Before You Begin

Step 1

Map Development

Step 2

Build Relationships

Step 3

Develop Community Profile

Step 4

Increase Equity With Data

Step 5

Prioritize Needs and Assets

Step 6

Document and Communicate Results

Step 7

Plan Equity Strategy

Step 8

Develop Action Plan

Step 9

Evaluate Progress

Develop a Community Health Profile

The Community Health Profile includes geographic and demographic information and identifies social drivers of health. This profile is drawn from both quantitative and qualitative sources.

Specifying geographic focus and population characteristics determines the scope of your assessment and any implementation strategies. Stratifying quantitative data by ZIP code, census tract or neighborhood and qualitative data from community members will help inform this important section of your CHA.

View additional resources to futher your CHA journey.

Step 3 Resources


Seek to understand different perspectives.

Community and hospital partners may bring very different perspectives on the need for and use of data. Take time to understand one another’s perspectives on how data will play a role in supporting individual and shared goals of the CHA. To gain a deeper understanding, review the scope of past CHAs and the extent to which they engaged community members.


Define the CHA Geographic Boundaries

The geographic focus can include counties, cities or towns, neighborhoods, schools or other governmental districts or a collection of ZIP codes. Consider the hospital’s service area as a starting point to describe the community. In some cases, you may choose to go beyond primary and secondary service areas to areas with greater unmet health needs. Review your past CHAs to see how your community was defined and determine whether and how that definition needs to change.

Identify Population Characteristics and Groups

Now that your community is defined, take an unbiased look at who lives there. The American Community Survey (ACS) of U.S. households and residents is a good source of information on population characteristics. Replacing the long-form census questionnaire, it is administered to one in 38 U.S. households each year. The chart below lists population characteristics to research as well as further references beyond the ACS. Remember to include your external stakeholders in this step; they can add insight and context to the data.

Population Characteristics

  • Age (e.g., children and youth, adults, older adults)
  • Race and ethnicity
  • Income level
  • Education level
  • Insurance status
  • Language preference
  • Disability status
  • Veteran status
  • Sexual orientation
  • Gender identity

Data Sources

  • Hospital/health system employee needs surveys
  • Social needs screening and referrals data
  • Community input
  • Electronic health record and referral platforms such as Epic, Aunt Bertha, Unite Us
  • CDC PLACES and Social Vulnerability Index
  • 211s
  • Aggregators such as City Health Dashboard and commercial vendors

Recognize the Societal Factors that Influence Health

Your CHA process is a great opportunity to identify and then address SDOH. Below are examples of resources to learn more about these powerful systemic and structural factors that influence the health of communities your hospital serves. In addition, your hospital or health system may have rich internal data — through the electronic medical record, registration and patient accounting systems — on the SDOH affecting patients.

Economic Stability

U.S. Bureau of Labor Statistics, state economic development agencies and local governments. These range from unemployment percentages and job categories to types and locations of licensed businesses


U.S. Census Bureau American Community Survey and local, county and state government websites

Food Access

U.S. Department of Agriculture and local health departments. Feeding America, a nonprofit, provides its own data on food insecurity, as well

Health Care Access

Centers for Disease Control and Prevention, Health Resources & Services Administration, Centers for Medicare & Medicaid Services and state health departments


U.S. Department of Housing and Urban Development, local sheriff’s offices (eviction data), U.S. Environmental Protection Agency, American Chemical Society (ACS), among others


Federal Bureau of Investigation (FBI) and local police departments

Social Connectedness

American Community Survey, 100 Million Healthier Lives Well-being Assessment (adult and youth)


National, state and local departments of transportation. The EPA also provides data about pollution caused by traffic

Substance Abuse

The Substance Abuse and Mental Health Services Administration National Survey on Drug Use and Health


Although quantitative data can illustrate the scope and severity of health issues in populations, numbers alone cannot express the sense of urgency or importance a community has assigned to particular social structures or issues affecting their residents. This critical information can be obtained only by hearing directly from community members and sharing their lived experiences. Make sure this listening is part of your efforts to create a community profile. Learn more about gathering qualitative data in Step 4: Deepen Understanding and Increase Equity through Data.


Collaborate with other organizations conducting health assessments.

Nonprofit hospitals are among the many organizations--including, but not limited to, local health departments, social services organizations and agencies on aging--that are required to assess the health needs of their communities. Collaboration with. other community organizations on community assessment is mutually beneficial.

If you are not already engaged in collaborative needs assessment, consider partnering with other local hospitals or health systems even if they have a different geographic scope than your hospital. Leveraging mutual interests will ensure that priority populations such as uninsured and underinsured persons, the medically underserved, low-income persons, older adults and historically marginalized populations are included in the assessment. Moreover, this process will open up more meaningful opportunities to address community health needs in your region.