Using your community health needs assessment to identify service delivery gaps and process improvements

In the new health landscape, hospitals need to balance the triple aim of reducing cost, improving care, and improving population health. Successful providers will need to collect relevant and meaningful data and correctly interpret the data to strategically and effectively monitor and manage their patient populations.

The IRS-mandated community health needs assessment (CHNA) plays a significant role in helping hospitals to better understand the health needs and perceptions of the community.
A strategically focused CHNA can benefit both the community and the bottom line. It can also help an organization plan and prepare for future healthcare delivery by identifying high-risk populations and predicting health needs that will affect future programs and resources.

Our client’s needs

Tying CHNA mandate to your population health management strategy

A newly integrated health system sought to comply with IRS regulations to conduct a community health needs assessment (CHNA) for its eight hospitals, including three that were newly acquired. The health system was looking for a firm that could do more than conduct a needs assessment; they wanted a firm that could provide strategic recommendations for their future growth and provide them with industry and business knowledge.

While the health system’s last round of CHNAs had been conducted independently for each hospital, the system sought a process that would allow them to identify priority community health needs across its entire service area, while providing insight for population health management strategies.

The Baker Tilly solution

Baker Tilly developed a system-wide approach to the CHNA across the organization’s entire service region.  Profiles for individual hospital service areas were created and compared across the system to identify cross-cutting opportunities. Publicly reported data, as well as hospital utilization data were collected and analyzed to identify the intersection of community health needs and service delivery gaps.

Identifying health disparities

Recognizing the impact of social determinants of health on a community’s health status and needs, Baker Tilly collected and analyzed publicly reported health and socio-economic data including morbidity and mortality statistics, maternal and child health measures, behavioral health trends, education, and poverty rates, among other data.

“Social determinants of health are factors within the environment in which people live, work, and play that can affect health and quality of life.”  

Identifying service delivery gaps

An analysis of the health system’s data was performed to identify utilization patterns for inpatient and outpatient volumes, readmissions, and emergency department trends. Baker Tilly used the hospital’s own data (rather than relying on third party data) so results represented actual patient visits. The utilization data analysis helped identify areas within the hospital’s service area with the most opportunity for outreach and education such as zip codes with high volumes of emergency room visits and readmissions for chronic conditions.


Baker Tilly’s CHNA and healthcare data specialists helped the health system to identify the intersection between community health needs and service delivery gaps to direct population health management strategies and identify process improvements.  The health system was able to determine common community health concerns across its system service area and adopt system-wide priorities for community health improvement while leveraging local partners and resources. Further, correlating socio-economic measures and healthcare utilization trends allowed the health system to identify specific zip codes within each hospital service area in which to focus resources and community outreach.

Baker Tilly’s research findings helped the client pinpoint high-risk populations while proving insight for patient engagement, process improvement, and community partnerships to advance concurrent population health strategies.

For more information on this topic, or to learn how Baker Tilly healthcare specialists can help, contact our team.