Conducting a Meaningful Community Needs Assessment

December 2019 Vol 10, No 12
Theresa A. Allen, OPN-CG
Senior Manager, Patient Navigation,
American Cancer Society,
Des Moines, IA

We have all done community assessments, right? As a matter of fact, we generally start there when embarking on a new project, although sometimes we already have the information we need to proceed. To effectively serve a community, it is critically important to understand the community. It is also imperative to understand what resources or assets a community already has available, and where the gaps may be. This way you are not reinventing the wheel but focusing on filling gaps and reducing barriers. The findings from a community assessment should help to strategically plan, develop, and deliver relevant and timely services.

There are many types of assessments; however, they primarily focus on the following:

Step 1: Define the scope of the assessment and the community of focus

Step 2: Collaborate or do solo

Step 3: Collect data

Step 4: Determine key findings

Step 5: Set priorities and create an action plan

Step 6: Share your findings

One goal of a community assessment is to develop an understanding of the needs and the gaps that exist within the community of focus, or the barriers faced by many in the community. When the American Cancer Society (ACS) began to develop its patient navigator program in the late 1990s, one of the first things we did was to explore the barriers that we knew were facing cancer patients and how we might best be able to assist them. No surprise, access to care (transportation and lodging) while traveling long distances for cancer treatment was at the top of the list. We also thought it was important to partner with cancer centers to offer solutions through partnerships. We developed a “site profile,” one portion of which is completed by the hospital/cancer center and the other by ACS staff working in the area of patient programs. This site profile assisted our regions in considering all aspects of their patient navigator placements. The tool is also intended to assess the facility, current ACS collaboration, and the overall strength of the ACS patient navigator program operations. This profile, completed by the hospital/cancer center, focused on general facility information and patient population demographics, including age, race, ethnicity, sex, insurance status and type, types of cancer treated, and oncology treatment services and patient support services provided by the healthcare system. The profile completed by the ACS staff focused on programs and resources available in the area provided by ACS and other community resources. For instance, if there was a need for additional volunteer drivers in the area, or free/reduced-cost lodging options, we worked to build up those resources before moving forward with the placement of an ACS patient navigator.

The ACS has developed a database, “Cancer Resource Connection,” that houses all our cancer-specific information, prevention and screening information, events, and resources to help cancer patients and their families through the journey with cancer. We have a team that works to keep this database current and link appropriate entries to our organization’s website— When this database was being developed, we basically conducted a community assessment across the country and collected any and all resources that were either free or at a reduced cost that could be of assistance to cancer patients and their families. Many of these resources address the needs surrounding access to care—transportation and lodging—for patients who must travel away from home to receive lifesaving treatments.

The ACS is always looking for new partners and/or projects to help fill the gaps around access to care that patients have expressed to us. A recent project was a partnership with Health Outreach Partners (HOP) to develop a tool kit and training. HOP believes that outreach and conducting assessments fulfill a critical need to increase access to health and social services and decrease health disparities for low-income, vulnerable populations. HOP supports safety net health organizations, such as community health centers, to build and strengthen their efforts to increase access and services and decrease disparities. For this project, we identified 6 health systems (cancer centers) to participate in a quality improvement pilot project. Two representatives from each of the 6 systems and their ACS staff partners participated in a daylong training during which they reviewed the developed tool kit and then worked in teams to discuss steps to implement the project. Each of the selected systems was given a small grant to use toward the project, and each group used the funds in a different way.

The group I was with, University of Colorado Anschutz Cancer Pavilion, purchased 8 tablets for their social work team to utilize with patients. We then developed a SurveyMonkey questionnaire asking 15 questions to ascertain the needs of patients around transportation and barriers they were facing. This survey was conducted over a 2-week period, and the results were quite interesting. Here are the questions that were asked:

  1. Please select who is completing the survey (patient or caregiver)?
  2. What means of transportation do you use to get to your appointments (drove self, family member, friend, public transportation, etc)?
  3. Did you have any problems getting to your appointment today?
  4. How many minutes did it take you to get here?
  5. How far away do you live from the cancer center?
  6. If you did not drive yourself, who paid for the ride?
  7. If you live outside Denver Metro area, are there transportation resources not already mentioned that you use to get to the cancer center?
  8. Within the last year, have you ever missed or canceled an appointment related to your cancer care?
  9. If yes, what was the reason you missed or canceled an appointment?
  10. Has your cancer diagnosis and/or treatment affected your ability to obtain transportation to your cancer-related appointments?
  11. If you answered yes to #10, what has had the largest impact?
  12. Are you able to use preferred modes of transportation since your cancer diagnosis and/or treatment?
  13. Please share your age (date ranges to select from).
  14. What type of health insurance do you have (private, Medicare, Medicaid, Military, no insurance, etc)?
  15. On a scale of 1 to 10, is it difficult to get to your appointments (1 = not difficult at all and 10 = extremely difficult)?

Each individual who completed the survey was given a copy of the Getting There Guide ( and shown an online version of the ACS Patient Service flyer.

Here is a sampling of questions and the results:

  • When asked the distance patients had to travel to their treatment centers, the average distance was 56 miles one way. The closest patient traveled 8 miles, and the furthest was 300 miles one way
  • When asked if they had to rely on someone other than family or friends for transportation to treatment, 15% indicated that they had to use public transportation (ie, cab, bus, or a ride-sharing option)

During the 2-week time frame, just over 100 patients/caregivers were surveyed about any barriers they faced in getting to the treatment center. Of the respondents, 65% were patients and 35% were caregivers.

The full final report from this project should be released by the end of 2019. It will be interesting to learn the results of all 6 projects and the steps we can take collaboratively to help patients overcome the challenging barriers they face on a daily basis to comply with their cancer treatments.

Related Articles
Defining the Role of the Oncology Nurse Navigator
Lindsey M. Reed, BSN, RN, OCN, ONN-CG, Kristina Rua, MSN, RN, OCN, ONN-CG
March 2020 Vol 11, No 3
Understanding your role (and setting boundaries) allows you to remain focused on the tenets of oncology navigation—providing compassionate patient-centered care.
Delineating Roles in a Hybrid Nurse and Patient Navigation Model Can Reduce Care Variation
Heather Ciccarelli, MSW, OPN-CG, Valerie P. Csik, MPH, CPPS, Aliya Rogers, RN, BSN, OCN, Kathy Scheid, RDN, OPN-CG, Caryn Vadseth, BSN, RN, OCN, ONN-CG(T)
January 2020 Vol 11, No 1
Navigators from the American Cancer Society review and share their experience with establishing a hybrid approach to oncology navigation.
Utilizing a Gap Analysis to Strengthen the Strategy of Navigation Programs
Veronica Campos, DNP, MSN, RN, NE-BC, OCN, Deidra Hamilton, MSN, RN, OCN, ONN-CG
December 2019 Vol 10, No 12
Wondering how to identify the gaps in your Navigation Program? Read this to find out.
Last modified: August 10, 2023

Subscribe Today!

To sign up for our print publication or e-newsletter, please enter your contact information below.

I'd like to receive:

  • First Name *
    Last Name *
    Profession or Role
    Primary Specialty or Disease State