Chapter 3: Prioritizing Needs in a Health Care System: A Framework for Action

Sitaji Gurung

Learning Objectives:

• Define the concept of a community health needs assessment and explain its purpose.
• Describe the process by which a needs assessment identifies and prioritizes health needs within a community.
• Explain the concepts of health equity and healthcare access, particularly in relation to chronic disease management.
• Identify strategies for navigating and improving access to health resources within diverse communities.
• Develop a basic logic model to guide program or policy evaluation and illustrate its key components.

Needs assessments help healthcare systems identify and address health disparities, improve services, and target resources effectively. By systematically evaluating the health challenges and resource gaps in a community, providers can prioritize interventions to achieve better outcomes. In an era of strained budgets and rising chronic disease burdens, needs assessment plays a central role in public health planning.

Discussion Questions

1. Why is conducting a needs assessment essential before launching a new healthcare program?
2. How might healthcare outcomes improve when community needs are clearly identified?

Understanding the Community Context

A needs assessment begins with understanding the social, economic, and environmental context in which people live. Factors such as housing, education, transportation, and access to food deeply influence health outcomes. NYC Health + Hospitals emphasizes community voice and local context in shaping healthcare strategies.

“Video 1: 2021-2023 Community Health Needs Assessment” by Fairview Health Services is licensed under CC BY-NC 4.0

Discussion Questions

1. What community-level factors most influence health in your local area?
2. How can healthcare providers better incorporate community perspectives?

Defining the Scope and Purpose of the Assessment

Clarifying the goals and boundaries of the needs assessment is crucial. Whether focusing on chronic disease management, behavioral health, or access to services, a clearly defined scope ensures that the assessment remains manageable and actionable.

Discussion Questions

1. How does a focused scope improve the effectiveness of a needs assessment?
2. What challenges arise when the purpose of an assessment is too broad?

Engaging Stakeholders and Gathering Input

Stakeholder engagement builds trust and legitimacy. Involving patients, providers, community leaders, and policy makers ensures the assessment reflects diverse perspectives. NYC Health + Hospitals modeled this by incorporating community feedback into its Community Health Needs Assessment (CHNA) process.

Discussion Questions

1. Why is stakeholder input crucial in shaping the outcomes of a needs assessment?
2. What methods can be used to ensure inclusive stakeholder participation?

Setting Goals and Objectives

Once the needs are identified, goals and objectives should be established. These guide the design of interventions and resource allocation. Clear, measurable goals, like reducing diabetes-related hospitalizations, can drive focused action and monitoring.

Discussion Questions

1. What makes a goal both measurable and meaningful in CHNA?
2. How can objectives guide the choice of interventions?

Choosing the Right Data Collection Methods

Effective needs assessments use various methods, surveys, focus groups, health records, and community observations, to collect reliable data. The chosen method depends on the population, the topic, and available resources.

Discussion Questions

1. What are the strengths and weaknesses of qualitative vs. quantitative data in needs assessments?
2. How does choosing the right method impact data accuracy and usefulness?

Analyzing and Interpreting the Data

After collecting data, analysis reveals patterns, trends, and service gaps. For example, identifying high rates of uncontrolled hypertension in specific neighborhoods might lead to tailored interventions. Interpretation should consider contextual factors like language access or economic hardship.

“Video 2: 5 Things to Know About Health Literacy” by U.S. Department of Health and Human Services is in the Public Domain, CC0

Discussion Questions

1. Why is contextual knowledge important when interpreting health data?
2. What tools or techniques can support accurate data analysis?
3. Prioritizing Health Needs

With many competing needs, prioritization is key. Factors like urgency, severity, community concern, and feasibility guide decisions. Tools such as prioritization matrices and logic models help visualize and evaluate potential strategies.

Discussion Questions

1. What criteria should guide the prioritization of health issues?
2. How can logic models support the prioritization process?

Developing and Implementing Recommendations

Recommendations should be specific, actionable, and tailored to the community’s context. Implementation involves securing resources, partnerships, and timelines. NYC Health + Hospitals, for example, addressed behavioral health needs through loan repayment programs to attract clinicians.

Discussion Questions

1. How can partnerships support effective implementation of recommendations?
2. What are potential barriers to implementing recommendations in low-resource settings?

Monitoring and Evaluating Progress

Evaluation ensures that programs remain responsive and effective. Metrics should track progress toward goals, and results should feed back into program refinement. NYC Health + Hospitals integrates continuous monitoring into its health system planning.

Discussion Questions

1. What types of indicators are useful for monitoring healthcare programs?
2. Why is ongoing evaluation critical even after a program is implemented?

Using the CDC Framework for Program Evaluation

The CDC Framework provides a structured way to conduct evaluations by emphasizing stakeholder engagement, focused evaluation design, evidence collection, and justifying conclusions. It supports transparency, rigor, and community relevance in healthcare planning.

Discussion Questions

1. How does the CDC evaluation framework enhance program accountability?
2. Which step in the framework is most critical for your community and why?

Applying the Donabedian Model to Evaluate Quality

The Donabedian Framework breaks down healthcare quality into structure, process, and outcomes. Understanding this model allows systems to assess both the capacity to deliver care and the effects on patient health.

Discussion Questions

1. How does each part of the Donabedian model contribute to a complete quality evaluation?
2. In what ways can structure and process influence outcomes?

Health Equity as a Central Focus

Achieving health equity means recognizing and addressing disparities in health outcomes and care access. Needs assessments that center equity are more likely to produce fair and just recommendations, especially in diverse urban centers like New York City.

Discussion Questions

1. What does it mean to incorporate equity into a needs assessment?
2. How might the results of a needs assessment differ if equity is not prioritized?

Building a Logic Model for Change

Logic models visualize the path from inputs to outcomes and clarify assumptions. They support planning, implementation, and evaluation. A well-constructed model shows how resources translate into impactful health changes.

Figure 1: Basic Components of a Logic Model

Source: hhs.gov

License: Public Domain

Discussion Questions

1. What are the key components of a logic model?
2. How can logic models be used to communicate program goals to funders or stakeholders?

A Roadmap for System Change

Understanding and prioritizing healthcare needs isn’t just a technical task, it’s a moral imperative. By using needs assessment frameworks, engaging communities, and following data-driven strategies, health systems can be more equitable, responsive, and impactful.

Discussion Questions

What role does leadership play in the success of a needs-based initiative?How can communities hold health systems accountable for addressing identified needs?

Developing a Needs Assessment Case Study

Figure 2: Community Health Needs Assessment and Implementation Strategy Plan

Attribution: NYC Health + Hospitals

Here are three examples showing how a student can develop a needs assessment paper based on your notes and guidelines. Each example includes a clearly defined service (X variable), health outcome (Y variable), target population, and program from the NYC Health + Hospitals CHNA.

Example 1: Asthma Management with Mobile Health Units

Program of Interest: NYC Health + Hospitals SHOW (Street Health Outreach and Wellness)
Service Provided (X): Mobile asthma education and in-home environmental assessment services
Health Outcome (Y): Reduction in emergency room visits due to asthma exacerbations
Target Population: Children (ages 5–17) with moderate-to-severe asthma in public housing in East Harlem
Community of Focus: East Harlem

Outline:

Introduction – Explain why asthma is a priority in East Harlem, and introduce the SHOW mobile program.

Community Context – Discuss environmental triggers (e.g., mold, air pollution), housing conditions, and access to care.

Program Description – Detail how the mobile units provide education, inhaler training, and environmental assessments.

X and Y Variables Defined – Connect service (X) to the outcome (Y): how education and assessments reduce ER visits.

Logic Model – Present a planned logic model linking resources to short- and long-term outcomes.

Methodology – Describe how effectiveness will be measured (e.g., comparing pre/post ER visit rates, survey feedback).

Discussion & Recommendations – Discuss policy implications and potential for scaling to other high-risk NYC communities.

Planned Logic Model

Inputs	Activities	Outputs	Short-Term Outcomes	Long-Term Outcomes
Mobile units, trained asthma educators, HEPA filters, air quality monitors	Home visits, environmental assessments, education for families	# of homes visited, # of kits distributed	Better asthma self-management and awareness	Fewer asthma emergencies and hospitalizations

Example 2: Improving Maternal Health Equity through SHOW

Program of Interest: Street Health Outreach and Wellness (SHOW) Program
Service Provided (X): Mobile prenatal screenings and maternal education services
Health Outcome (Y): Increased early prenatal care engagement and reduction in maternal morbidity
Target Population: Low-income immigrant women in Jackson Heights, Queens
Community of Focus: Queens (Jackson Heights & Elmhurst)

Outline:

Introduction – Highlight disparities in maternal outcomes among immigrant women in NYC.

Community Context – Discuss barriers like language, insurance, and transportation.

Program Description – Explain how SHOW mobile units provide early screenings and connect women to OB/GYN care.

X and Y Variables Defined – Link early intervention services to reductions in pregnancy complications.

Logic Model – Include a clear logic model with outputs like “# of prenatal visits” and outcomes like “fewer ER births.”

Methodology – Note the use of focus groups or surveys, or secondary data analysis from NYC Health + Hospitals records.

Discussion & Recommendations – Address how SHOW can be expanded to address postnatal care or mental health screening.

Planned Logic Model

Inputs	Activities	Outputs	Short-Term Outcomes	Long-Term Outcomes
Mobile health vans, OB/GYN staff, health educators, translation services	Conduct screenings, provide maternal checkups, connect to hospitals	# of women screened, # of referrals made	Early detection of risks, better prenatal monitoring	Improved maternal health outcomes, reduced disparities in maternal mortality

Example 3: Telepsychiatry for Youth Mental Health in the Bronx

Program of Interest: Expansion of Behavioral Health Services
Service Provided (X): Telepsychiatry access for anxiety and depression
Health Outcome (Y): Increased therapy participation and reduced mental health crises
Target Population: Low-income Black and Latino young adults (ages 18–35)
Community of Focus: South Bronx

Outline:

Introduction – Explain growing youth mental health concerns post-COVID in underserved NYC areas.

Community Context – Outline mental health stigma, lack of access, and service deserts in the Bronx.

Program Description – Describe how telehealth increases access to early mental health support.

X and Y Variables Defined – Show how access to therapy reduces crisis events and improves treatment engagement.

Logic Model – Highlight inputs (staff, tech), activities (screenings), and outcomes (reduced 911 calls, more follow-ups).

Methodology – Discuss possible indicators like PHQ-9 screening scores or missed appointment rates.

Discussion & Recommendations – Explore long-term sustainability and integration into primary care.

Planned Logic Model

Inputs	Activities	Outputs	Short-Term Outcomes	Long-Term Outcomes
Telehealth platforms, trained mental health professionals, funding, outreach team	Deliver telepsychiatry sessions, conduct outreach via clinics and community events	# of sessions delivered, # of individuals reached	Improved screening and early detection of anxiety and depression	Reduced emergency psychiatric visits, sustained engagement in care

Discussion Questions

1. How does specifying a target population improve the effectiveness of a needs assessment?
2. In what ways do logic models support equity-driven program design?

Key Terms

X Variable (Program Service Variable): The specific service or intervention provided by the program (e.g., telepsychiatry, home visits, testing, vaccination).

Y Variable (Health Outcome Variable): The specific health-related result or impact the program aims to achieve (e.g., reduced ER visits, improved mental health access, improved testing process, increased vaccination rate).

Target Population: The specific group of people the program is designed to serve (e.g., Black and Latino young adults in the Bronx).

Mobile Health Program: A healthcare delivery initiative that uses mobile units to reach underserved communities with essential services.

Health Outcome: A measurable change in the health status of individuals or populations due to a program or intervention.

Program Service: An activity or support provided by a program to address a health need.

In-home Assessment: A service conducted in a person’s home to evaluate environmental or health-related factors.

Logic Model: A planning tool that outlines a program’s resources, activities, and intended outcomes.

Community-Based Intervention: A program implemented within a local community setting to address specific health needs.

Needs Assessment: A systematic process for identifying and addressing gaps between current conditions and desired health outcomes.

References

Centers for Disease Control and Prevention. (n.d.). Logic models. CDC Stepeh B. Thacker CDC Library.

Fairview Health Services. (2021). 2021–2023 Community Health Needs Assessment [Video].

Healthy People 2030. (n.d.-a). Social Determinants of Health. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion.

Healthy People 2030. (n.d.-b). Health literacy in Healthy People 2030. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion.

NYC Health + Hospitals. (2022). Community Health Needs Assessment 2022 (CHNA).

NYC Health + Hospitals. (2022). Implementation Strategy Plan 2022.

U.S. Department of Health and Human Services. (n.d.). 5 things to know about health literacy [Video].