Evaluation of Community Health Needs Assessments and Health Improvement Plans among Georgia, Iowa, and Florida Critical Access Hospitals Open Access

Evans, Paige (Spring 2019)

Permanent URL: https://etd.library.emory.edu/concern/etds/5q47rp750?locale=en


Background: Critical Access Hospitals (CAHs) reduce the financial vulnerability of rural hospitals and improve access to healthcare by maintaining essential services in rural communities. CAHs are required to (1) develop Community Health Needs Assessments (CHNAs) to identify community needs and (2) produce Health Improvement Plans (HIPs) that describe which initiatives were taken to address health priorities. These are useful tools for hospitals to be held accountable for the health of their community.


Objective: Our objective was to evaluate the correspondence between CHNA priorities and HIP initiatives of all CAHs in Iowa (n=71), Georgia (n=30), and Florida (n= 12) in 2017 to identify how well CAHs respond to the health needs in rural populations. We further assessed CAH financial distress indicators and examined whether financial distress was related to initiatives undertaken in HIPs.


Methods: CAH websites were used to obtain CHNA and HIP reports. Financial information for CAHs was obtained from the American Hospital Directory.Health needs identified in CHNAs and health needs prioritized by HIPs were categorized as health conditions and behaviors, social and economic issues, clinical care, or environmental factors.  Financial distress was measured with 10 variables: current ratio, quick ratio, operating margin, operating income, days cash on hand, average payment days, net patient revenue, Medicare revenue, state and local indigent program revenue, and uncompensated medical care revenue. We examined whether financial distress measures were related to the discrepancies between priorities identified in CHNAs and initiatives undertaken in HIPs categorized by agreement levels in FL, GA, and IA CAHs. 


Results: There were a total of 560 identified needs in the CHNAs and a total of 399 HIP initiatives planned to be implemented by hospitals in IA, FL, and GA. There was a highdegree of agreement on the top priorities in the CHNAs as compared to the initiatives undertaken in the HIPs.Mental healthand obesity were thetop needs identified in the CHNAs and just as likely to be prioritized in HIPs. On average, high agreement between CHNAs and HIPs in CAHs had more favorable financial indicators than low agreement CAHs. 


Discussion: In their HIPs, CAHs responded reasonably well to the needs of their CHNAs. Our findings indicate that CAHs that had strong alignment between CHNAs and HIPs also had healthier financial profiles. The ability for a non-profit organization to pay its bills is a crucial financial tool and determines its ability to adopt new strategic priorities.While these data were not statistically significant, they can allow for advocacy groups to identify areas for additional educational training, lobbying, and grants to support CAHs in the rural Southeast and Midwest. 

Table of Contents

Chapter 1: Introduction to Critical Access Hospitals             1

Overview        1

Rural Population Characteristics        2

Community Health Needs Assessments: Mandatory Reporting for CAHs   3

Problem statement      6

Purpose statement       7

Aims   7

Significance statement            8

Key Terms:     8

Chapter 2: Comprehensive Literature Review           8

Introduction    8

Poverty in Rural Florida, Iowa, and Georgia11

The History of Medicare in the United States            12

Professional shortages in CAHs         14

Telemedicine in Rural Settings          15

Chapter 3 Methodology          16

Context           16

Health Improvement Plans     17

Inclusion of CAHs in this evaluation18

Evaluation Measures  18

Financial Measures     19

Analysis          21

Chapter 4: Results      23

CHNA and HIP Results          23

CAH financial distress            25

Chapter 5: Conclusions and Recommendations         28

Conclusions    28

Recommendations      30

Acknowledgements    32

Appendices     33

Bibliography   37

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