Assess Needs and Resources

Photo of a main street of a town

The key concepts below describe how to effectively assess needs and resources in the community and among stakeholders. As you complete this step, remember to consider in advance how you will Evaluate Actions and outcomes.

Working with your partners to assess needs and resources increases efficiency and impact. Instead of conducting separate assessments of overlapping populations and geographic areas, consider conducting a joint assessment of a common population of mutual interest.

Key Concepts

  • A broad definition of the community is established that allows for measurable opportunities to address population-health issues, while being focused enough to address health disparities
  • Community assets, in addition to gaps and needs, are identified and leveraged, including human capital and physical and social resources (e.g., parks, trails, charities, churches, food banks)
  • Use of public and private data, including pooled/shared data from stakeholders to comprehensively inform the CHI process, with consideration of shared-measurement systems to evaluate outcomes (see the Evaluate Actions section for more details)

Tools for Getting Started

Tools are listed below in an order roughly aligned with the order of the key concept(s) they support above.

For preliminary identification of vulnerable populations/disparities:

The tools listed below are intended to facilitate the initial identification of areas of need within the community so that CHI efforts can help bridge disparities. They are intended to serve as one input, among several, to help guide you early in the planning phase and inform initial thoughts on prioritization. Prioritization is addressed in the Focus on What’s Important section.

  • Vulnerable Populations Footprint
    • This data-visualization tool is designed to help the user map an estimated percentage of residents in poverty, and those with low educational attainment, in order to identify likely health disparities and communities most in need at the census tract level. (Note: It requires free registration to log in.)
  • A Practitioner’s Guide to Advancing Health Equity—Meaningful Community Engagement for Health and Equity
    • Go to pages 18–21 for a collection of health-equity considerations for policy, systems, and environmental strategies. Included are questions for you to consider and examples of how to integrate health equity into local practice.
  • Community Need Index™
    • This public health planning tool identifies the severity of health disparities and demonstrates linkages between community need, access to care, and preventable hospitalizations down to the ZIP-code level.

For community asset mapping:

  • Livability Index
    • This data visualization tool scores communities (by zip code) on several “livability” measures, such as housing, transportation, environment, and community engagement, and compares detailed metrics for each against the median US neighborhood.
  • Identifying Community Assets and Resources
    • Go to the Main Section, Checklist, and Tools tabs for an overview of how to identify, map, and harness community assets and resources to meet community needs and strengthen the community as a whole.

For conducting the assessment:

  • CDC Community Health Status Indicators (CHSI 2015)
    • This tool produces health profiles at the county level that include key indicators and factors that have the potential to influence health outcomes, such as health care access and quality, health behaviors, social factors, and the physical environment.
  • Understanding and Describing the Community
    • Go to the Main Section, Checklist, and Tools tabs for guidance on examining, understanding, and describing a community, including how to frame your findings.
  • Community Health Needs Assessment (CHNA)
    • Click on “Run an Indicator Report”, which allows you to select a specific geographic area (down to the census-tract level) and in a single click, generate an initial report that identifies relevant demographic and needs-assessment data for the selected area to potentially inform your CHNA report. (Note: It requires free registration to log in.)

Click here for additional tools related to the key concepts.

Relevant Excerpts from the Internal Revenue Service (IRS) Final Rule
The IRS Final Rule on Community Health Needs Assessments for Charitable Hospitals contains language related to select key concepts above. An excerpt of this language is provided below. To see the full regulation, click on the hyperlinked references below this paragraph.14

“In defining the community it serves for purposes of paragraph (b)(1)(i) of this section, a hospital facility may take into account all of the relevant facts and circumstances, including the geographic area served by the hospital facility, target population(s) served (for example, children, women, or the aged), and principal functions (for example, focus on a particular specialty area or targeted disease). However, a hospital facility may not define its community to exclude medically underserved, low income, or minority populations who live in the geographic areas from which the hospital facility draws its patients (unless such populations are not part of the hospital facility’s target patient population(s) or affected by its principal functions) or otherwise should be included based on the method the hospital facility uses to define its community. In addition, in determining its patient populations for purposes of defining its community, a hospital facility must take into account all patients without regard to whether (or how much) they or their insurers pay for the care received or whether they are eligible for assistance under the hospital facility’s financial assistance policy.”15

“To assess the health needs of the community it serves for purposes of paragraph (b)(1)(ii) of this section, a hospital facility must identify significant health needs of the community, prioritize those health needs, and identify resources (such as organizations, facilities, and programs in the community, including those of the hospital facility) potentially available to address those health needs.”16

“These needs may include, for example, the need to address financial and other barriers to accessing care, to prevent illness, to ensure adequate nutrition, or to address social, behavioral, and environmental factors that influence health in the community.”17

Note: The above statements do not constitute legal advice or regulatory guidance from CDC. Questions regarding the application of law to a specific circumstance or circumstances should be submitted to an attorney or other qualified legal professional.

14Additional Requirements for Charitable Hospitals; Community Health Needs Assessments for Charitable Hospitals; Requirement of a Section 4959 Excise Tax Return and Time for Filing the Return, 79 Fed. Reg. 78,953 (December 31, 2014) (to be codified at 26 C.F.R. pts. 1, 53, and 602), available at IRS Final Rule on Community Health Needs Assessments (CHNA) for Charitable Hospitals .
15Id. at 79,002.

Third Time’s a Charm – A Coalition Refines its Community Health Assessment Process

Since its inception in 2006, the Frederick County Health Care Coalition has worked to improve the availability of and accessibility to quality health care in Frederick County, Maryland. Although historically focused on health care, the Coalition holds a broad view of health. The Coalition is currently conducting its third triennial community health assessment and used the CHI Navigator to help refine its assessment process. Highlighting the Assess Needs and Resources page of the Tools for Successful CHI Efforts section, Coalition leaders recognized “the importance of identifying and making people aware of the community assets and resources that exist, not just needs and gaps in the community’s health.” This page of the CHI Navigator also helped further the Coalition’s idea of pooling and sharing data to inform the assessment and larger CHI process. As one Coalition member noted: “We intend to make more data available for wide distribution, and to offer more opportunities for community engagement in review of the data and discussion of the priorities for local health improvement”. For example, the Coalition plans to use a platform called LiveStories to consistently communicate about data updates and “to get everyone on the same page”.

Learn more about the Frederick County Health Care Coalition here, or contact Coalition member and health officer for Frederick County, Barbara Brookmyer at or 301-600-2509.

Additional Resources