Community Health Needs Assessment

HSS routinely assesses the health needs of its diverse community. A comprehensive Community Health Needs Assessment (CHNA) is conducted every three years. The results of this assessment will be used to initiate and improve community healthcare programs. This report provides a snapshot of the CHNA assessment process, results, and program implementation.

Goals

  • Assess the needs of our diverse communities
  • Identify health disparities
  • Develop and implement programs to address community health needs

Service Areas

HSS’s primary service area consists of the five boroughs of New York City, while its secondary service area is comprised of Hudson Valley, New York; Northern and Central New Jersey; Connecticut; Long Island, New York; and Palm Beach County, Florida.

Approach

  1. Collect data: Collect and analyze data from community surveys, community partner interviews, and local, state, and federal systems to highlight the community’s health needs
  2. Obtain input: Establish a collaborative environment to obtain community input from HSS stakeholders, community partners, and health agencies serving diverse populations
  3. Prioritize health needs: Identify and prioritize health needs through community forums
  4. Implement action plan: Develop and implement an action plan to address identified health needs and disparities

 

1. Collect Data

Interviews were conducted virtually with 22 community partners serving diverse communities in the five boroughs of New York City; Westchester, NY; and Connecticut. Themes from the interviews are presented below:

  • Musculoskeletal and rheumatological conditions
  • Lack of education and awareness
  • Pain and pain management
  • Falls and lack of balance

  • Limited access to healthcare system due to cost, cultural barriers, and transportation
  • Discrimination in healthcare settings, including stereotyping and lack of resources

  • Offer educational programs in the community
  • Improve access to care through transportation and insurance coverage

  • Emphasize the cultural competency of medical experts
  • Leverage marketing strategies

A community survey was conducted with a total of 18,248 responses received from patients and community members, which was given online and in-person in English, Spanish, Chinese, and Russian. The results below provide a snapshot of our respondents and their reported musculoskeletal health needs.

Age

  • 20% < 20 years
  • 30% 20-39 years
  • 23% 40-59 years
  • 38% 60-79 years
  • 6% 80+ years

Gender Identity

  • 66% Female
  • 32% Male
  • 1% Other
 

Race

  • 57% White
  • 23% Black/African American
  • 8% Asian
  • 7% Other
  • 2% American Indian/Alaska Native
  • 1% Native Hawaiian/Other Pacific Islander

Hispanic Origin

  • 74% Non-Hispanic/Latino
  • 23% Hispanic/Latino

Annual Household Income

  • 28% < $35,000
  • 28% $35,000-$99,999
  • 27% ≥ $100,000

  • Top three most common musculoskeletal health conditions reported:
    1. Osteoarthritis
    2. Chronic pain
    3. Some other form of arthritis
  • Almost half (45%) reported low confidence in managing their condition
  • < 20% reported poor physical or mental health
  • 3 in 10 fell in the past year
  • 4 in 10 rated their sleep quality terrible or poor

  • 3 in 4 lack physical activity
  • Top barriers to eating healthy
    • Eating habits of friends/family
    • Taste
    • Cost
  • More than one-third report using prescription pain medicine or opioids
  • 75% report not using complementary alternatives to manage pain

  • Top issues affecting health/wellbeing
    • COVID-19 related issues
    • Social isolation/loneliness
    • Limited places to exercise
  • 42% could not access healthcare when needed in the past year
  • Top barriers to accessing care
    • Getting an appointment
    • Cost of care
  • Over 60% were interested in using telehealth
  • Top barriers to telehealth use
    • Lack of knowledge
    • Concerns about medical errors/confidentiality
  • Top barriers to following medical advice
    • Side effects
    • Cost
  • Over half respondents reported experiencing discrimination to care where clinicians did not listen to them

  • 7 in 10 did not participate in health education last year
  • Preferred health education activities
    • Virtual exercises classes
    • Virtual lectures
    • On-demand videos
  • Preferred health education topics
    • Exercise
    • Healthy eating
    • Mental health

Community Profile

In addition to the interviews and community survey, local, state and federal data were reviewed to create a community profile to provide essential information and insight on a broad range of health issues in our community.

Race/Ethnicity1

  • 41% White
  • 29% Hispanic/Latino
  • 24% Black/African American
  • 14% Asian

Immigrant-Population2

  • More than 1 in 3 are foreign-born

Sex3

  • 52% female

Age

  • 15% of the population is aged 65+ years1
  • This is expected to grow to 21% in 20403
 

  • 8% do not have health insurance3
  • 1 in 10 could not access healthcare when needed in the past year4
  • 77% self-report good health5
  • Over 2 in 10 drink more than one sugary beverage per day6
  • Spanish is the most widely spoken language at home other than English3
  • 18% live in poverty6
  • More than 8 in 10 have a high school diploma or higher1

References

  1. United States Census Bureau. (2021, July 1). QuickFacts. Retrieved from United States Census Bureau: https://www.census.gov/quickfacts/newyorkcitynewyork
  2. NYC Health. (2018, January 19). New York City Neighborhood Health Atlas. Retrieved from Tableau: https://public.tableau.com/app/profile/nyc.health/viz/NewYorkCityNeighborhoodHealthAtlas/Home
  3. Cortés-Vázquez, L. (2020). Annual Plan Summary. New York: New York City Department for the Aging. Retrieved from https://www1.nyc.gov/assets/dfta/downloads/pdf/reports/AnnualPlanSummary111820.pdf
  4. NYC Health. (2019). Health Care Access and Use - Subtopic: Health Care Use. Retrieved from EpiQuery: https://a816-health.nyc.gov/hdi/epiquery/visualizations?PageType=ts&PopulationSource=CHS&Topic=2&Subtopic=17
  5. New York City Department of Health and Mental Hygiene. Community Health Survey [2019]; public use dataset accessed on [29 August 2022].
  6. Shin, J., Krampner, J., Virgin, V., & Hill, A. (2021). New York City Government Poverty Measure 2019. New York: The City of New York. Retrieved from https://www1.nyc.gov/assets/opportunity/pdf/21_poverty_measure_report.pdf
2. Obtain Input

Throughout the CHNA process, HSS engaged various constituents in data collection and to guide the selection of the health needs and services to address in its community programming. Input was obtained from the following groups:

  • HSS CHNA Steering Committee
  • HSS internal stakeholders
  • Public Health Departments and other experts
  • Community partners
  • General public
3. Prioritize Health Needs

The results of the CHNA were shared with community members and stakeholders through a series of 8 virtual forums reaching 131 community members. At the forums, community members engaged in an open discussion about the CHNA results, then were asked to rank seven health indicators in order of importance.

Top 7 Health Needs

  1. Osteoarthritis
  2. Stress
  3. Stiffness
  4. Fatigue
  5. Chronic pain
  6. Lupus
  7. Injury prevention
4. Implement Action Plan

To address the health needs identified through community forums, HSS offers a diverse range of targeted, culturally-relevant, evidence-based programming. Please click on each program below for more information.

Aging with Dignity

  • Support groups and creative workshops to target social isolation and improve coping skills
  • Health Needs Addressed: Stress, chronic pain

Asian Community Bone Health Initiative

  • Community-based exercise and education program to help Asian older adults manage their chronic musculoskeletal conditions and increase access to care
  • Health Needs Addressed: OA, stiffness, fatigue, chronic pain

Charla de Lupus/ Lupus Chat®

  • A free national peer health education and support program to increase knowledge of lupus among Hispanic/Latino and African American communities
  • Health Needs Addressed: Lupus

Musculoskeletal Health & Wellness Initiative

  • Exercise and education programs to raise awareness, educate and reduce the impact of musculoskeletal conditions
  • Health Needs Addressed: OA, stiffness, fatigue, chronic pain

LANtern® (Lupus Asian Network)

  • A free national bilingual peer support and education program for Asian Americans with lupus and their families
  • Health Needs Addressed: Lupus

Leon Root, MD, Pediatric Outreach Program

  • A community-based screening and education program to detect, treat, and prevent sports related injuries in young athletes
  • Health Needs Addressed: Injury prevention

Inflammatory Arthritis (IA) Support and Education Programs

  • A support and education program for community members and families living with rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA) and gout
  • Health Needs Addressed: Lupus, stiffness, fatigue

Youth Sports Safety Program

  • A primary and secondary sports injury prevention program for young adults, coaches, teachers, and parents
  • Health Needs Addressed: Injury prevention

VOICES 60+ Senior Advocacy Program

  • An advocacy program to help low income, culturally diverse patients aged 60+ years, with arthritis and related chronic illnesses, with accessing services and support to improve quality of life
  • Health Needs Addressed: OA, stiffness, fatigue

Past Community Health Needs Assessment

 

For more information, please contact us at communityed@hss.edu.

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