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Abington Jefferson Health - Abington-Lansdale Hospital
Community Health Needs Assessment Implementation Plan
Introduction
Abington Jefferson Health (AJH) serves patients primarily in Montgomery and Bucks Counties
in Pennsylvania. AJH conducted a community health needs assessment (a “CHNA”) of the
geographic areas served by Abington-Lansdale Hospital ("Hospital") pursuant to the
requirements of Section 501(r) of the Internal Revenue Code (“Section 501(r)”).1 The CHNA
findings were approved by the Board in April 2016 and are available on the Hospital’s website.2
This implementation strategy (“Strategy”), also required by Section 501(r), documents the efforts
of the Hospital to address and prioritize the community health needs identified in the 2016
CHNA.
The Strategy identifies the means through which the Hospital plans to address needs that are
consistent with the Hospital’s charitable mission as part of its community benefit programs from
2016 through 2019. Beyond the programs discussed in the Strategy, the Hospital is addressing
many of these needs simply by providing care to all, regardless of ability to pay. The Hospital
anticipates health needs and resources may change, and thus a flexible approach was adopted in
the development of its Strategy to address needs identified in the 2016 CHNA. In addition,
changes may be warranted by the publication of final regulations.
Overview of Implementation Strategy
1. Community Served by the Hospital
2. Hospital Mission Statement and Community Benefit Charge
3. Priority Community Health Needs
4. CHNA Implementation Strategy
5. Needs Beyond the Hospital’s Mission or Community Benefit Program
1. Community Served by the Hospital
Abington-Lansdale's Community Benefit (CB) areas are defined as the areas proximate to the
hospital where approximately 70% of inpatients reside. This includes communities in
Montgomery and Bucks counties that are aggregated into 4 geographically contiguous regions
defined by zip codes. For comparison, the combined data for Bucks and Montgomery counties is
provided.
1 The Patient Protection and Affordable Care Act (Pub. L. 111‐148) added section 501(r) to the Internal Revenue
Code, which imposes new requirements on nonprofit hospitals in order to qualify for an exemption under Section
501(c)(3), and adding new reporting requirements for such hospitals under Section 6033(b) of the Internal Revenue
Code. 2 The Community Health Needs Assessment Report is available on the Abington Jefferson Health website at
http://www.abingtonhealth.org.
3
In Abington-Lansdale's CB areas, almost 6,600 residents identify themselves as Hispanic and
most live in North Penn and Indian Valley. One third of Hispanics in the Abington-Lansdale CB
area are from Puerto Rico; Mexico, South America, and Central America are each originating
areas for approximately one sixth of residents and the remaining Hispanic population is from the
Caribbean and other places. Although they share a common language, each Hispanic community
is culturally unique, and internally diverse by gender, generation, class, and race.
The Asian community in Abington-Lansdale's CB areas is predominantly of Korean and Asian
Indian descent, with North Penn serving as home to the most residents of Asian origin.
Montgomery County has the oldest population in Southeastern Pennsylvania, and the Abington-
Lansdale CB area has a higher percentage of older adults than Bucks/Mont.
Demographic Bucks/Mont Hospital Community Benefit Area
Population 1,411,000 199,000 (14% of Bucks/Mont residents)
Projected population
growth, 2015-2020 1.3% 2.4%
White, non-Hispanic 80.4% 79.4%
Black, non-Hispanic 6.7% 4.0%
Hispanic 4.9% 3.6%
Asian and Pacific Islander,
non-Hispanic 6.0% 11.2%
Population 65+ 16.7% 17.2%
Source: AJH CHNA, 2016
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2. Hospital Mission Statement and Community Benefit Charge
The Hospital has a long history of engaging our community in identifying health issues and
implementing strategies to address needs. Our mission, "Health is all we do," demonstrates our
commitment to improving well-being, and our vision "to re-imagine health, health education and
discovery to create unparalleled value, and to be the most trusted healthcare partner” expresses
our focus on innovative solutions. Effective community programs are an integral part of our
mission and vision.
To fulfill our Community Benefit mandate, the Abington Health Foundation formed a
Community Benefit Committee. The committee is responsible for overseeing and
recommending policies and programs designed to carry out the charitable mission of Abington
Hospital and Abington-Lansdale Hospital, protect its non-profit status, and to enhance the health
status of communities served by AJH based on the results of a community health needs
assessment.
Specifically, the Committee was charged to:
Oversee the conduct of a community health needs assessment at least every three (3) years.
Review and recommend for approval, a Community Benefit Plan outlining long-term
strategies based on a community health needs assessment and other objective sources of data,
and recommend updates to such Plan.
Guide and monitor the planning, development, and implementation of programs aimed at
improving the health status of the local community consistent with the Community Benefit
Plan.
Establish criteria for priority-setting among potential community benefit activities and
projects, consistent with financial capabilities and resource limitations.
Periodically make recommendations for program continuation or termination based on
progress toward identified measurable objectives, available resources, level of community
ownership, and alignment with criteria for priorities.
Review and make recommendations regarding the annual Community Benefit Report,
including the information provided to the IRS on Form 990. Additionally, identify
opportunities for disseminating information to the public about the organization’s community
benefit activities.
Review annual goals specifying principal work focus areas for the coming year. Review
hospital financial assistance policies and practices and provide recommendations as
necessary in an effort to increase efforts to communicate these policies.
The Community Benefit Committee are trustees, staff, physicians, nurses, other clinicians, clergy
and various diverse representatives of the communities served by AJH.
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"Actual Needs"
Resources, feasibility,
policy
Public's perceived
needs, priorities
3. Prioritizing Community Health Needs
The focus of the Community Benefit Implementation Strategy is the intersection of the scientific
evidence, public support, and political backing.3 The "A" in this model is the area with the
greatest potential for mobilization of resources and action.
Poor health status is due to a complex interaction of challenging social, economic,
environmental, and behavioral factors, combined with a lack of access to care. Addressing the
root causes of poor community health can improve quality of life and reduce mortality and
morbidity.
The following table describes the community health needs identified through the 2016 CHNA as
priorities. In order to maximize the resources available to the Hospital, the Strategy will focus
on the priority health needs listed as “Most Important.” Many of the remaining needs are
addressed in normal operations of AJH and therefore will not have a dedicated plan.
AJH will not directly focus on youth health behaviors, medication access, community safety,
transportation, or the built environment needs identified as “important or less important” in the
2016 CHNA. Those priorities are beyond the scope of AJH and are being addressed by other
community based and government organizations. AJH will collaborate with groups of experts in
these areas to foster appropriate and safe referrals and identify opportunities for partnership and
inclusion in community benefit initiatives.
AJH will continue our collaboration regionally with other hospitals and health systems within
Bucks and Montgomery Counties through partnerships, cooperation, and coordination on public
health issues.
3 Green and Kreuter, Health Program Planning, 4
th ed., NY; McGraw Hill, 2005, fig 2-3, p.40.
Scientific
Evidence
Political Backing
A Public
Support
6
Domain Priority Health Needs/Issue Ranking
Score
Priority Level
Access to Care Mental Health Services 26.3 Most Important
Access to Care and Healthy
Lifestyle Behaviors and
Community Environment
Social and Health Care Needs of
Older Adults 25.7 Most Important
Chronic Disease Management Obesity 24.3 Most Important
Healthy Lifestyle Behaviors
and Community Environment Alcohol/ Substance Abuse 23.3 Most Important
Health Screening and Early
Detection Women's Cancer 22.7 Most Important
Chronic Disease Management Chronic Disease Management
(diabetes, heart disease and
hypertension, stroke, asthma)
21.7 Most Important
Access to Care Health Education, Social Services
and Regular Source of Care 20.7 Most Important
Health Screening and Early
Detection Colon Cancer 20.3 Most Important
Access to Care ED Utilization and Care
Coordination 18.3 Important
Healthy Lifestyle Behaviors
and Community Environment Youth Health Behaviors 18.0 Important
Access to Care Medication Access 18.0 Important
Access to Care Language Access, Health Literacy
and Cultural Competence 17.3 Important
Access to Care Maternal and Child Health 17.0 Important
Healthy Lifestyle Behaviors
and Community Environment Physical Activity 16.3 Important
Access to Care Health Insurance 16.0 Important
Internal Organizational
Structure Hospital Readmissions 14.3 Less Important
Healthy Lifestyle Behaviors
and Community Environment Access to Healthy Affordable Food
and Nutrition Education 14.0 Less Important
Healthy Lifestyle Behaviors
and Community Environment Food Security 14.0 Less Important
Healthy Lifestyle Behaviors
and Community Environment Community Safety 13.7 Less Important
Access to Care Access: Transportation 13.3 Less Important
Healthy Lifestyle Behaviors
and Community Environment Smoking Cessation 13.0 Less Important
Internal Organizational
Structure Workforce Development and
Diversity 12.3 Less Important
Healthy Lifestyle Behaviors
and Community Environment Built Environment 9.7 Less Important
Health Screening and Early
Detection HIV 8.3 Less Important
7
To address the needs identified in the 2016 CHNA process, AJH convened 7 Community Benefit
Action teams consisting of key community stakeholders and AJH administrative and clinical
leaders to develop and implement goals and action plans. Leaders of these teams will report on
progress quarterly through reports shared with the Community Benefit Committee.
In addition, AJH professionals will collaborate with Jefferson colleagues to improve health status
in conjunction with the hospital’s partnerships. Best practices will be shared with the aim of
enhancing infrastructure, stretching resources, and incorporating knowledge about social
determinants of health and health literacy to better the population's health and well-being.
4. CHNA Implementation Strategy
The Hospital has a strong tradition of meeting community health needs through its ongoing
community benefit programs and services. The Hospital will continue this commitment through
the strategic health priorities set forth below that focus primarily on four (4) high-priority health
need domains.
Not all programs provided by the Hospital that benefit the health of patients in the Hospital’s
primary service area are discussed in the Strategy. Further, given evolving changes in health
care, the Hospital maintains the right to change its strategies, and new programs may be added or
eliminated. The Strategy laid out in this document has two major parts: implementing programs
to address the priority needs from the CHNA, then evaluating the impact of those activities.
A. Identifying Areas of Impact and Planning to Evaluate Proposed Community Benefit Programs
The 2016-2019 focus of the Hospital’s grant-funded community benefit and in-kind resources
was identified based on the CHNA findings, the prioritized health needs, and recommended
initiatives to impact the health of the community.
The Strategy is organized according to the following domains:
Access to Care
Chronic Disease Management
Health Screening and Early Detection
Healthy Lifestyle Behaviors and Community Environment
Through implementing evidenced-based strategies to address these four domains of community
health need, the Hospital anticipates the following positive impact and improvements in
community health:
Positive impact on disease management and disease prevalence, including mental health,
substance abuse, obesity and obesity-related diseases (including stroke, cardiovascular
disease, and diabetes), asthma, women's cancers, and colon cancer;
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More appropriate use of health resources, including the social and health care needs of
older adults, health education, social services, and a regular source of care, a reduction in
unnecessary hospital admissions and use of some hospital services including emergency
department visits, improved access to medications, and an increase in use of culturally
appropriate primary care and health screenings; and
Improvement in community health status, including reduction in health disparities,
increased physical activity, reduced rates of smoking, improved health and nutrition
status, and improved maternal and child outcomes.
These improvements will be evaluated through review and monitoring of existing data sources,
which may include but are not limited to:
1. Internal Hospital data, including referral and inpatient and outpatient service data
2. Public Health Management Household Health survey data
3. Surveys and key informant interviews with providers and clients
4. Reports from government agencies, which may include the Bucks and Montgomery
County Health Departments, the Bucks County Area Agency on Aging, Montgomery
County Drug and Alcohol, and the Montgomery Office of Aging and Adult Services
5. External community data sources
B. Address Priority Health Needs through Hospital’s Existing and New Community Benefit
Programs
The Hospital plans to provide community benefit programs responsive to the health needs
identified in the 2016 CHNA. As part of this Strategy, the Hospital will focus first on those
needs designated as “Most Important” between 2016 and 2019, and will continue to evaluate
those needs that were designated as “Important” and “Less Important”. Only those needs
identified as "Most Important" are detailed in this Implementation Plan. The recommended
actions may be modified based on on-going input and recommendation from internal and
external partners, identification of new partnership opportunities, changes in the healthcare and
community environment, and availability of resources. Throughout the implementation period,
the Community Health Department will identify grants and internal and external funding sources
as appropriate to support the strategies and activities. Resources to implement programs are
provided in-kind unless otherwise noted.
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DOMAIN: ACCESS TO CARE
The anticipated impact of the following actions may include: increase in access to primary
care with related reduction in emergency room (ER) visits and hospital readmissions; increase in
the number of insured adults and adults with AJH financial assistance; increase in the number of
patients and providers in dental clinic care; increase in number of patients connected with social
services; improvement in access to and utilization of culturally appropriate primary care,
reduction of health disparities, improvement in maternal and child outcomes; improvement in the
social and health status of older adult; improvement in the capacity of community-based
organizations to address behavioral health issues among clients/program participants; and
reduction in transportation barriers to receiving medication and care.
1. Action: Improve access to Mental Health Services
Include behavioral health professionals in primary care and specialty practices
Explore the feasibility and enhancement of depression screening in practices and ER
Develop and implement Mental Health First Aid training
Partner with community based organizations and behavioral health professionals to
develop a comprehensive network of care
Promote the Safe Harbor program for grieving children, teens, and families
2. Action: Social and Health Care Needs of Older Adults
Continuously refine Elder Med programming with input from community members
and community based organizations
Increase the number of Medicare recipient annual wellness visits
Decrease appointment wait times at the Geriatric Assessment Center
Offer the Hospital Elder Life Program at both the Abington and Lansdale campuses
Coordinate community based health fairs, health screenings, and speaker requests
Offer caregiver support groups
Offer activities to improve cognitive health
Offer programming to promote falls reductions
3. Action: Improve access to Health Education Social Services and Regular Source of
Care
Assist patients and their families in accessing government based insurance options
(Medical Assistance, children’s health insurance program [CHIP], health insurance
marketplace). For patients who are over 65 or disabled options include Medicare,
Medical Assistance, private insurance (Medigap, Medicare advantage plans), and
supplements (PACE, PACENET, Part D providers)
Assist patients and their families who are not eligible for public or private health
insurance with the application process for the AJH Financial Assistance Program
Ensure that all staff participate in cultural diversity training
Provide patient education materials in multiple languages
Ensure that eligible babies receive free care at the Abington Children's Clinic until
their insurance coverage is processed
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Maintain and enhance AJH’s strong health education outreach programs
Enhance the services offered by the AJH Dental Clinic and AJH Dental Care Access
Program by increasing the number of available appointments, improving satisfaction
for patients and providers, and referring individuals not eligible for services to other
dental providers. Continue to provide a clinic social worker to facilitate enrollment
and coordinate the AJH Dental Access Program. Foster the relationship between the
AJH Dental Clinic and AJH Dental Access Program.
Utilize a clinic social worker and/or students to conduct outreach and provide direct
assistance to patients in need at AJH Children’s Clinic, Ambulatory Services Unit
(ASU), Abington Family Medicine, and North Hills Health Center to connect them
with relevant social services such as Supplemental Nutrition Assistance Program
(SNAP), subsidized housing, subsidized child care, and Lifeline (free cell phone
program). Cultivate relationships with local community organizations to keep abreast
of available services/programs.
Increase the number of under and uninsured patients receiving care at ASU primary
care practice by:
charging an ASU RN Care Manager to audit ER visits and make appointments for
interested patients at ASU
assigning an RN Care Manager in ASU to schedule post discharge ASU
appointments
empowering the Social Work team to provide assistance to ASU patients in need
of transportation assistance
Increase access for women with language barriers at the OB/GYN Center; schedule
according to availability of multi-lingual clinicians, currently fluent in Spanish,
Portuguese, and Korean
DOMAIN: Chronic Disease Management
The anticipated impact of the following actions may include: improved health behaviors
including utilization of preventive screenings, improved disease management including
adherence to treatment recommendations and better communications between patients, families,
and providers, and elevated health status as a result of increased continuity of care.
1. Action: Reduce Obesity
Continue/expand existing nutrition education programs: presence at kids' days, health
fairs, and community events; participation in the Million Hearts program in
partnership with Montgomery County Health Department; preschool, elementary, and
after school nutrition curriculum at North Penn YMCA
Establish new partners for nutrition education programming and physical activity
opportunities such as libraries, faith based organizations, and community centers
Educate health care providers on strategies and available resources for reducing
obesity in their patient populations
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Develop partnerships and resources to communicate physical activity opportunities
Create opportunities on campus for healthy food choices including evaluating a
healthy vending machine pilot, a Community Supported Agriculture (CSA) program
for AJH employees, farmers' market days in the cafeteria, digital display of nutrition
information, and events encouraging healthy choices
2. Action: Enhance Chronic Disease Management (diabetes, heart disease and
hypertension, stroke, asthma)
Offer comprehensive diabetes education programs
include intensified insulin self-management training, nutrition counseling, pre-
diabetes intervention, and gestational diabetes management at the Abington
Health Center-Willow Grove, Jefferson Health
support inpatients and refer to diabetes resources
refer patients identified as at risk for diabetes at community based assessments for
appropriate follow-up
provide Save Your Soles education and screening programs in underserved
communities
Provide education and support programs to reduce hypertension prevalence and
improve hypertension management
offer health coaching, educational materials, and referrals for people identified at
blood pressure screenings with Stage I and higher hypertension
make follow-up calls to consenting participants to refer to needed services such as
health care providers, screening locations, chronic care management programs,
and other community resources
Provide education and support programs to reduce stroke and heart disease
prevalence and improve disease management
offer blood pressure and risk assessments to raise awareness about prevention and
early detection and tPA (for stroke)
present education programs at community outreach events
offer stroke support groups for patients and caregivers
Provide education and support programs to reduce asthma prevalence and improve
disease management
offer community based education to raise awareness about warning signs of
asthma to promote earlier diagnosis, avoid "asthma triggers," gain better control,
and understand treatments
reduce asthma-related health disparities through outreach to faith-based
organizations
12
Collaborate with community based organizations and other health care providers to
support chronic disease prevention and management initiatives
coordinate a faith based advisory council that trains congregational nurses with
chronic disease management and community health programming skills
partner with community based organizations that serve non-English speaking
communities to expand the capacity of bilingual staff to provide chronic disease
prevention and management education refer smokers to smoking cessation programs
expand AJH chronic disease self-management programming at community sites
DOMAIN: Health Screening and Early Detection
The anticipated impact of the following actions may include: increased screening rates for
breast, cervical, colon and other women's cancers
1. Action: Increase access to care and screening for women's cancers, especially cervical
and breast cancer, for underserved populations
Recruit AJH staff members to assist with screenings and education
Enhance strategies to effectively reach Latino, Korean, and other Asian
populations
Develop strategies to increase screenings for low income non-Latina white
women
Educate primary care and gynecology practices about the Pennsylvania Healthy
Woman Program for breast screening services and the Pennsylvania Breast
Cancer and Cervical Cancer Prevention and Treatment Program and provide
assistance for qualified women to enroll in these programs
2. Action: Increase access to care and screening for colon cancer
Develop multi-disciplinary approach with the American Cancer Society (ACS) to
educate and promote screening colonoscopies
Schedule meetings with primary care physicians to educate them about the ACS
goal of screening 80% of people age 50+ and available resources
Explore primary care physician partnership to advocate for the ACS 80% goal and
continued screening
Provide educational outreach to Latinos and low income communities using
culturally and language appropriate presentations
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DOMAIN: Healthy Lifestyle Behaviors and Community Environment
The anticipated impact of the following actions may include: increased identification and
referral of patients to addiction counseling and services
1. Action: Decrease alcohol and substance abuse
Collaborate with the Montgomery County Hospital Partnership (MCHP) to
commit all prescribers to abide by the new CDC recommendations for prescribing
opioids for chronic pain
Educate AJH physicians using the Pennsylvania Medical Society approach to
prescribing opioids and Naloxone
Implement the AJH/Abington Health Physicians (AHP) commitment to increase
compliance with patient "contracts" for chronic opioid use
Integrate education on alcohol and opioid use issues and CDC guidelines into
continuing medical education
Incorporate pain management curricula into AJH's educational framework for all
levels of providers starting with students
Educate prescribers on voluntary guidelines developed by PAMED
Work with law enforcement to communicate about "Drug Take Back" programs;
evaluate initiation of an AJH program
Review sponsorship requests from school districts and other non-profit agencies
to host events that educate parents, students, or professionals on alcohol and/or
substance abuse
Expand the relationship with Gaudenzia, a provider of drug and alcohol treatment
programs
Develop a relationship with Montgomery County Drug and Alcohol leadership for
information and communication of programs and services
14
C. Collaborate with Community Partners to Address Health Needs
This Strategy will be implemented in collaboration with other entities including but not limited
to:
Southeastern Pennsylvania Collaborative Opportunities to Advance Community Health
(COACH)
This community health collaborative sponsored by the Hospital and Health System Association
of Pennsylvania (HAP) brings together hospitals, public health, and community partners to
address community health issues in southeastern Pennsylvania. COACH participants prioritized
community health needs most important to address collaboratively and identified chronic disease
prevention/management and mental health as top priorities.
Montgomery County Hospital Partnership
This partnership engages all Montgomery County hospitals, federally qualified health centers,
behavioral health providers, the Montgomery County Health Department, and other stakeholders
to collaborate to address key community needs within the county. The partnership will focus on
specific activities to address behavioral health needs in Montgomery County.
5. Needs Beyond the Hospital’s Mission or Community Benefit Program
Addressing all of the health needs present in a large community requires resources beyond what
any single hospital or social service agency can bring to bear. The Hospital is committed to
fulfilling its mission as well as remaining financially viable so that it can continue its
commitment to excellence in quality care and provide a wide range of community benefits.
Between 2016 and 2019, the Hospital will focus its efforts in order to make a true and
measurable impact, and thus plans to implement actions that will address those needs identified
through the Community Health Needs Assessment as “Most Important”. The Hospital will
continue to evaluate opportunities for funding or resources to commit to addressing the
remaining needs.
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