The Affordable Care Act requires nonprofit hospitals to collaborate with public health agencies and community stakeholders to identify and address community health needs. As a rural organization, Wabash County (Indiana) Hospital pursued new approaches to achieve these revised requirements of the community benefit mandate. Using a case study approach, the authors provide a historical review of governmental relationships with nonprofit community hospitals, offer a case study application for implementing legislative mandates and community benefit requirements, share the insights they garnered on their journey to meet the mandates, and conclude that drawing upon the existing resources in the community and using current community assets in novel ways can help conserve time, and also financial, material, and human resources in meeting legislative mandates.
Key Words: Community benefit mandate, community health needs assessment process, collaboration, community planning, community engagement, Affordable Care Act, IRS 990, community needs assessment, population health assessment, collaborative task force, nonprofit hospitals
Summary
... it is imperative that nurse leaders understand new legislative requirements and new community benefit requirements for nonprofit hospitals that are necessary to maintain their tax-exempt status. The launch of the Affordable Care Act (ACA) has ushered in a new era of healthcare accountability (PPACA, 2010). From value-based purchasing to Accountable Care Organizations, it is imperative that nurse leaders understand new legislative and community benefit requirements for nonprofit hospitals that are necessary to maintain their tax-exempt status. In this article, we will provide a historical review of governmental relationships with nonprofit community hospitals, offer a case study application for implementing legislative mandates and community benefit requirements, share the insights we garnered on our journey to meet the mandates and conclude that drawing upon the existing resources in the community and using current community assets in novel ways can help conserve time, as well as financial, material and human resources in meeting legislative mandates.
Historical Review of Governmental Relationships with Nonprofit Community Hospitals
...widespread inconsistencies in the community benefit activities reported among hospitals have been noted, underscoring the need for a clear definition of community benefit expectations. Since 1969, the United States (US) Internal Revenue Service (IRS) has exempted nonprofit hospitals from federal taxation, with community benefit activities serving as the justifying criteria for their exemptions. These activities are reported to the IRS through Form 990 (Principe, Adams, Maynard, & Becker, 2012; Rubin, Singh, & Jacobson, 2013). Community benefit requirements can be met through activities that promote the health of the community as a whole. Historically these activities have varied widely from charity care to health fairs, research, health professions education, and more (Principe et al., 2012; Rubin et al., 2013).
However, widespread inconsistencies in the community benefit activities reported among hospitals have been noted, underscoring the need for a clear definition of community benefit expectations (Robert Wood Johnson Foundation [RWJF], 2012; U.S. Government Accountability Office, 2008). Analyses from the Congressional Budget Office (2006) have demonstrated that many nonprofit hospitals provide similar levels of charitable care when compared to for-profit hospitals. Dollars saved by nonprofits through various tax exemptions in 2002 approached $12.6 billion. In 2012 dollars, this tax savings is estimated at $16.1 billion dollars annually (Horwitz & Cutler, 2015).
Nonprofit hospitals are now required to collaborate with public health agencies and community stakeholders by conducting a community health needs assessment (CHNA) and developing a strategic plan to address priority community health needs. With the advent of the ACA, community benefit expectations have been further defined, with specific requirements mandated for all nonprofit hospitals (Patient Protection and Affordable Care Act [PPACA], 2010). Noncompliance with the mandate involves a sizeable penalty, including loss of nonprofit status and a $50,000 excise tax (Marietta, 2010; PPACA, 2010). Nonprofit hospitals are now required to collaborate with public health agencies and community stakeholders by conducting a community health needs assessment (CHNA) and developing a strategic plan to address priority community health needs (PPACA, 2010). Expectations include input from community members and stakeholders, diverse community engagement efforts, and a multisector, collaborative process to determine priority community health needs, as well as a strategic plan to address those needs (PPACA, 2010; Rosenbaum, 2013).
The ACA now requires nonprofit hospitals to document and justify their tax-exempt status through the additional measures related to CHNA and a strategic plan to address community health needs (Abbott, 2011). As a result, community health promotion and disease preventive efforts previously provided by the public health sector can be augmented through joint efforts with acute care organizations (Leonard, 2011; Rosenbaum, 2011). One such example of a successful interagency endeavor includes the HOMEtowns Partnership in Portland, Maine (MaineHealth, 2012; Prybil et al., 2014). This collaboration successfully expanded the community capacity for population-level health promotion in order to improve health outcomes in the areas of weight, nutrition, physical activity, and tobacco use (MaineHealth, 2012; Prybil et al., 2014).
Working collaboratively, nonprofit hospitals can draw upon the expertise of public health agencies as they engage with community stakeholders to impact change. Rosenbaum (2013) has provided a synopsis of best practices, or principles, to guide nonprofit hospitals through the CHNA process (see Table 1). These principles include: multisector collaborations that support ownership; proactive, diverse community engagement; a definition of community that encompasses population-level interventions; maximum transparency to improve community engagement; evidence-based interventions; evaluation to inform continuous improvement; and the use of high quality data from diverse sources (Rosenbaum, 2013). These principles are endorsed by the Centers for Disease Control and Prevention (CDC) (2013) to direct the CHNA process. Although the guiding principles may be familiar to those within the public health sector, they are, in some cases, unfamiliar to those within the acute care setting. Working collaboratively, nonprofit hospitals can draw upon the expertise of public health agencies as they engage with community stakeholders to impact change.
Table 1. Application of Principles to Inform Implementation of the Affordable Care Act Community Health Needs Assessment (CHNA) Provisions (Rosenbaum, 2013).
| Principles to Inform CHNA | Application of Principles to Wabash County Hospital (WCH) CHNA |
| Multisector collaborations that support shared ownership of all phases of community health improvement, including assessment, planning, investment, implementation, and evaluation. | Sectors represented include business, education, healthcare, government, public health, law enforcement, social services, recreation, faith communities, and lay members of the community. |
| Proactive, broad, and diverse community engagement to improve results. | Intentional engagement of community members and stakeholders from multiple sectors through focus groups, surveys, and collaborative task force activities. |
| A hospital’s definition of community that encompasses both a significant enough area to allow for population-wide interventions and measurable results, and includes a targeted focus to address disparities among subpopulations. | Wabash County community identified as the population served. Specific vulnerable subpopulations in Wabash County targeted to reduce health disparities (such as pregnant teens and youth). |
| Maximum transparency to improve community engagement and accountability. | Collaborative work of the WCH community health task force documented and open for community review. Shared decision making integrated throughout the assessment, planning, implementation and evaluation phases. |
| Use of evidence-based interventions and encouragement of innovative practices with thorough evaluation. | WCH community health task force evidence-based findings used to inform the planning and implementation of community health interventions. |
| Evaluation to inform a continuous improvement process. | Specific outcome metrics designed to measure the impact of targeted population health interventions. |
| Use of the highest quality data pooled from, and shared among, diverse public and private sources. | Current, valid, reliable population health data from the national databases, public health departments, healthcare and social service organizations informed the assessment process and continue to be monitored by the collaborative team. |
In summary, community benefits have historically been required to justify tax-exempt status for nonprofit hospitals. However, a collaborative approach with the public health system and community stakeholders to conduct a comprehensive CHNA and strategic plan are new elements involved in the process to secure a tax exemption from the IRS. In addition to meeting the ACA legislative requirements, this shift away from the traditionally ‘siloed’ models of care toward an integrated approach between public health facilities and hospitals is congruent with strategies recommended by the CDC (2014) to improve community health.
The processes involved to meet the requirements are both time- and resource-intensive, regardless of the organization. As noted by the American Hospital Association (AHA, 2011), rural, independent facilitates may face additional challenges unique to their location and organizational size, such as more limited infrastructure for special projects, lack of staff with community health expertise, and smaller budgets for community-wide initiatives. The following case study application shares the process by which one independent, rural hospital used limited resources in the journey toward meeting the ACA community benefit requirement. In this case study, we will offer an approach to implementing these new legislative mandates and community benefit requirements. We will also share insights gathered through the journey.
Case Study Application
In this section, we will describe the setting in which our case study application took place. We will also delineate the steps of the Community Health Needs Assessment (CHNA) that were followed.
Setting
Wabash County Hospital (WCH) is a small, independent hospital located in rural, northern Indiana serving a community with notable health disparities as compared to state and national benchmarks. These disparities include higher rates of adult obesity, smoking, and low birth weight (see Table 2) (County Health Rankings, 2012). The disparities provide evidence of continued unmet health needs within the community. Historically the primary focus for WCH has been the provision of excellent acute care services, rather than addressing unmet community health needs. Yet from the outset of the CHNA process, aligning with the spirit of the legislation, hospital leadership has asserted that efforts toward compliance with the community benefit mandate should be substantive and meaningful, integrate collaboration and engagement with county stakeholders and citizens, and result in positive health outcomes for community members. Since nonprofit status is essential to continued hospital operations, the cost of noncompliance with the mandate more than justifies the expenses incurred in this effort, due to realizing significant tax savings.
Table 2. 2010 – 2012 Comparison of Wabash County Health to National Benchmarks for Selected Health Outcomes
| Health Outcome | 2012 Wabash County/ | 2011 Wabash County/ | 2010 Wabash County/ |
| Premature death (YPLL) | 8,468 per 100,000 / 5,466 per 100,000 | 8,218 per 100,000 / 5,564 per 100,000 | 8,225 per 100,000 / 6,324 per 100,000 |
| Residents’ rating of their health status as ‘poor or fair’ | 15% / 10% | 16% / 10% | 16% / 13% |
| Low birth weight | 8.7% / 6.0% | 8.5% / 6.0% | 8.1% / 6.4% |
| Teen birth rate | 38 per 1000 / 22 per 1000 | 40 per 1000 / 22 per 1000 | 42 per 1000 / 30 per 1000 |
| Adult smoking | 23% / 14% | 26% / 15% | 30% / 21% |
| Adult obesity | 36% / 25% | 31% / 25% | 29% / 25% |
| Uninsured | 16% / 11% | 12% / 13% | 11% / 12% |
Note: Years of Potential Life Lost (YPLL) is the measure used by County Health Rankings to report premature death; YPLL are tabulated based upon all deaths occurring before the age of 75. Data obtained through County Health Rankings (2012).
WCH committed the necessary resources for the assessment, planning, and intervention, and intentionally communicated the value of this process both within the organization and to community stakeholders and citizens. Partnerships were proactively developed across community sectors to increase the capacity for community health promotion within the county. For example, collaboration with a local public health nurse educator established the groundwork for potential academic-practice partnerships in the future.
Community Health Needs Assessment Steps
The process of the Community Health Needs Assessment (CHNA) and strategic planning includes five distinct phases... The process of the Community Health Needs Assessment (CHNA) and strategic planning includes five distinct phases, which can be categorized as follows: (a) establish the collaborative task force; (b) assess the community health needs; (c) analyze data to determine priority needs; (d) develop and implement a strategic plan; and finally (e) reassess community health needs. These activities are mandated to occur every three years (PPACA, 2010). Across these phases, WCH purposively applied the guiding principles for a CHNA (2013). Transparency was intentionally integrated throughout the process, as were approaches to engage diverse stakeholders and support collaboration between community members. For example, open discussions; availability of minutes and record keeping; inclusion of data provided by county stakeholders; pursuit of feedback regarding the group process; and shared decision making were incorporated to encourage involvement among all community stakeholders. The following sections will describe the five phases of the community assessment and planning.
Key leaders across varying sectors of the community, as well as county citizens, were contacted by the hospital administration and invited to participate in the endeavor. Establish collaborative task force. The initial steps involved the establishment of a community-based, multisector collaborative task force, consisting of community members and leaders across Wabash County, to conduct the CHNA. Key leaders across varying sectors of the community, as well as county citizens, were contacted by the hospital administration and invited to participate in the endeavor. A combination of emails, phone calls, and letters were used to reach individuals; a response was requested to indicate willingness to participate in the CHNA and strategic planning efforts. Over 80 partners from across community sectors engaged in the initial task force activities, which included the CHNA and the data analysis. These partners included representation from county citizens as well as from the following sectors: law enforcement, public K-12 education, higher education, business, public health, government leaders, social services, faith communities, and the healthcare sector.
Assess community health needs. The assessment process included the identification of community resources and barriers to accessing healthcare coupled with a thorough review of current, aggregate health data already collected and reported by the state and local departments of health. The assessment process included the identification of community resources and barriers to accessing healthcare coupled with a thorough review of current, aggregate health data already collected... Aggregate data specific to Wabash County were also obtained from nationally recognized projects, such as the County Health Rankings (2012), a program of the RWJF (see Table 2). These aggregate data were compared across time and across national, population-health benchmarks, such as Healthy People 2020 (United States Department of Health and Human Services, 2014), to facilitate the identification of health trends and disparities. The CHNA also integrated data provided directly by members of the collaborative task force, such as crime statistics provided through local law enforcement, socioeconomic issues provided by social service agencies, and population-specific risks, such as teen substance abuse and pregnancy rates, shared by local school districts and health agencies. Individual interviews with experts across community sectors (e.g., business, education, healthcare, public health, government, and social services), and small group meetings with community leaders and county citizens were conducted to further assess perceived community health needs in the county.
Analyze data to determine priority needs. Analysis of data generated by the above assessment process was conducted over the course of two, day-long intensive workshops that each collaborative task force member attended. The first workshop day included a presentation of the community assessment findings, which included key population health indicators. Discussion of assessment findings occurred next, in facilitated break-out groups with six to eight members each. Groups were charged to identify health needs within the county that emerged from the findings.
... task force members systematically identified areas of strength in the community, through deliberate listing of existing resources, assets, and community health programming... During the second workshop day, we discussed identified health needs with the larger collaborative task force body. Through large group discussion, community health needs generated and identified via small work groups were synthesized to 29 health needs. Following this activity, task force members systematically identified areas of strength in the community, through deliberate listing of existing resources, assets, and community health programming, and also noted the most significant resource gaps. Finally, each task force member voted, indicating their top community health need. The following four health-need priorities emerged:
- Increased incidence of substance abuse among teens in the county
- Increased incidence of obesity and unhealthy lifestyle behaviors among county residents
- Limited access to healthcare for mothers, children, and families in the county
- Limited health literacy among county residents
Develop and implement a strategic plan. The next phase in the process is currently underway. The focus is development and implementation of a strategic plan to address the four priority community health needs in the county. Half of the task force members (n=42) committed to regular, focused work with the development and implementation of a strategic plan to address each of the priorities. We formed a committee for each priority health need to determine: the specific issue, what is currently being done to address the issue, anticipated outcomes to achieve, and actions needed to meet the outcomes. Early planning efforts aim to integrate the following into the strategic plan: interagency partnerships to expand health promotion services and access to care; sharing of information regarding current resources available within the county; enhancement of stakeholder communication within the community; and targeted educational interventions to address alcohol and drug use, tobacco cessation, health promotion, prenatal care, well-child needs, and healthy lifestyle choices across the lifespan.
To date, several spontaneous interagency partnerships have occurred. To date, several spontaneous interagency partnerships have occurred. For example, when monies presented themselves to provide a smoking cessation program for pregnant women, the Wabash County Tobacco Free Coalition partnered with the Wabash County Extension Agency, WCH, and the Life Center (pregnancy center) to launch these services. When the local schools expressed a need for drug and tobacco education, local law enforcement from both the county and city joined with community mental health practitioners and WCH to provide the needed service. To build upon a ‘Fall into Fitness’ community event, local physicians partnered with fitness centers, YMCA staff, nutritionists, coaches, and the county extension agency to offer ‘Walk with a Doc’ education and exercise sessions. To promote access to perinatal services and transportation systems, cooperative, interagency communications were initiated through the 2-1-1 telephone information system and Internet links to resource listings. In addition, hard-copy resource guides were developed and distributed at locations throughout the county which are frequented by this vulnerable population, such as local department and thrift stores, grocery stores, the health department, schools, and child care centers. These less formal interventions provided an opportunity to garner support from the community and validate the efforts and commitment of team members.
Integral next steps will involve implementation of the strategic plan, strengthening of existing interagency partnerships, and identification of new opportunities for collaboration. Because implementation will be driven by the strategic plan, tasks and activities are not yet fully delineated and will require negotiation of funding streams across all partners. Integral next steps will involve implementation of the strategic plan, strengthening of existing interagency partnerships, and identification of new opportunities for collaboration. These steps will focus on expanding the capacity for health promotion within the county. Planned interagency partnerships with faith communities and local schools of nursing will be pursued to increase the capacity for health promotion in the community. Evaluation of outcomes will be addressed as the strategic plan unfolds, with specific efforts on the assurance of oversight, capacity, and sustainability of the community health assessment and targeted intervention processes through external funding streams and the expansion of partnerships.
Reassess community health needs. As noted earlier, the ACA community benefit mandate requires reassessment of community health needs every three years. To inform future assessment efforts, task force members were asked to provide feedback regarding the collaborative process. The vast majority of members reported high levels of satisfaction, thus validating the positive working relationships and the replication of this approach for reassessment in three years.
Our Insights
Insights garnered through our journey will benefit others embarking upon this process. Initial recommendations include the following: building upon strengths of existing resources, establishing positive relationships within the community, and developing a shared vision to augment the collective impact of stakeholders working on a common goal. In essence, these recommendations validate the principles set forth by Rosenbaum (2013) and the CDC (2013) to facilitate hospitals throughout the CHNA process (See Table 1).
The Value of Existing Resources
...the task force intentionally focused on identifying and building upon existing resources within the county. Despite the small size of this rural community, members of the task force intentionally focused on identifying and building upon existing resources within the county. This perspective prompted the sharing of ideas and brainstorming about how to use current resources in new, creative, and efficient ways. For example, as discussed earlier regarding perinatal education, members of the task force worked collaboratively to determine available local resources and identify barriers that limited access to those services, such as lack of transportation. By drawing upon strengths already present within the community and using them in new ways, the task force is sharing resources and expertise to increase the capacity for perinatal education in the county.
The Value of Positive Relationships
The impact of positive relationships was, and continues to be apparent throughout efforts to meet the community benefit requirements... The impact of positive relationships was, and continues to be apparent throughout efforts to meet the community benefit requirements; these relationships continue to strengthen the process today, as sustained collaboration is needed to meet the full intent of the requirements. Early in the process, hospital leaders, community stakeholders and members agreed upon ground rules to support effective communication, such as holding regular and frequent face-to-face meetings, considering input from all parties, working to establish a consensus, making decisions jointly, and maintaining professional interactions. Whether the venue is an individual email exchange, small group work, or a large forum, there is evidence of positive relationships across the community sectors. Specifically, nurse leaders noted the benefits of clear, two-directional communication; the acceptance of and respect for differing opinions; mutual valuing of contributions from all sectors of the community (healthcare, education, business, government, law enforcement, social services, faith communities, and citizens); and a willingness to listen to the insights of others. It is not surprising that these characteristics parallel the tenets of effective communication, and served as a cornerstone for successful group process and community planning efforts in Wabash County.
The Power of Shared Vision
...the power of a shared vision... provided a sustaining force and sense of ownership in the early stages of the process; and it continues to do so today. Finally, the power of a shared vision among Wabash County citizens and the members of the community-wide, collaborative task force provided a sustaining force and sense of ownership in the early stages of the process; and it continues to do so today. Following principles put forth by the CDC (2013) and the National Institutes of Health (2011), active engagement with and participation of community citizens and leaders was intentionally initiated and maintained from the beginning. Strategies were regularly employed to foster inclusiveness and shared decision making, such as interagency representation on subcommittees; transparent, two-way communication; and inclusion of citizen feedback. In addition, shared validation of assessment findings and cooperative approaches to problem solving were intentionally included. The collective impact of a shared vision and common purpose among community members, stakeholders, and hospital administration facilitated successful achievement of community benefit requirements.
Conclusion
Purposeful development and maintenance of positive relationships with stakeholders and citizens throughout the community will provide a tangible demonstration of the value of their input. In sum, we recommend that others embarking upon this process include intentionally engaging a diverse group of community members from multiple community sectors in order to fully appreciate the strengths and needs present within the community. We recommend that other hospitals draw upon the existing resources in the community, and consider using such assets in new ways in an effort to conserve time as well as financial, material, and human resources. Purposeful development and maintenance of positive relationships with stakeholders and citizens throughout the community will provide a tangible demonstration of the value of their input. Finally, by promoting inclusivity and shared decision making throughout the process, the community as a whole will benefit from the collective impact of multisector collaboration.
Collaborative approaches to meet the health needs of individuals, families, and populations are documented in the literature, supported through practice, and have served as a hallmark within the discipline of public health for decades (CDC, 2010; Valente, Chou, & Pentz, 2007; Varda, Chandra, Stern, & Lurie, 2008). The ACA community benefit requirements launch a new era of collaboration between nonprofit hospitals, public health systems, and community stakeholders across a variety of sectors. For independent, rural hospitals in the United States, there are unique challenges on the journey to compliance with the community benefit requirements. Human resources, funding streams, and material supports may be limited; yet substantive and meaningful compliance with both the letter of the law and the spirit of the mandate is within reach, despite these barriers. Building upon the strengths of existing resources, positive relationships within the community, and a shared vision can facilitate the collective impact of community-wide endeavors. Although the territory ahead will be new, it is not completely foreign. Collaborative models offering best practice insights, such as the journey taken by WCH and community members that we have shared in this article, can serve as an exemplar for the road ahead.
Author
Allison V. Sabin, DNP, RN, APHN-BC
Email: asabin@sf.edu
Dr. Sabin is Associate Professor of Nursing in the School of Health Sciences at the University of Saint Francis in Fort Wayne, Indiana. She received her BSN degree from Kent State University in Kent, Ohio, and her MSN degree from Valdosta State University in Valdosta Georgia, specializing in nursing education and community/public health nursing. She received her DNP degree from Rush University in Chicago, Illinois, with a focus in systems leadership. Dr. Sabin has had over 25 years of experience in community/public health nursing practice and education. Specific areas of focus within the practice setting include the community health assessment and population-focused program planning and evaluation. Dr. Sabin has also had extensive experience in post-licensure nursing education, in several institutions, including Valdosta State University (Valdosta Georgia), University of Alaska (Anchorage, Alaska), Hawaii Pacific University (Honolulu, Hawaii), Ashland University (Ashland, Ohio), Indiana Wesleyan University (Marion, Indiana), and the University of Saint Francis (Fort Wayne, Indiana).
Pamela F. Levin, PhD, APHN-BC
Email:Pamela_F_Levin@rush.edu
Dr. Levin is Professor and Acting Chair, Department of Community, Systems, and Mental Health Nursing at Rush University College of Nursing, in Chicago Illinois. Dr. Levin received her BSN degree from Boston University (Boston, MA) and her MS and PhD degrees in nursing sciences from the University of Illinois at Chicago (Chicago IL), with a specialization in public health and occupational health nursing. She has over 25 years of clinical and teaching experience focusing on workforce development in hospitals and community/ public health agencies, including Lake Forest Hospital (Lake Forest IL), Advocate Lutheran General (Park Ridge, IL), University of Illinois at Chicago (Chicago, IL) and Rush University Medical Center in Chicago IL. For the last 10 years, she has served as faculty/Co-Director of a federally funded advanced nursing education grant to develop graduate programming in advanced public health nursing and integrating population health into primary care.
© 2015 OJIN: The Online Journal of Issues in Nursing
Article published , October 22, 2015
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