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The Community Health Data Base: An Innovative Model Using Local Data to Create New Programs that Bridge the Gap between Clinical and Population Health

Featured Social Innovations

Under the Patient Protection and Affordable Care Act, hospitals are required to conduct a community health needs assessment (CHNA), which is a cost-saving process which looks at the healthcare needs of the entire community. These findings then lead to the development of a community health implementation plan (CHIP). CHNAs and CHIPs have changed the way public and private healthcare providers see community healthcare needs. They have also created more collaboration among providers of health and social services, as the CHNAs/CHIPs reveal common population health problems that cross service providers' roles and geographical boundaries, resulting in less duplication of services, improved population health, and cost savings due to fewer unnecessary hospital admissions1

Because of their utility in identifying unmet healthcare needs in community populations, CHNAs have become more broadly used by foundations, social services agencies and government agencies such as public health departments. CHNAs enable a systematic approach to ensuring that the healthcare system uses its resources to improve the health of the population in the most efficient way.[2] By using quantitative and qualitative data to systematically collect and analyze data to understand health issues within a community, leaders can help to create innovation programs to address any overlooked or unmet needs. 

Public Health Management Corporation (PHMC) recognized the need for these assessments more than 30 years ago, and created the Community Health Data Base to provide population-based data at the local level on health status, access to care, health screenings, use of care, health behaviors and many other factors that influence health in Southeastern Pennsylvania. This information, collected from over 10,000 randomly-selected households in the five counties in Southeastern Pennsylvania in a biannual telephone survey, provides users with information that identifies unmet health needs in small geographic areas that can be configured to exactly match a provider’s service area.  

PHMC’s CHDB model has been successful in Southeastern Pennsylvania for 30 years, and has been expanded recently into Delaware. Recently, the CHDB Household Health Survey was used by CHDB staff to conduct CHNAs for 28 hospitals and health systems in 2013, the first year CHNAs and CHIPs were required by the Affordable Care Act, and, after some hospital consolidation, for 23 hospitals and health systems in 2016. Additional hospitals and health systems used the survey data to complete their CHNAs and CHIPs themselves.  

The large number of hospitals who have used the CHDB data for their CHNAs allow the hospitals to create innovative programs to address any unmet needs. The following are two examples for how the CHDB and CHNAs have created new and innovation programs to meet the needs of a community. 

  1. An innovative community health partnership between Main Line Health’s Lankenau Medical Center and The Food Trust to reduce obesity is working with Lankenau’s primary and specialty physicians who serve uninsured and under-insured individuals in the Philadelphia region. The program provides eligible patients with $6 worth of Philly Food Bucks that they can redeem for fresh fruits and vegetables at any Food Trust farmer’s market. Lankenau has funded three farmer’s markets. At each market, Lankenau health educators provide shoppers with free nutrition information, health screenings and family wellness activities. This program is bridging the gap between primary care and healthy food access in the community. Each Food Buck is linked to a patient so health improvement can be measured by Lankenau providers.
  2. As a result of their CHNA, Doylestown Hospital adopted support for cancer and heart disease prevention programs, including screening and health education outreach, as its primary focus areas. The Doylestown Hospital assessment showed a lack of resource awareness regarding heart disease and cancer education in their service area, so the hospital increased the emphasis on social media and technology solutions to compliment traditional outlets for information sharing. The hospital  increased its audience on popular social media channels like Facebook, Twitter and LinkedIn by nearly 50%, with more than 136,000 impressions in the first few months of Fiscal Year 2016. 

Overall, the expected social impact of the PHMC’s CHDB, and its potential for replication in other geographic areas, is to improve health status at the community level by identification, outreach and treatment for residents of communities who have previously had no or only episodic contact with health care. The large number of hospitals/healthcare systems who have used the CHDB data for their CHNAs and CHIPs allows hospitals and other health-planning organizations, such as county health departments, to compare data across service areas. This can lead to more efficient collaboration between hospitals on common problems. It also helps hospitals and other providers to examine the potential for services that might be needed in the future, or to design innovative services that better meet current needs in new areas, increasing their regional impact.


Catholic Health Association of the United States, “Assessing & Addressing Community Health Needs,” Discussion Draft, revised June 2013.