Let's face it. With population health management emerging as the new priority for hospitals and health systems, you can never have enough data. You need data to understand who lives in your community — their ages, their socioeconomic statuses, their lifestyles. You need data to delineate the health issues most prominent in your community and where disparities exist. You need data to identify those folks who are “high users” of your emergency department and other services. You need data on social factors that contribute to community health. You need data about your partners across the care continuum. You need data on clinical and organizational processes to fully understand the quality of the care you deliver, as well as your expenses — and the variations and inefficiencies that impact both.

And then you need still more data to determine how successful — or unsuccessful — your strategies to address each of those issues are.

Factor all that into the reality that most hospitals and health systems don’t serve a single, homogeneous community, but rather a whole bunch of communities with sometimes widely varied characteristics, and you need all the help you can get.

That’s where a tool developed by the Dignity Health system might come in handy. The Community Need Index identifies health issues and the socioeconomic factors that contribute to those issues. Layered with utilization and other data, the CNI allows a hospital to develop a strategy targeted to a specific community health need.

The tool can be applied as narrowly as you want. Dignity Health uses it to create a needs assessment for every ZIP code within its service area. In an interview with H&HN’s Jan Greene, Ellen Barsi, corporate senior director of community benefit for the San Francisco-based system, offered plenty of examples of how CNI has been helpful. In one case, CNI revealed that utilization in certain ZIP codes “leapt off the page” for late-stage breast cancer. The local hospital dispatched a mobile mammography van to the area. In a neighborhood with a large Latino population, CNI showed high risk of diabetes, so the system launched a comprehensive education campaign for both physicians and local residents.

Barsi suggests small and rural hospitals pair CNI with a website called communitycommons.org. The site was developed by the Centers for Disease Control and Prevention to enable smaller hospitals to map local needs in depth for free.