Working together on the assessment design and sharing the cost of conducting it allows health systems to obtain a more comprehensive assessment than a single health system would likely do on its own.
No healthcare leader in the Milwaukee area needs to wonder about the top health issues facing Milwaukee County.
The most recent community health needs assessment (CHNA), sponsored by four health systems working together through the Milwaukee Health Care Partnership, has documented those needs: chronic diseases, alcohol and other drugs, injury and violence, and mental health.
The shared CHNA helps the health systems fulfill the federal mandate to conduct such assessments, and it also provides in-depth information to identify individual community-benefit initiatives and joint efforts that address Milwaukee-area community health challenges.
By collaborating on the design of the assessment and sharing the cost of conducting it, the health systems obtain a much more comprehensive assessment than a single health system would likely do on its own.
“We are looking beyond compliance to actually having an impact on the community health needs in the communities we serve,” says Mark Huber, chair of the Milwaukee Healthcare Partnership Health Systems Community Benefit Workgroup.
The health systems—Ascension (formerly Columbia St. Mary’s and Wheaton Franciscan Healthcare health systems in Milwaukee), Aurora Health Care, Children’s Hospital of Wisconsin, and Froedtert Health—are all members of the partnership. Its members also include four Federally Qualified Health Centers (FQHCs); the Medical College of Wisconsin and city, county, and state health departments. The partnership is a public/private consortium working to improve healthcare access, insurance coverage, and care coordination for low-income, medically underserved populations.
“The CHNA is extremely valuable in helping inform the partnership’s annual plan priorities,” says Clare Reardon, the partnership’s director of organizational advancement.
The shared CHNA grew out of focused needs assessments that Aurora Health Care started performing more than two decades ago. Those assessments, conducted in various communities Aurora serves, were used to support local-level community improvement efforts.
In 2003, Aurora sought to develop a consistent set of population health data across all the communities it serves so it conducted its first comprehensive community health needs phone survey. From then on, Aurora divided its service area into thirds and conducted needs assessments in the three sub-areas on a rotating basis every three years.
Because all the area health systems worked together on partnership initiatives, representatives of the other systems recognized the value of a central source of health data for decision-making. In 2010, the health systems committed to joint responsibility for designing and funding a shared CHNA every three years. Their first collaborative assessment for Milwaukee County was completed in 2012 and the second in 2015.
Each assessment draws on three sources of data:
- A phone survey of nearly 2,000 Milwaukee County residents, based on the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance Survey
- Input from interviews with key stakeholders, such as public health officials, and focus groups
- A secondary data report, compiled by a research organization, that analyzes data from the U.S. Census and American Community Survey, the Wisconsin Department of Health Services, and city and county health data reports
As chair of the workgroup, Huber oversees the contracts of research organizations that collect and analyze the survey findings and secondary data.
The key stakeholder interviews are conducted by members of the partnership’s workgroup, using a structured interview format. The interviewers enter responses into templates that a research organization uses to organize and summarize the findings.
Recognizing Partnership Pros and Cons
An obvious benefit of the shared CHNA is distributing the costs. “Each system isn’t duplicating the expense of collecting, analyzing, and reporting the data, which allows us to focus our limited community resources on actions to address needs, rather than on assessing needs,” says Huber, Aurora’s vice president of social responsibility.
Another benefit is a reduced burden on the community agencies that contribute data or perspectives to the assessment. Rather than fielding requests from each health system, those agencies respond to a single request.
The CHNA report, which is available on the partnership website, provides a common set of information that community organizations can access and use to inform their programming.
Perhaps most significantly, the partnership members use the shared CHNA to come to a consensus on prioritizing community needs.
“By doing it together, we have the added advantage of collectively looking at that information and agreeing among ourselves which priority needs are best aligned with our abilities as healthcare systems and how we might address them to improve the health of the community―individually and collectively,” Huber says.
But conducting a shared CHNA also comes with challenges.
Timing. The four health systems have different fiscal calendars that must be considered when budgeting each system’s expenses related to the CHNA. Those varying fiscal years also must be considered when deciding when to release each health system’s mandated individual CHNA report and community benefit implementation strategies.
Geography. Each health system has its own service territory—for example, Aurora serves 21 Wisconsin counties—and developing a CHNA that covers all the counties served by the health systems would be impractical. The partnership chose to focus specifically on the six counties that have the greatest common service area. That decision required bringing in one additional health system, which is not part of the partnership, because it serves one of the counties.
Cost-sharing. Expenses were not divided equally among the four health systems because the organizations vary greatly in size and market penetration. “What we eventually came up with was a formula in which those systems that had a hospital location within any one of the six counties would equally share the cost for that county,” Huber says. “In Milwaukee County, that was every one of us, but in the other counties, the cost is shared by one or two or three of the systems.”
The assessment, which includes a survey, stakeholder interviews, and secondary data analysis, is conducted every three years. The assessment process is overseen by the work group that Huber heads. A broader planning team, including representatives from the health systems and the local public health departments, designs the assessment.
Sample questions used during a telephone survey that is part of the assessment include the following:
- In the past 12 months, have you or anyone in your household not taken prescribed medication due to prescription costs?
- On an average day, how many servings of vegetables do you eat? One serving is one-half cup of cooked or raw vegetable or 6 ounces of juice.
- In the past 30 days, while you were driving, how often were you distracted by technology, such as texts, e-mails, or phone calls?
- During the past 12 months, has your child experienced any bullying?
Informing Community Strategies
The information provided by the CHNA is used in a wide variety of ways. “It informs our existing collaborations and might steer us into new directions within those collaborations,” Huber says.
For example, the United Way of Greater Milwaukee and Waukesha County manages a Healthy Birth Outcomes collaboration that seeks to address the high rate of infant mortality in the area. The CHNA provides information used by a healthcare access committee, through which area provider organizations coordinate their efforts related to reducing infant mortality.
Of course, the health systems participating in the shared CHNA use the information for their own initiatives. For example, Aurora operates a sexual assault and domestic violence services program for the Milwaukee area, and Ascension/Columbia-St. Mary’s operates the largest school-based oral health program in the state.
“Each of us has areas that we focus on and we use the community health needs assessment to develop our implementation strategies,” Huber says.
Meanwhile, the partnership looks to the CHNA to inform its own annual plan priorities.
“Following the most recent CHNA, we made additional grants to FQHCs that were increasing their services to address behavioral health, as well as to a new clinic that is focused on integrated primary care and behavioral health services,” Reardon says. “Also, the partnership increased its involvement in a violence prevention effort spearheaded by the city.”
Capitalizing on Partnerships
A shared CHNA requires CEO-level support from all participating organizations, Huber says. “The leaders who are doing the community benefit work within each of the health systems generally have a pretty good ability to work together outside of the market competition among the organizations,” Huber says. “But if you don’t have that CEO ‘buy in’ that we are going to work together to jointly fund this initiative, you’re not going to go anywhere.”
The health systems that collaborate on the Milwaukee-area CHNA benefitted from two key advantages: They all had already been working together on other initiatives through the partnership before the CHNA initiative started, and Aurora had years of experience with needs assessments, including an in-depth survey of residents.
Although the infrastructure that the partnership provides is not essential, health system leaders in other communities that are considering a shared CHNA need a process for making decisions.
“What might be thorny for others without an established consortium is putting together the scope of the work and how that will be underwritten,” Reardon says.
In Milwaukee, the collaborating health systems had experience in deciding how to fund new initiatives through the partnership. Also, they were committed to Aurora’s idea that a phone survey is an essential component of a needs assessment, even though a survey is not mandated by the government.
By bringing the area’s provider organizations together, the partnership seeks to address community-wide challenges more effectively than any single health system could do on its own. The CHNA provides the data and information that leads to a consensus on the top health issues facing the community, as well as tracking progress on dozens of health-related issues of interest to individual health systems and others in the community.
Lola Butcher is a freelance writer and editor based in Missouri.
Mark Huber is vice president of social responsibility, Aurora Health Care, Milwaukee.
Clare Reardon is director of organizational advancement, Milwaukee Health Care Partnership, Milwaukee.
Forum members: What do you think? Please share your thoughts in the comments section below.
1. Does your organization collaborate with others on community health needs assessments?
2. How does your CHNA influence your community investments and initiatives?