Engaging Underserved Populations in Affordable Care Act-required Needs Assessments

The implementation of the Affordable Care Act (ACA) provides an opportunity for undergraduate students to observe and experience first-hand changing social policies and their impacts for individuals and communities. This article overviews an action research and teaching project developed at an undergraduate liberal arts university and focused on providing ACA enrollment assistance as a way to support student engagement with community health. The project was oriented around education, enrollment and evaluation activities in the community, and students and faculty together reflected on and analyzed the experiences that came from the research and outreach project. Student learning centered around applying concepts of diversity and political agency to health policy and community health systems. Students reported and faculty observed an unexpected empowerment for students who were able to use their university-learned critical thinking skills to explain complex systems to a wide range of audiences. In addition, because the project was centered at a university with no health professions programs, the project provided students interested in community and public health with the opportunity to reflect on how health and access to health care is conditioned by social context. The structure and pedagogical approaches and implications of the action research and teaching project is presented here as a case study for how to engage undergraduates in questions of community and public health through the lens of health policy and community engagement.

Systems are investing in workers who come from the communities they serve to meet patient needs that extend well beyond clinic walls.

Nonprofit hospitals are exempt from paying taxes. To maintain this status, they must provide benefit to the community they serve. In an attempt to improve accountability to these communities and the federal government, the Patient Protection and Affordable Care Act of 2010 includes a provision that requires all nonprofit hospitals to conduct a community health needs assessment (CHNA) and implement strategies to address identified health priorities every 3 years. This Act's provision, operationalized by a regulation developed and enforced by the Internal Revenue Service, mandates the involvement of public health agencies and other community stakeholders in the completion of the CHNA. To better understand community participation in nonprofit hospital-directed community health assessment and health improvement planning activities. Using a 2-phased, mixed-methods study design, we (1) conducted content analysis of 95 CHNA/implementation plan reports and (2) interviewed hospital and health system key informants, consultants, and community stakeholders involved in CHNA and planning processes. Community participation was assessed in terms of types of stakeholders involved and the depth of their involvement. Our findings suggest that many hospitals engaged and involved community stakeholders in certain aspects of the assessment process, but very few engaged a broad array of community stakeholder and community members in meaningful participation throughout the CHNA and health improvement planning process. Vast improvements in community participation and collaborative assessment and planning can be made in future CHNAs. On the basis of the findings, recommendations are made for further research. Practice implications include expanding community engagement and participation by stakeholder and activity type and using a common community health improvement model that better aligns hospital CHNA processes and implementation strategies with other organizations and agencies.

The importance of process in resolving environmental disputes

As a first step in a proposed program of community-based participatory research, this study investigated access to care and specific health needs in a population of Hispanic women from a medically underserved, urban community. There were 66 Hispanic women recruited at a local church to complete a 94-item researcher-developed survey. Thirty-two percent of women in the study were not U.S. citizens. Being insured, being a citizen, and having a medical diagnosis were significant in satisfaction with care. The most prevalent health issue for this population was being overweight or obese. This study demonstrates the use of the community needs assessment process in the development of interventions to improve a community's health and health care. This is especially true in the Hispanic community in which large variations based on culture and country of origin will impact the success of planned interventions.

In 2006, Methodist Le Bonheur Healthcare (MLH) created the Congregational Health Network (CHN, TM pending) which works closely with clergy in the most under-served zip codes of the city to improve access to care and overall health status of the population. To best coordinate CHN resources around high-utilization and address the largest health needs in the community, MLH applied hot spotting and geographic information system (GIS) spatial analysis techniques. These techniques were coupled with the community health needs assessment process at MLH and qualitative, participatory research findings captured in collaboration with church and other community partners. The methodology, which we call “participatory hot spotting,” is based upon the Camden Model, which leverages hot spotting to assess and prioritize community need in the provision of charity care, but adds a participatory, qualitative layer. In this study, spatial analysis was employed to evaluate hospital-based inpatient and outpatient utilization and define costs of charity care for the health system by area of residence. Ten zip codes accounted for 56% of total system charity care costs. Among these, the largest zip code, as defined by a percentage of total charity costs, contributed 18% of the inpatient utilization and 17% of the cost. Further, this zip code (38109) contributed 69% of the inpatient and 76% of the outpatient charity care volume and accounted for 75% of inpatient and 76% of outpatient charity care costs for the system. These findings were combined with grassroots intelligence that enabled a partnership with clergy and community members and Cigna Healthcare to better coordinate care in a place-based population health management strategy. Presentations of the analytics have subsequently been made to HHS and the CDC, referred to by some as the “Memphis Model”.

ABSTRACTThe Primary Care Capacity Project (PCCP) of the Gulf Region Health Outreach Program aims to expand access to integrated high quality, sustainable, community-based primary care with linkages to specialty mental and behavioral health, and environmental and occupational health services in four Gulf States following the Deepwater Horizon Oil Spill. This paper presents findings from community and clinic assessments in Gulf Coast counties and parishes impacted by the oil spill and how these findings informed technical assistance and funding to Federally Qualified Health Centers (FQHCs) and the communities they serve. This process included community and clinic assessments. The community health assessments included existing and data and data from community stakeholders on demographics, health determinants, and health status. Existing data were gathered from sources including the U.S. 2010 Census, Vital Statistics, and the Center for Disease Control and Prevention's Behavioral Risk Factor Surveillance System and Gulf State Population Survey. State, county, and sub-county level data were gathered for 17 Gulf coast counties. These data were summarized and analyzed to create community profiles for each of the counties to characterize their demographic profile, health status, healthcare access, social environment, and oil spill impact. These profiles were then used to facilitate a community prioritization process with county stakeholders. Stakeholders representing multiple sectors of the community participated in focus groups and a group consensus building activity to determine the health priorities for their counties. Concurrent to the community assessment, clinic assessments were conducted with FQHCs identified through the Health Resources and Services Administration Data Warehouse in 16 of the 17 counties. The clinic assessment was conducted with FQHC administrative staff and clinic staff to measure clinic capacity and needs.Data gathered from the community and clinic assessments suggest that mental health and chronic illness, such as diabetes, hypertension, and heart disease are health priorities in the Gulf Region. Primary care and mental health care provider shortages were “access to care” priorities as evidenced by both the community and clinic assessments. Also, transportation and proximity to primary care facilities were access to care priorities. These findings helped to inform funding and technical assistance to the FQHCs located in Gulf Coast counties. The assessment processes and how the data and information gathered through them can translate to preparedness, response, and recovery action planning and decision making following oil spills or other natural or man-made disasters.

The community-based participatory research (CBPR)-driven health needs assessment was a tool used to inform community-led, -implemented, and -sustained research and prevention strategies. The Morehouse School of Medicine Prevention Research Center (MSM PRC) research and prevention initiatives are implemented in direct response to priorities identified through this process and tool. Led by a community-majority coalition board, the assessment coupled state and city secondary data with primary survey data collected by and from community residents. Hypertension, diabetes, obesity, and sexually transmitted infections were most frequently cited individual and community health priorities. Lack of social and family cohesion, limited or no opportunities to exercise, poor nutrition and lack of awareness and knowledge about diseases, and insufficient access to affordable health care were cited determinants of health priorities. The CBPR-driven community health needs assessment (CHNA) informed and established a data-driven community engaged research agenda, policy, systems and environmental change approaches, community-led grants and job creation leveraging neighborhood contexts and strengths.

ABSTRACTThe purpose of this paper is to discuss how university–community partnerships can be utilized to provide affordable and accessible health care for the elderly at community health clinics. A review of community health clinics, usage data from 2013 to 2014 by a sample of aging individuals will be described along with faculty perspectives about the usefulness of the university partnership and suggestions for improving future partnerships. Recommendations for future university–community partnerships are discussed.

Although the Affordable Care Act requires nonprofit hospital organizations to report how they identify and invest in community health needs, the utility of mandated reporting documents for tracking investments in the social determinants of health has been questioned. Using public reporting documents and focusing on housing as a social determinant of health, we describe how nonprofit hospital organizations in 5 communities with the highest rates of homelessness document needs and investments related to housing on their Community Health Needs Assessments, Implementation Strategies, and Schedule H (990H) tax forms. Of 47 organizations, 55% identified housing as a health need, 36% described housing-related implementation strategies, and 26% reported relevant 990H spending. Overall concordance among identified needs, strategies, and spending was low, with only 15% of organizations addressing housing across all 3 documents. Regulatory reform could help promote accountability and transparency in organizations' efforts to address housing and other health-related social needs.

Community health assessments (CHAs) are a core function of local health departments (LHDs). Recently, completing a CHA has become a prerequisite for LHDs seeking accreditation by the Public Health Accreditation Board (PHAB). Similarly, under the Affordable Care Act, nonprofit hospitals are required to conduct periodic community health needs assessments (CHNAs). Opportunities thus exist for LHDs and hospitals to jointly complete CHAs/CHNAs. This study examined existing LHD-hospital collaborations around CHAs/CHNAs, focusing specifically on the relationship between LHDs' level of engagement with PHAB accreditation activities and their collaboration with hospitals around CHAs/CHNAs. Data came from the 2013 NACCHO (National Association of County & City Health Officials) Profile Study and the Area Health Resource File. Complete data were available for 1332 LHDs that participated in the 2013 NACCHO Profile Study. Logistic regression explored the relationship between LHDs' completion of accreditation prerequisites, in particular completion of a CHA, community health improvement plan, and strategic plan, and their involvement in collaborations with tax-exempt hospitals around CHAs/CHNAs. LHDs that collaborated with tax-exempt hospitals on CHAs/CHNAs were larger, more likely to be locally governed, and more likely to have a local board of health. Bivariate analysis showed that CHA/CHNA-related collaboration with hospitals was significantly correlated (P < .01) with an LHD's completion of accreditation prerequisites. In multivariate regression analysis, completion of all 3 PHAB accreditation prerequisites significantly increased the odds of LHDs collaborating with hospitals when controlling for other LHD and community-level characteristics. PHAB accreditation prerequisites together with IRS requirements for hospitals foster potential for collaboration around CHAs/CHNAs. Joint completion of CHAs/CHNAs not only allows partners to complete the assessment more efficiently but has also been shown to produce higher-quality assessments, thus building a strong foundation for continued collaboration to improve community health.

Healthcare management in rural and underserved regions remains one of the most complex challenges within contemporary public health systems, particularly in developing economies where disparities in infrastructure, workforce availability, and financial resources significantly influence healthcare outcomes. This study examines the structural, administrative, and policy-related dimensions that shape healthcare delivery in rural and underserved communities, with a focus on identifying practical management strategies capable of improving accessibility, efficiency, and quality of care. Rural populations frequently experience limited availability of medical facilities, shortages of trained healthcare professionals, inadequate diagnostic services, and poor transportation networks, all of which contribute to delayed treatment and higher rates of preventable morbidity and mortality. In addition to geographic isolation, socioeconomic factors such as poverty, low health literacy, and limited insurance coverage further complicate the management of healthcare services in these settings. The research analyzes how healthcare administrators, policymakers, and local institutions can collaboratively address these challenges through integrated planning, community-based service delivery models, and innovative resource allocation approaches. Particular emphasis is placed on the role of decentralized healthcare management, mobile health initiatives, telemedicine platforms, and community health worker programs in extending essential medical services to remote populations. The study also explores the importance of strengthening primary healthcare systems as the foundational pillar for rural health management, ensuring early diagnosis, preventive care, and effective referral networks. Furthermore, the research evaluates the influence of government policies, public– private partnerships, and non-governmental organizations in bridging systemic gaps in rural healthcare infrastructure and service delivery. Through a comprehensive examination of existing frameworks and emerging healthcare management practices, the paper highlights how strategic planning, digital health integration, workforce training, and community participation can collectively enhance healthcare accessibility and sustainability in underserved areas. The findings suggest that effective healthcare management in rural contexts requires a multidimensional approach that integrates technological innovation, administrative efficiency, and culturally responsive healthcare practices. Strengthening health information systems, improving supply chain management for essential medicines, and promoting locally adapted healthcare policies are also identified as critical components for long-term improvement. Ultimately, the study contributes to the ongoing discourse on equitable healthcare systems by presenting practical insights into how management strategies can reduce disparities and support inclusive health service delivery. By addressing both systemic limitations and emerging opportunities, the research underscores the importance of adaptive, community-centered healthcare management models that can ensure equitable access to quality healthcare for rural and underserved populations while promoting sustainable public health development.

The mission of Kaiser Permanente, the largest not-for-profit integrated health care delivery system in the USA, is “to provide high-quality, affordable health care services to improve the health of our members and communities we serve.” This paired focus on the health of individuals and communities derives from the organization’s core value of health equity, which encompasses two notions: (1) the organization’s own members must have equal access to the highest-quality care, regardless of socioeconomic or any other factors; and (2) that health systems must address unhealthy environmental factors that disproportionately pose barriers to both members’ and the larger community’s ability to thrive. Health information technology (IT) is a critical enabler of Kaiser Permanente’s work to address health equity. This chapter describes the specific IT systems and tools used by Kaiser Permanente to identify and narrow or eliminate disparities in care for its members, including one of the nation’s largest electronic health records (EHRs), panel health management tools, a patient portal, and various telehealth technologies. The chapter concludes with a caution—that use of information technology in health care can itself lead to disparities in care—and discusses ways that delivery systems can and must work to ensure a future in which these tools are used to improve care for everyone.

L of health insurance has been linked to decreased preventive services, increased hospitalizations and emergency room visits, and diagnosis at later stages of disease, leaving those without insurance vulnerable to poor health outcomes.1 In 2006, Massachusetts instituted health care reform that by 2011 resulted in the highest health insurance rate in the country, with over 90% of residents having access to a consistent source of care.* Th e Patient Protection and Aff ordable Care Act (ACA), signed into law in 2010, will extend health coverage to an estimated 32 million uninsured Americans starting in 2014. Implementing the ACA’s health insurance mandate will require states to reach, educate, and successfully enroll individuals and families who have had little experience with health coverage.2 Th e uninsured are likely to require considerable individualized application and enrollment support. Consumer advocates believe there is a need for ongoing support so that the newly insured retain their coverage, navigate their way eff ectively through the health care system, and engage in wellness and prevention activities. As many states prepare to enroll millions of lowincome uninsured Americans, the experience of Community Health Workers (CHWs) in Massachusetts can inform outreach and enrollment eff orts across the country.3 Community health worker is an umbrella term for job titles, such as community health advisor, family advocate, health educator, liaison, promoter, outreach worker, peer counselor, patient navigator, health interpreter, and public health aide.4 Eff ective CHWs understand the populations and communities they serve and are seen as trusted leaders.5 In Massachusetts, CHWs are employed by community health centers, and community action, public health, and other communitybased agencies to help individuals and families enroll in MassHealth (the Massachusetts Medicaid and Children’s Health

Understanding social, economic, and structural barriers to accessing pet care services is important for improving the health and welfare of companion animals in underserved communities in the U.S. From May 2018-December 2019, six questions from the validated One Health Community Assessment were used to measure perceptions of access to pet care in two urban and two rural zip codes. One urban and one rural community received services from a pet support outreach program (Pets for Life), while the other served as a comparison community. After propensity score matching was performed to eliminate demographic bias in the sample (Urban = 512 participants, Rural = 234 participants), Generalized Estimating Equations were employed to compare the six measures of access to pet care between the intervention and comparison communities. The urban community with the Pets for Life intervention was associated with a higher overall measure of access to pet care compared to the urban site that did not have the Pets for Life intervention. When assessing each of the six measures of access to care, the urban community with the Pets for Life intervention was associated with higher access to affordable pet care options and higher access to pet care service providers who offer payment options than the community without the Pets for Life intervention. Further analyses with a subset of Pets for Life clients comparing pre-intervention and post-intervention survey responses revealed statistically significant positive trends in perceptions of two of the six measures of access to pet care. This study provides evidence that community-based animal welfare programming has the potential to increase perceptions of access to pet support services.