Determining If the Hospitals in Your State Have Conducted a CHNA and If Tobacco Was Prioritized

Two states were selected to use as test states to articulate how to identify which hospitals had identified tobacco use as a driver and if a strategy was included in the implementation plans. Oregon was selected because it includes over 60 tax-exempt hospitals, has a high community profile, is a Medicaid expansion state, and a recent report indicated that more than 70 percent of LHDs have collaborated with a non-profit hospital on a CHNA. Nevada was selected because fewer than 40 percent of LHDs have collaborated on a CHNA, is a Medicaid expansion state, has fewer hospitals (37) and a greater mix of for-profit and not-for-profit, has a statewide community health planning requirement in even-numbered years, and has several counties pursuing accreditation by the Public Health Accreditation Board (PHAB). The results below provide some guidelines that may be helpful for searches. We also provide a time estimate for both states.

The first four steps below will provide a public health professional with information about which hospitals have identified tobacco as a driver and which of those prioritized tobacco in the subsequent implementation plan. Step five describes three different outcomes in terms of next steps.  Step six simply provides an estimate of the time it took to generate this information for our two trial states. This will help inform resource allocation decisions to obtain the information necessary to pursue working with hospitals and their CHNAs.

1. Every hospital in your state that is a 501(c)(3) federal tax-exempt organization is required to conduct a CHNA and adopt an implementation strategy. 
   1. To find a list of tax-exempt hospitals, you can search the state hospital association’s website. Many state hospital associations publish a guide to the state’s hospitals.  Searching “Oregon hospital association” led us to their website, which in turn helped us find the Oregon Hospital Guide.
   2. You can also use the federal Medicare hospital compare site to identify all hospitals in your state.
   3. A general search of “hospitals in [state] or “nonprofit hospitals in [state]” also produces assorted lists.
   4. Create a spreadsheet and use that to track whether tobacco use was identified as a driver and if tobacco was prioritized in the implementation plan.
2. Do a web-based search for each hospital’s CHNA.
   1. Perhaps the easiest approach is to do a global search such as “Nevada hospital community health needs assessment.”  Because the CHNAs and implementation plans must be posted, this typically provides a link to most of the state’s hospitals’ CHNAs. Your spreadsheet can help identify gaps.
   2. If you are not finding the CHNA using a global serach, use IRS Form 990 Schedule H to find the hospital's CHNA and Implementation Plan.
      1. The IRS requires all tax-exempt hospitals to file a Form 990 Schedule H that provides information regarding the CHNA and its implementation plan (see IRS Reporting Requirements in CHNA Background for more detail).
      2. Two sites that provide access to hospital 990s are:
         1. http://www.communitybenefitinsight.org/?page=search.home
         2. https://projects.propublica.org/nonprofits/
   3. Be aware that some multi-hospital systems will do a CHNA for each hospital while others will do an integrated CHNA for the whole system.
3. Save the pdf CHNA plans as well as CHNA implementation strategies. 
   1. Sometimes these are included in a single document and other times they are a separate document.
4. Search the documents for the keyword “tobacco.” In reviewing content, look for two distinct components:
   1. If tobacco use is identified as a driver of poor health – typically found in the CHNA
   2. If a tobacco cessation strategy is included in the implementation plan
5. There are three possible outcomes
   1. Tobacco use as a driver, tobacco prevention or cessation as a strategy: This is the best possible outcome since it indicates that the hospital has prioritized tobacco control in its implementation plan. Review the document and consider how your agency may contribute to the hospital’s strategy. This may mean suggesting alternative strategies to ensure ongoing success. Make sure to find out when the next CHNA will be conducted to ensure tobacco remains a priority. 
   2. Tobacco use as a driver, no tobacco strategy: In this case, it is likely that the hospital will be receptive to identifying ways to integrate tobacco control but primarily in the context of the areas already prioritized. Review the document and identify what strategies were selected and for what conditions. It is likely that most of the conditions prioritized will have a tobacco component. Review the strategies and identify ways that a tobacco cessation component could accelerate progress. This provides an opportunity to reach out to the hospital to contribute to their efforts. If a CHNA will be redone soon (every three years), contact the hospital to find out who will be leading the work and suggest ways that your agency can contribute.
   3. Tobacco use not identified as a driver: If tobacco use is not viewed as a driver of poor health in the community, there will be no tobacco component in the implementation plan. While more challenging, the process of linking tobacco to the drivers and strategies selected will identify mechanisms by which the public health agency can suggest adding tobacco. The goal is not to have the hospital change its mind about its priorities but rather to suggest ways to leverage available tobacco control resources to contribute to their selected priorities.
6. Time Estimate
   1. Oregon has over 60 hospitals and all but two are required to conduct a CHNA.  The process of completing steps 1 – 4 took approximately five hours.
   2. Nevada has almost 40 hospitals with a slightly greater mix of for-profit than not-for-profit.  The process of completing steps 1 – 4 took approximately two hours.
   3. If you need to search for a hospital's 990 it may take longer. Although the websites provided are helpful, it requires more careful searching to ensure you have the right organization (e.g. not the hospital's foundation that may go by the same name).

These time estimates are important because they underscore that it takes a relatively small investment of time to have a good understanding of which hospitals have identified tobacco use as a driver and which have also included tobacco cessation as a strategy in their implementation plans.