CAHs' Community Health Needs Assessments and Implementation Plans: How Do They Align? (FMT Briefing Paper #39)



The Medicare Rural Hospital Flexibility (Flex) Program supports the development of local systems of care with Critical Access Hospitals (CAHs) as the hubs, including initiatives to address local population health priorities. This view of CAHs as central resources in rural systems of care is consistent with ongoing efforts by the Internal Revenue Service (IRS) to hold tax-exempt (501(c)(3)) hospitals, including CAHs, accountable for addressing unmet needs in the communities they serve. Relevant IRS hospital accountability initiatives include the establishment of a mandatory community benefit reporting framework in 2007 and the Affordable Care Act (ACA)-mandated changes to the IRS tax code that require 501(c)(3) hospitals to conduct triennial community health needs assessments (CHNAs), develop implementation plans to address identified needs, and implement written financial assistance and billing policies. Many community benefit and hospital experts view these regulatory requirements as an opportunity to encourage tax-exempt hospitals to target their spending in these areas to improve the health of the residents of their communities. The principal aim of this study was to provide a snapshot of how CAHs are using the CHNA process and information to address community needs. This brief examines community benefit data from the IRS Form 990, Return of Organization Exempt from Income Tax filings, CHNA reports, and implementation plans for a sample of 50 tax-exempt CAHs to understand how these hospitals are fulfilling their community obligations and the extent to which these reports are being used to support their population health improvement activities. The brief also describes opportunities for CAHs to strengthen their efforts to address unmet community needs, identifies resources needed to enhance CAH population health performance, and discusses how state Flex programs can support CAHs in meeting their community obligations and improving the health of their communities.


  • The most commonly identified needs in the community health needs assessments (CHNAs) included obesity, physical activity, and healthy eating; substance use; mental health services; tobacco use; chronic disease and diabetes; and access to primary care, specialty care and other services.
  • While these needs were commonly addressed in the implementation plans of study hospitals, a substantially lower percentage of the hospitals proposed to address substance use, mental health services, and tobacco use than the other commonly identified needs.
  • It was difficult to identify the extent to which the study hospitals engaged members of vulnerable populations in their CHNAs or the quality and depth of their community engagement activities.
  • Implementation strategies proposed by the study hospitals emphasized medical rather than population-level factors affecting the community and, in some cases, emphasized hospital-level facility and/or technology needs.
  • Although the CHNAs and implementation plans aligned with IRS guidelines, CAHs appear to need technical assistance related to the engagement of the community and vulnerable populations, prioritization of community needs, justification for those needs not addressed, and the use of the CHNA process to fulfill both their community accountability obligations and their own internal strategic planning needs.


Community Engagement Community Health Needs Assessments (CHNA) Community Impact Mental Health Substance Use