Quick Safety Issue 60: Understanding the needs of diverse populations in your community
The COVID-19 pandemic has shed a light on the many gaps in health care that diverse populations have experienced for decades. As integral parts of their communities, hospitals and medical centers need to understand the diverse populations they serve, including minority groups and vulnerable populations.
July 13, 2021
The COVID-19 pandemic has shed a light on the many gaps in health care that diverse populations have experienced for decades. As integral parts of their communities, hospitals and medical centers need to understand the diverse populations they serve, including minority groups and vulnerable populations. Disparities in health care are major patient safety and quality concerns which should be addressed by organizations with the same level of urgency as other health care-acquired conditions. There is a growing need – socially, politically, morally, and ethically – to address the health and well-being of diverse populations in communities throughout the U.S.
Some hospitals are forming new collaborative partnerships with government, nonprofit and other community organizations to find new ways to help them address community health issues that are outside of their traditional expertise, such as social determinants of health and mental health.1
The focus on population health and more equitable care has grown since the roll out of the Affordable Care Act (ACA), which established an expectation that nonprofit hospitals (nearly two-thirds of U.S. hospitals) complete Community Health Needs Assessments (CHNAs) at least every three years, in addition to consulting outside stakeholders and at least one public health agency. 1 The objective of CHNAs is to help these hospitals identify pressing community health needs and when this assessment is performed in a comprehensive manner, it can be an effective tool in developing specific interventions to improve community health.
The Centers for Medicare & Medicaid Services (CMS) Innovation Center has an interest in supporting innovative care models that address the needs of local populations. Currently, CMS is in the testing stage of an ongoing initiative, its Accountable Health Communities (AHC) model. Designed to address health-related social needs of CMS beneficiaries,2 the model also assesses whether identifying and addressing these needs improves the quality of care and reduces costs at the individual-beneficiary level.3,4
The AHC model acknowledges that health is not the product of a single community entity or even a single sector, and that community health improvement therefore requires a collective impact approach, aligning efforts across a variety of clinical and community-based organizations to achieve a common goal.3
In addition, hospitals and academic medical centers have an economic and moral interest in helping to ensure that surrounding communities are safe, vibrant, healthy, and stable. By utilizing their performance improvement infrastructure and available resources, hospitals can make significant, meaningful advances in health equity promotion. For example, promoting housing initiatives, such as recuperative care for homeless individuals; or providing access to healthy food through hospital food prescription programs.2
Safety actions to consider:
Hospitals and medical centers can use the following strategies/actions to help identify and support their diverse communities, thereby paving the way for improving the health of the community.
- Leadership makes equity a strategic priority within your institution. This requires leaders to leverage policies and practices that embrace anti-racism both within and beyond the hospital walls, nurture partnerships and professional pipelines within communities, and intentionally act on addressing adverse social determinants of health.5
- Use a social intervention framework, such as CMS’ AHC model (mentioned above), to help identify needs of your patient populations. The AHC model focuses on screening in 5 domains: housing instability, difficulty paying utility bills, food insecurity, transportation, and interpersonal violence. Your patient populations may have higher needs in some of these domains and lower or no needs in others. When needs in the community are identified, incorporate referrals to community resources and patient navigation (typically through a community health worker or patient navigator) in the social intervention framework you decide to use.2
- Create a strategic plan for community outreach. The plan should begin with an understanding of your organization’s culture, mission, vision and values, as well as an understanding of the patient populations that your organization serves.6 Identify opportunities to partner with the community and determine the level of involvement your organization would like to have with the community.
- Support the local workforce. Organizations should make an effort to hire into entry level positions persons from their communities and provide advancement and professional development opportunities. This could potentially develop a pipeline for marginalized groups into health care professions, fostering career advancement and professional development for all employees.5
- Cronin CE, Franz B, Garlington S. Population health partnerships and social capital: Facilitating hospital-community relationships. SSM-Population Health, 2021;13.
- Highfield L, Ferguson G, Walsh R, et al. A conceptual framework for addressing social needs through the Accountable Health Communities Model. The American Journal of Accountable Care, December 2020.
- Billoux A, Conway PH, Alley DE. Addressing population health: Integrators in the Accountable Health Communities Model. Journal of the American Medical Association, 2107;318(19).
- Centers for Medicare & Medicaid Services. CMS Finding at a Glance. Accountable Health Communities: Evaluation of Performance Years 1-3 (2017-2020). (Accessed April 20, 2021).
- Dave G, Wolfe MK, Corbie-Smith G. Role of hospitals in addressing social determinants of health: A groundwater approach. Preventative Medicine Reports, 2021;21.
- 3 steps to define a hospital’s role in the community. Beckers Hospital Review, July 3, 2013.
Note: This is not an all-inclusive list.