In partnership with UVM Medical Center

It’s become clearer than ever that health isn’t just about what happens in the hospital or the doctor’s office. Every three years, more than 20 community organizations come together to identify the most pressing needs impacting the health of our community. In this conversation, the UVM Medical Center’s Community Health Improvement Team and Community Health Centers of Burlington discuss the importance of identifying community health issues. 

What is the Community Health Needs Assessment?

UVM Medical Center: The CHNA, as it’s called, is a review of data about what the most pressing needs are in Chittenden and Grand Isle counties. The Affordable Care Act now mandates that we do one every three years, but we’ve been doing this work for almost 30 years as part of our mission. This survey really informs us about what’s going on, and we use that information to make plans and make an impact. Health care is really broadening from inside hospital walls, out to communities. Where we work and live really affects our health outcomes. Economic status, early childhood experiences, the neighborhood you grew up in – all those things have been found to be connected to your overall health.

What needs have been identified as most pressing here? 

UVM Medical Center: Things like affordable housing, safe neighborhoods and access to mental health services all come up consistently. Substance use disorder and healthy aging come up as well. We’ve actually taken a look back to the 1990s and found that some of these needs repeat. Particularly in Chittenden County, affordable housing has been an issue for decades. When we identify an issue, we make a plan – and we bring in our partners.

Community Health Centers of Burlington: This is where we come in. With housing, for example, we have worked with the Champlain Housing Trust and UVM Medical Center to develop the Bel Aire and Beacon Apartments. These are places where we can help people who are experiencing homelessness, provide patients with somewhere to go when they are discharged from the hospital, and provide them with wraparound case management services.

What’s the benefit of having so many organizations involved?

Community Health Centers of Burlington: Bringing in 20 organizations to talk about what they see – these are boots-on-the-ground organizations – makes us so much stronger. At CHCB, we run reports, analyze data about top diagnoses. But then what do you do with it and who do you work with? Now we’re doing real, tangible work with our partners to get at these needs. Whether it’s affordable housing or other issues, we are making progress on these really complex needs. Working together, that’s where the power is.

As a Federally Qualified Health Center (FQHC), when we reapply for federal funding, we use information from the CHNA. The federal government wants to be sure they’re funding a group who knows the needs of the community, and that shows what they’re doing is working. The fact that we have all this data that we can in turn use to help the community, that’s really useful.

What does your work look like “on the ground”?

Community Health Centers of Burlington: We provide on-site case management services, skilled professionals in these housing settings who can see day-to-day what these individuals need. It can be transportation, mental health and substance abuse counseling, or just help navigating a system of forms that many of us take for granted.

UVM Medical Center: Yes, it’s about looking at the whole person, just like we need to look at the whole community. Health care is housing, it’s access to healthy and nutritious food, it’s all these needs that we are working together to identify and tackle.

Is this survey something anybody can participate in?

Definitely. Whoever wants to take it, they can. The groups on the steering committee will be sharing it, we’re working with interpretation and translation services to make sure it’s accessible, and it will also be posted online. If anyone reading this article would like to participate in the community survey when it opens on June 10, they can send a note to, and they will receive a link to the survey.