Two Hospitals Assess Community Health Needs and Devise a Plan to Address Them

    • December 12, 2014

Dates of Project: September 2011 through August 2013

Description: Saint Peter’s University Hospital and Robert Wood Johnson University Hospital conducted a community health needs assessment and created a plan to address those needs in Middlesex County and the southeast section of Somerset County—their combined service area in central New Jersey.

The needs assessment consisted of four research efforts:

  • Analysis of behavioral risk factors using 2010 data from the CDC’s Behavioral Risk Factor & Surveillance System
  • Analysis of the hospitals’ discharge data to determine avoidable hospitalizations and emergency department visits
  • Analysis of self-reported data about health, health care, and access from a telephone survey of 1,000 randomly selected adults in the service areas
  • Twenty-six in-depth interviews with relevant key informants, and nine focus groups with the service areas’ health care consumers in five languages

The project team, with assistance from 80 community partners, then used key findings from the needs assessment to develop a community health improvement plan.

Key Findings/Results

  • The analysis of behavioral risk factors showed that, overall, the combined county sample fared better than the sample representing New Jersey as a whole. The counties fared worse on only three of the 33 measures (no exercise in the past month, no PSA test for males age 40 and over in the past two years, and never had an HIV test).
  • Low-income respondents and the uninsured fared worse than higher-income respondents and the insured on nearly all health status measures.
  • The analysis of hospital discharge records showed that population-based rates of avoidable hospitalizations and emergency department visits were lower for the service area of the hospitals compared to New Jersey overall, suggesting relatively higher adequacy of primary care.
  • The community phone survey of the service area showed that 56 percent of adults had been diagnosed with at least one chronic condition, and 31 percent had been diagnosed with high blood pressure.
  • Key informant interviews and consumer focus groups revealed that the hospitals had a high concentration of health care resources in New Brunswick, but the distribution of these resources throughout the service area was uneven. But even in the New Brunswick area, resources for dental care, addiction treatment, long-term mental health care, and sources of affordable medication were inadequate or lacking.
  • The project team and its 80 community partners identified the following four goals to achieve by the end of 2016; it also laid out implementation plans to meet them:
    • Strengthen coordination and communication among community health partners
    • Ensure that every person has access to health and wellness services that meet the culture and language needs of his or her community
    • Build a community that promotes, supports, and fosters healthy behaviors and preventive care services
    • Achieve physically and mentally healthy communities by addressing obesity, diabetes, and mental health


Chakravarty S, Brownlee S, Tong J, et al. A Community Health Needs Assessment for Saint Peter’s University Hospital & Robert Wood Johnson University Hospital. 

Middlesex and Somerset Community Health Improvement Plan

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Building a #cultureofhealth: 2 hospitals assess community health in central NJ & develop improvement plan