collaborative effort between a research team at Allegheny College and administrators from the local community hospital, the Meadville Medical Center (MMC).The MMC is a 249 bed, independent hospital located in Meadville, Pennsylvania.Meadville is the county seat of Crawford County.The city of Meadville has approximately 13,000 residents who are served by the Meadville Medical Center; approximately two-thirds of the 88,000 residents of Crawford County are also served by the hospital.The MMC has conducted community health needs assessments in the past; however, the hospital has not followed a consistent protocol nor has it conducted an assessment once every three years.
The research team leading the community health needs assessment must also be committed to collaboration within the group.The team must be committed to: clear communications; providing constructive feedback; and providing reliable information [3]- [6].Above all of these principles, the research team must establish trust within and outside of the group [3] [5] [7] [8].The research team leading the assessment should be trustworthy and passionate about the project and committed to using the data collected to improve the health of the community [3].To this end, the collaborative research team leading our CHNA hosted three meetings with community groups as well as local governmental and non-governmental agencies to discuss the plans and timeline for the project.We specifically initiatied and formed relationships with the city government, county health and human services agencies; the local school district; school nurses; and the United Way.Additionally, key informant interviews with each of these groups have been conducted to learn more about the services offered by and needs of each of the groups working in our community.
Successful collaboration requires that all partners communicate clearly and trust one another.The recommendations above parallel the process of community-based participatory research [9].Community health needs assessments should adhere to the tenants of community-based participator research [8] [10]- [13].Specifically, focusing on the primary tenant of community-based participatory research that the research team should collaborate with community members throughout the process and allow the community to guide the work to identify health needs.
Community-based participatory research methodologies do provide a framework for collaborating with community members to conduct a health needs assessment.However, in working with community partners, the hospital required to conduct the needs assessment must not lose sight of the ACA requirements and the timeline that is mandated.Clear communications with community partners about the project timeline and requirements at the beginning of the collaboration is a necessity.All partners involved in the community health needs assessment need to share the hospital's goal and mandate to meet the ACA requirement of conducting a community health needs assessment every three years.

Developing a Mixed-Methods Protocol
The definition of a community health needs assessment from the public health literature specifically states that both quantitative and qualitative data be collected.We found the most effective way to conduct a community health needs assessment is to use a variety of data collection strategies to compile both quantitative and qualitative data to identify and prioritize the community health needs [3] [5] [6] [8] [10] [11] [14]- [25].Data collected through the community health needs assessment must be analyzed, interpreted, and distributed to the community.All materials distributed to the community need to be written in a way that is understandable; public health and epidemiological jargon should be avoided.
Through our research, we found that a mixed methods community health needs assessment protocol should include the following: 1) Review of public health surveillance data; 2) Community forums; 3) Key informant interviews; and 4) Community survey.
The review of relevant health surveillance data will include publicly available data from the Pennsylvania Department of Health, Centers for Disease Control and Prevention, US Census Bureau, Environmental Protection Agency, and Robert Woods Johnson Foundation.We also plan to analyze emergency room and in-patient admissions data to determine the services being used and those needed at the Meadville Medical Center.
The Meadville CHNA will include each of these components.The results of each of the four parts of our protocol will be presented in a final CHNA Report.This report will also include a list of suggested activities or interventions that can be undertaken to improve the health of our community.

Disseminating Valid and Reliable Results
After data from a mixed-methods community health needs assessment has been collected, all of the data should be analyzed with the goal of understanding community health needs.The findings should be disseminated to the community [8]- [10] [14] [26] [27].The analyzed data is intended to be used by the hospital and the community to prioritize the health needs of the community.Prioritization of the health needs must be done before new programs, policies, or interventions can be implemented to improve the community's health [3] [24].Prioritization of the community's health needs should be done by engaging community members and partner organizations.Potential methods that can be used to prioritize the health needs of the community are to assess the severity of the health impact, the healthcare costs, the perceptions of the community, and the effectiveness of a possible program, policy or intervention [3].
After data collection is complete and community health needs have been prioritized, a final report must be completed and shared with the community [6] [8] [10] [16] [17] [22] [26].The ACA requires that a final report be made available to the population served by the hospital [26].This final report must include a description of the population, the processes used to collect data about health needs, the results of the data analysis, and any limitations or biases in the data [8] [10].The researchers should also address in the report any and all impacts these limitations and biases might have had on the study results.They should also create a plan to avoid these mistakes in future community health needs assessments.Additionally, the final report must discuss the prioritized health needs, process for determining the most important health needs, and plans to implement policies, programs, and interventions to improve the community health.

Conclusions
Our review of the literature resulted in the development of a mixed-methods approach for conducting a community health needs assessment.Specifically, we found that developing partnerships, using an assortment of data collection methods, and reporting the findings were common themes among the articles and important steps to complete a successful needs assessment.We are planning to conduct a community health needs assessment for the Meadville Medical Center over a two-year period.At the end of year 1, we intend to prioritize the health needs of our community that are identified through the secondary data analysis, community partner meetings, and the perceptions data from community members.We also hope that our work with community organizations and members will increase the visibility of the project, thus encouraging people to participate in our data collection activities during year 2.
During year 2, we will develop and administer a volunteer survey to the population served by the hospital.This survey will ask questions that will provide information about community health needs not found or clearly understood during year 1 of the project.We hope that this systematic review and future publication from our community health needs assessment work will provide methodological guidance and an example of how to conduct a community health needs assessment that meets the ACA requirements for hospital is other rural communities.