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Step 1: Needs Assessment

Guidance for completing an assessment to identify a community's needs.


Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: June 09, 2016

LTSS Planning

A needs assessment means collecting information that provides a complete picture of your community’s needs and existing resources.

The assessment helps you identify and prioritize your community’s areas of need, which helps you avoid investing valuable resources into services that may be unnecessary or are not a good fit for your community.

Watch a video about Menominee Indian Tribe of Wisconsin's Model of Long-Term Care to see an example of how the tribe conducted a needs assessment.

Conducting a needs assessment will provide you with a deeper understanding of:

  • Your community's current LTSS situation and needs
  • Existing strengths and resources within the community
  • Funding priorities for your program
  • The best approaches to developing your program and creating program policies
  • Data to include when writing grant proposals (See Who Pays for LTSS? for more on grant funding.)

Evaluation assistance

Tribes have the knowledge and skills to perform their own evaluations. Some tribes choose work with expert researchers from within the tribe or from tribal colleges or nearby community colleges. The National Resource Center on Native American Aging can also provide evaluation assistance.

Need more information on what to measure in your needs assessment and how to measure it? See Intro to Evaluation.

Needs assessment model

A needs assessment is the first step for planning a program. If you’re expanding an existing program, you should still do a needs assessment to examine whether the current program meets your community’s needs.

Identify initial needs

First, determine community problems and needs. This initial identification is key because you will measure future progress against it.

Determine needs and potential problems
Identify the services you need and potential barriers to implementing a program or service.

Examples of needs:

  • Specialized care for people with dementia
  • Training for caregivers
  • A home- and community-based care model that fits your budget

Example of challenges to implementation:

  • Few staff members
  • Limited funding
  • Lack of space to build or renovate

Identify Stakeholders

Stakeholders can include the people a program serves and those who have interest in the program, like tribal leaders.

Read more on the importance of tribal leader support for your program and how to gain that support.

Examples of Stakeholders

  • Tribal elders or people with disabilities who receive care from an LTSS program
  • People with disabilities who need care but don't currently have a way to receive it
  • The families of tribal elders or people with disabilities
  • Tribal leaders
  • The tribal health department
  • A local organization that provides services to the people your program will serve

Collect Data

Collect data to help identify the needs in your community. You can collect data by interviewing people or having them complete surveys or join focus groups. Good people to include are:

  • Elders
  • People with disabilities
  • Caregivers
  • Health care providers
  • Tribal officials
  • Title VI directors

You can also collect valuable data by reviewing reports or other research, such as:

  • Census data
  • Data on clinic users
  • State or county economic profiles
  • Electronic health records (make sure to abide by HIPAA rules)
  • Resource and patient management system (RPMS) numbers (for communities served by IHS)

Organize and study the data you find.

Define LTSS needs

After gathering information for your assessment, evaluate what you found to better understand your community's LTSS needs. You may find that your early assumptions about needs or problems were correct, and you may discover new issues that you didn't expect. Follow these steps to analyze the information:

  • Know the current facts: Become familiar with the data discovered during this assessment. This initial data forms the baseline against which you can measure changes in the future.
  • Uncover additional needs: Consider each issue, and break large issues into smaller pieces.  Are there needs you weren’t aware of that you now anticipate based on the data?

Describe LTSS needs

Based on your needs assessment results, identify:

  • Who needs LTSS?
    • Number of people
    • Age and gender breakdown
    • Disabilities in this population
    • Location (living on tribal lands or elsewhere)
    • Populations within this group who may require special services (e.g., people with dementia or Veterans)
  • What types of services does your community need (e.g., transportation or caregiver respite)?
  • What services are available now?

You are now ready to choose goals and objectives toward meeting the needs you identified in your assessment. Make sure you keep documents used for the needs assessment, such as reports and data collection tools, to use as a starting point for evaluating your program later.

Proceed to Step 2.

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