MHA is collecting stories about hospitals’ health improvement efforts. Please share examples of how your hospital or health system is working to implement your community health needs assessment or partnering with local organizations to address health challenges locally.

When you share stories on social media, please use the hashtag #MoHospitalsCare to help us identify and amplify your efforts. In addition to sharing on social media, we’ll include select stories in our multimedia campaign to broaden awareness at MissouriHealthMatters.org.

MHA also developed ready-to-use implementation plan templates addressing priority areas such as mental/behavioral health, substance use, chronic conditions, affordable care and support for unhoused populations. Each template includes evidence-based strategies, clear action steps, partner engagement, performance measures and timelines.

Together, these resources help hospitals move from assessment to action — driving measurable improvements in community health.

Hospitals and community partners have a powerful opportunity to drive meaningful, data-informed changes by leveraging the exploreMOhealth platform alongside the MissouriHealthMatters.org dashboards.

Together, these tools redefine how organizations understand and improve community health by delivering hyperlocal insights at the ZIP code level by enabling precise identification of disparities in chronic conditions, nonclinical factors that affect an individual’s health and overall outcomes, and ensuring resources are directed where they will have the greatest impact.

By embedding these data assets into community health needs assessments, stakeholders can ground their priorities in real-world evidence, uncover inequities across populations, and design targeted, person-centered interventions that truly meet individuals where they are in their health journey.

At the same time, shared dashboards and dynamic visualizations strengthen cross-sector collaboration, empowering hospitals, public health agencies, and community organizations to align strategies, monitor progress, and amplify collective impact.

Ultimately, these platforms do more than inform; they transform complex data into compelling, actionable insights that inspire action, deepen partnerships and accelerate measurable improvements in community health. This approach closely aligns with Missouri’s Transformation of Rural Community Health (ToRCH) Care model, where hubs can harness these tools to build robust, data-driven needs assessments that guide coordinated, strategic and community-centered efforts.

Health occurs in the places Missourians live, work, learn and play. An important element of how hospitals create value for patients and communities is their work in identifying the drivers of poor health and working collaboratively to address barriers — both clinical and nonclinical.

June 8-12 is Community Health Improvement Week. In the newest episode of the Missouri Hospital Association’s PolicyHuddle podcast, listeners will learn about the strategies Mercy and Citizens Memorial Hospital have implemented to connect more fully with patients and communities to improve health. Listeners will hear from the following guests.

• Gavin Helton, M.D., president of Mercy Primary Care at Mercy in Chesterfield, Mo.
• Jenna Hicks, director of quality and population health, at Citizens Memorial Hospital in Bolivar, Mo.

This edition of PolicyHuddle is approximately 20 minutes in length and available online or on your favorite podcast platform.

The assessment covers the following nine categories to evaluate an organization’s progress toward health improvement — leadership, patients and community, workforce, finance, data and technology, operations, legal and regulatory, outcomes, and policy and advocacy.

Once information from these disciplines is gathered from respective staff, the survey will take approximately 15 to 20 minutes to complete. A PDF version is available to help staff gather required information in advance, and hospitals may request a copy of their 2023 survey from MHA.

Health systems may choose to submit a single survey on behalf of all hospitals.

The survey results will inform MHA’s population health strategy that seeks to achieve better health for populations, better care for patients and increased value of care delivered, with a shared vision of building a statewide culture of health. Results will be shared with hospitals in September 2026.

MHA is collecting stories about hospitals’ health improvement efforts. Please share examples of how your hospital or health system is working to implement your community health needs assessment or partnering with local organizations to address health challenges locally.

When you share stories on social media, please use the hashtag #MoHospitalsCare to help us identify and amplify your efforts. In addition to sharing on social media, we’ll include select stories in our multimedia campaign to broaden awareness at MissouriHealthMatters.org.

Aligned with National Public Health Week, which runs from April 6 to 12 this year, the Missouri Hospital Association and its data company, the Hospital Industry Data Institute, refreshed the data powering ZIP-level health information rankings on dashboards hosted by the exploreMOhealth platform and MissouriHealthMatters.org. The updated platforms reflect 2023-2025 data across 938 Missouri ZIP codes.

MHA-member hospitals also have access to patient-specific insights via determinants of health through the HIDI Advantage^® platform. 

Learn more about MHA’s community health resources here. 

The Missouri Hospital Association, in collaboration with author Uzma Khan, M.D., MPH, and the Missouri Perinatal Quality Collaborative, released a publication on cardiovascular-kidney-metabolic syndrome. This syndrome is a complex disorder that encompasses cardiovascular disease, kidney disease, obesity and Type 2 diabetes, highlighting the interconnectedness of these conditions. 

In the U.S., from 2015 to 2020, one in four adults had at least one of these conditions, with overlapping conditions identified in one in 10 adults. CKM syndrome provides a unifying concept of a complex, multisystem disorder, allowing patients and health care providers to focus on prevention and targeted interventions to improve cardiovascular and metabolic health. 
  
The guidance provides background information on CKM syndrome, the different stages of the disorder, evidence of its prevalence, treatment options, and resources for providers and patients.    

As of Jan. 1, 2025, acute care hospitals are required by the Centers for Medicare and Medicaid Services to screen all inpatients 18 years and older for housing, food, transportation, violence exposure and access to utilities. This screening process requires hospitals and providers to connect patients with resources to meet their identified needs.

Health care organizations routinely rely on community-based organizations to address nonclinical factors; however, there is often a lack of awareness of services, coordination, team buy-in and a streamlined referral mechanism to ensure a fully functional closed-loop referral process to support seamless care coordination.

This resource provides some practical examples of how Missouri hospitals and organizations are leveraging social referral platforms and processes to promote health and wellness while reducing the cost of care.

Across Missouri and the nation, hospitals use community health needs assessments as an integral tool to identify local challenges, engage community partners and develop programs that improve health — both inside and beyond the hospital’s walls.

CHNAs identify care opportunities

To be treated as a nonprofit, hospitals must meet additional requirements including conducting a CHNA every three years and adopting an implementation strategy to meet community health needs identified in the assessment.

A CHNA is more than a regulatory requirement, according to Stephen Njenga, director of quality measurement and population health improvement at the Missouri Hospital Association, as these assessments seek to identify care gaps and opportunities that exist within each community, shaping the health and well-being of people.

“Every community is different because those in the community have varying levels of resources,” Njenga said.

CHNAs can be “eye opening” for hospital and health system leaders as they learn about factors outside of their hospital that can impact or interfere with their patients’ health, added Njenga, who works with Missouri hospitals as they develop their CHNAs.

The role of data in CHNAs

CHNAs are driven by both robust data and community engagement. With support from the Hospital Industry Data Institute, MHA’s data company, Missouri hospitals have access to cutting-edge tools that help identify strategies they can implement to close care gaps.

Two of those platforms include the exploreMOhealth.org website, HIDI’s flagship CHNA platform, and health data on MissouriHealthMatters.com , where hospitals can identify differences in the prevalence of diseases among different population segments, said Mat Reidhead, MHA’s vice president of research and analytics.

MHA and HIDI also offer hospital-specific Determinants of Health Dashboards, “where you can drill down to actual patients who experienced X, Y or Z — both in your health care setting and across any hospital setting in the state,” Reidhead said.

This data allow hospitals to determine what health needs and nonmedical factors are most acute in their communities for various segments of their patient population.

Connecting the data to the people who live, work, play and learn in the communities served by hospitals can provide important context, Njenga added.

Community forums with people who are representative of the hospital’s service area are often used in the CHNA process, ensuring different voices are heard, Njenga said. These individuals can offer insight on whether the presented data reflects real issues. Their firsthand knowledge of local challenges, demographics and available resources is essential.

From assessment to action

One example of how data provided by HIDI and a CHNA came together to benefit Missourians occurred at Barnes-Jewish Hospital in St. Louis. The hospital’s emergency department was seeing high rates of usage among patients experiencing severe behavioral health conditions that were exacerbated by housing instability, Reidhead said.

In response, Barnes-Jewish Hospital launched the Hospital to Housing program as a behavioral health priority area in the hospital’s CHNA. When the hospital partnered with St. Patrick Center and Living in Victory Recovery Sober Living to provide transitional housing to these individuals, emergency department utilization fell by half, resulting in a significant drop in overall health care spending.

The program illustrates how addressing nonmedical needs, like housing, can improve health outcomes, reduce hospital utilization, and according to a formal evaluation conducted by MHA, induce significant savings across the health care system.

While the robust return on investment created by the H2H program is critical to demonstrate when engaging payers and policy makers, the crux of the program is in its transformative effects on human lives, and that’s a beautiful thing that’s hard to quantify, Reidhead said.

At smaller hospitals in Missouri, Njenga has seen similar needs, such as food insecurity, being addressed through CHNAs. For instance, when one hospital identified patients who needed help with meals, staff responded by immediately providing food bags to meet patients’ short-term needs. Then, patients were connected with local food pantries and community resources to ensure they received ongoing access to food.

CHNA resources for hospitals

From CHNA templates to guidance and implementation strategies, MHA’s website offers many resources to assist hospitals with these assessments.

The webpage also includes 10 priority health issues commonly found in CHNAs from Missouri hospitals. They include mental health, substance use, obesity, access to care, diabetes, chronic conditions, affordable health care, the COVID-19 pandemic, heart disease and the unhoused.

In addition, Quality Works, a subsidiary of MHA, can provide hospitals with customized services for CHNAs, including primary and secondary data collection and analysis, facilitation of community input, survey design, writing the assessment and development of an implementation plan.

To learn more, listen to this episode of MHA’s PolicyHuddle podcast as Njenga and Reidhead discuss the tools and processes of successful CHNAs.

MHA embarked on a campaign to share hospitals’ community health-related stories from throughout the state.

Today, MHA launched the first — a video spotlighting the Hospital to Housing program supported by BJC HealthCare and Barnes-Jewish Hospital in St. Louis, and St. Louis social services agencies St. Patrick Center and LIV Recovery Sober Living. The program employs a long-range, multipronged approach designed to help people with complex, interrelated needs find housing and achieve better health.

To reach more Missourians and connect them to the good work going on in your community and throughout the state, MHA needs your community benefit stories. Please share examples of how your hospital or health system is working to implement your community health needs assessment or partnering with local organizations to address health challenges locally.

When you share stories on social media, please use the hashtag #MoHospitalsCare to help us identify and amplify your efforts. In addition to sharing on social media, we’ll include select stories in our multimedia campaign to broaden awareness at MissouriHealthMatters.com.

The more stakeholders know about the factors that influence health, the better hospitals and health systems — and their partners in public health and community-based organizations — can identify, manage and mitigate them.  

Resources for health improvement are often constrained. Data, including the robust ZIP code-level access to community health insights available on exploremohealth.org, can shape stakeholders’ investments and maximize the value of community and public health initiatives.  

In concert with National Public Health Week, the Missouri Hospital Association refreshed exploreMOhealth as of April 8. 

What is exploreMOhealth? 

Launched in 2018 with support from MHA, exploreMOhealth is a community data platform created to provide ZIP code-level rankings across major health behaviors and health outcomes to illuminate high-risk communities at the subcounty level.  

The platform features demographic data from the U.S. census and hospital discharge data specific to Missouri. The county-level health indicators are provided by County Health Rankings & Roadmaps. The ZIP code-level data are provided by the Hospital Industry Data Institute and Washington University School of Medicine through the Missouri ZIP Health Rankings Project. 

The ZIP code-level data included in the most recent updates on the exploreMOhealth platform are based on hospital discharges that occurred between fiscal years 2022 and 2024 (Oct. 1, 2021, through Sept. 30, 2024), and the 2023 American Community Survey of the U.S. census. 

These free, publicly available resources on exploreMOhealth are intended to help communities, hospitals, public health officials and other stakeholders identify local health needs by ZIP code or county, and to develop health needs assessments and actionable plans to improve public health. Data is the key to diagnosing and addressing the most pressing health issues. 

How hospitals can use exploreMOhealth 

With the detailed data available on the exploreMOhealth platform, hospital and health care leaders and providers can make informed decisions about serving their communities. 

The platform allows hospitals to develop comprehensive and customized community health needs assessments and offers summaries of leading health factors in different-sized communities through reports, such as the Chronic Condition Explorer, Missouri Health Atlas and Spotlight on ZIP Health. 

“Most of the hospitals that use exploreMOhealth are able to identify where gaps exist at a ZIP code level in the communities they serve and opportunities to close those gaps, using the power of data,” said Stephen Njenga, MHA’s director of quality measurement and population health improvement. 

Njenga added that this detailed level of information helps care providers target scarce resources where they are needed the most as opposed to implementing a blanket approach, hoping that it will work for the entire service area. 

Changes to exploreMOhealth for 2025 

In addition to new data, the site also has a refreshed look, along with some notable changes made to this year’s measurements and methodologies. 

The 2025 update to the Zip Health Rankings includes changes that improve accuracy and align with national standards. 

• Health Factor Domain, Clinical Care Subdomain: The Agency for Healthcare Research and Quality’s five Prevention Quality Indicators for emergency department settings replaced an outdated New York University algorithm for defining potentially avoidable emergency department utilization. 
• Health Outcome Domain, Quality of Life Subdomain: Anemia; anxiety disorders; atrial fibrillation; depression, bipolar or other depressive mood disorders; fibromyalgia and chronic pain and fatigue; hyperlipidemia; and hypothyroidism were added to the 20 most prevalent conditions in Missouri defined using the Centers for Medicare and Medicaid Services Chronic Condition Warehouse, as well as two standalone cancers — endometrial and prostate cancers — not previously included. Additionally, a new measure combines visits for anxiety, depression and inpatient mental health diagnoses. 
• Multiple Domains and Subdomains: Many measures were updated to align with CMS Chronic Condition Warehouse  and Agency for Healthcare Research and Quality Clinical Classifications Software-Refined, replacing older definitions. 

In addition, County Health Rankings & Roadmaps switched from a county rankings approach to a grouping approach in 2024. Counties now are assigned to one of 10 groups for the health outcome and health factors domains.  

The exploreMOhealth platform is available to anyone with an interest in community health at no cost thanks to funding from HIDI and the MHA Health Institute. Setting up an optional account allows users to customize their experience by saving geographic areas, health indicators, customized reports and other features. 

To learn more about exploreMOhealth, visit the FAQ page, or you can email questions to exploreMOhealth@mohospitals.org.