Community health needs assessments (CHNA)

80% of what impacts the health of children happens outside the clinic walls.

That’s why Children’s Minnesota continues to leverage community health needs assessments (CHNAs) to actively engage our partners across various social sectors to improve the health of the children and families we serve.

To be every family’s essential partner in raising healthier children, we’re committed to hearing from families and collaborating with community leaders and organizations. As extensive as our expertise is, it will never equal the insight children, families and communities have about their own health and well-being.


In 2016, Children’s Minnesota began to emphasize health equity in the assessment process and broadened potential topic areas to include community conditions that contribute to health outcomes such as poverty, education and housing. The 2019 CHNA focused on honoring what was learned in 2016 while also creating space for new discussion topics to emerge. See our progress since the 2016 CHNA.

IN 2018 …


children received emergency department services at Children’s Minnesota


children were admitted to a Children’s Minnesota hospital


visits used Children’s Minnesota’s interpreter services in 70 different languages


For the purposes of this CHNA, the community served includes the more than 700,000 children (0 – 17 years) who live in the seven-county Twin Cities region: Anoka, Carver, Dakota, Hennepin, Ramsey, Scott and Washington counties.

The assessment also placed emphasis on learning about the health needs, assets and priorities of children and families living in the following neighborhoods:

  • In Minneapolis: Phillips and Powderhorn
  • In St. Paul: West Side, Frogtown/Thomas-Dale, and Dayton’s Bluff
Patient density within Minneapolis and St. Paul communities (2018)

Priority Health Issues

Utilizing input from Children’s Minnesota staff and providers, community stakeholders and parents, as well as secondary data, five issues were identified as the most important to address for the health and well-being of children and their families:

Structural Racism

Structural racism refers to the ways in which the policies, practices and systems of organizations and institutions routinely advantage white residents while disadvantaging people of color and American Indians.

Structural racism contributes to disparities in areas such as employment, education, health, income and housing that disproportionately impact communities of color, including immigrant and refugee communities, and American Indians. Children’s Minnesota has intentionally focused on creating more accountable and equitable systems, and remains committed to addressing structural racism within the organization as well as in the communities we serve.

Structural racism impacts so much, yet there is still a lack of understanding. It affects a person’s ability to get an adequate education and quality employment, but it also causes trauma that can influence everything from mental health to birth outcomes.”
— Community-based organization staff


All contributors felt structural racism needs to remain a priority, as it is a systemic issue of critical importance to the health of children and the community. Structural racism impacts every facet of people’s lives including:

  • Causing and perpetuating trauma and chronic stress, which exacerbates symptoms of poor mental health.
  • Limiting opportunities for people of color to obtain income through good employment options, as well as homeownership, education and the intergenerational transfer of wealth.
  • Making access to resources more difficult as a result of systems and services being designed primarily from a dominant, white culture perspective, with providers being unaware of their own implicit bias and/or lack of familiarity with the needs and cultural values of the communities they serve.

Children’s Minnesota has intentionally focused on creating more accountable and equitable systems, and remains committed to addressing structural racism within the organization as well as in the communities they serve. To address structural racism, Children’s Minnesota believes it is critical to ensure staff are representative of the communities they serve and that the organization provides culturally appropriate services for all.

How we plan to respond ( Full Strategy)

Eliminate racism and resulting negative impacts on health by advancing health equity through changes in policies and practice, shifts in organizational culture and operations, and greater collaboration with community partners.

  • Identify and address policies, practices and systemic issues within the organization that contribute to structural racism
  • Further implement a racial equity impact lens into organizational goal setting, project planning and performance measures
  • Identify and address procedures, policies and practices that influence clinical health outcomes and perpetuate disparities at the point of care


A health equity and inclusion team focused on creating a diverse, equitable and inclusive culture that reflects the rich backgrounds of the communities we serve

The Children’s Minnesota Health Equity Council which addresses and promotes health equity within the Children’s Minnesota system and identifies and addresses policies, practices and behaviors that maintain or exacerbate inequities for patients, families and employees


Resilience, hope and a sense of cultural identity held within families and communities

Multiple community organizations and institutions recognizing and bringing attention to how structural racism and trauma impact children and families

Programs that foster the development of a positive cultural identity

Health Disparities

Health disparities are persistent and pervasive in Minnesota, leading to some community groups experiencing higher rates of disease and poor health. Health disparities are preventable differences in health outcomes caused by an inequitable and unjust distribution of resources, opportunities, and power.

The community groups most often impacted by health disparities include:

  • People who identify as persons of color or American Indian
  • Immigrant and refugee populations
  • Children from lower-income families
  • LGBTQ youth
  • Those living in the urban, densely populated and developed areas of the Children’s Minnesota community

It’s no secret that families in communities of color don’t have the same access to health care and that impacts people’s lives. Particularly with children, when we talk about asthma and even preexisting conditions, children just do not have the same support and access in communities of color.”
— Community-based organization staff


All contributors identified health disparities within their communities as they discussed the needs that must be addressed. Children’s Minnesota feels it is critical to ensure that disparities are identified and that they recognize and address the unique health needs of the communities they serve, particularly communities that have historically been marginalized. Key areas of concern include:

  • Continued gap in mental and behavioral health services for kids. While some community stakeholders and data suggest stigma around mental health may be declining among some youth, there are still disparities related to young people’s abilities to acknowledge and access services. Young women are more likely to identify having a behavioral health concern than men, making it more likely for them to access services.
  • Missed immunizations, vaccination hesitancy and targeted efforts to deter vaccination among community groups have been of particular concern for Children’s Minnesota staff. While inadequate resources may lead to missed immunizations, caregivers may also forgo vaccinating their children due to misinformation, religious practices or cultural values.
  • Asthma-related hospitalizations remain higher in Minneapolis and St. Paul downtown areas and nearby neighborhoods than other areas in the Twin Cities metro region. Overall, emergency department visits due to asthma are also higher for children in the metro compared to children who live in greater Minnesota.

It is important to acknowledge that health disparities are primarily caused by differences in social determinants, defined as the conditions in which children and families live, work, age, learn and play. Without simultaneously acknowledging the stark racial disparities in critical areas such as high school graduation rates, employment, income, housing/homelessness rates and adverse childhood experiences, only incremental progress can be made toward specific health-related disparities. While Children’s Minnesota can take important steps to reduce health disparities through its work to address structural racism, the work of multiple child and family-serving systems is needed to address these deeply entrenched disparities.

How we plan to respond ( Full Strategy)

Build internal capacity and work in partnership with the community to establish goals and implement strategies to significantly reduce targeted health disparities.

  • Share available and reliable disaggregated data with the community, including health disparities in vaccination rates and asthma condition support and management
  • Work with the community to co-create strategies to address health disparities
  • Engage the community regularly to share progress, refine strategies and prioritize additional health disparities to address


A social needs screening process implemented in Children’s Minnesota asthma clinic and referral services through the Community Connect program

Increased efforts to reduce asthma disparities and increase access to care at Children’s Minnesota

Experienced providers working to implement community engagement strategies and activities designed to improve vaccination rates


State and county public health initiatives and community partnerships focused on addressing health disparities and promoting health equity

Economic Opportunity and Income

Economic opportunity and income are factors that ensure families can access and obtain financial resources that support the well-being of children and the community. Wealth and higher household income are closely tied to better health outcomes.

Disparities, especially racial disparities, in poverty, income and employment are evident in Minnesota. Over 200,000 children in the Twin Cities metro live in households with incomes at or near poverty levels.

% of patients served in 2018 who had Medicaid as primary insurance

Emergency Department


Inpatient Hospitalization


Minneapolis & St. Paul Clinics


Suburban Twin Cities Clinics



All contributors identified economic opportunity and income as key issues within their communities. Key concerns include:

  • A lack of adequate employment opportunities, which prevents families from earning the income necessary for basic needs such as housing and transportation, healthy foods and health care. Low-wage jobs or those with few or no benefits do little to help employees accumulate the resources they need in the long-term.
  • Intergenerational poverty, which prevents equitable access to resources that support the accumulation of wealth such as education, employment, housing and investment opportunities. Without these things, families will continue to live paycheck-to-paycheck, unable to withstand a crisis or invest in their children’s future.
  • Community investment: without it, there’s limited commitment to the people served. Community stakeholders and Children’s Minnesota staff see an opportunity for the organization to further invest in the community by partnering with diverse, local organizations and vendors, and hiring staff from the community that reflects the race, ethnicity and culture of the children and families they serve.

How we plan to respond ( Full Strategy)

Invest in economic and employment opportunities for all of the communities Children’s Minnesota serves.

  • Increase investment of resources into local community businesses through supplier contracts and sponsorships
  • Increase employment opportunities for the community Children’s Minnesota serves, including patients and families themselves
  • Implement training, recruitment and retention strategies to achieve organizational workforce diversity, equity and inclusion goals
  • Expand programs and supports that help families access available benefits


Established relationships with local educational institutions and programs focused on equity and inclusion and creating a pipeline for health care careers

Membership in the North Central Minority Supplier Development Council, the Women’s Business Development Center and Quorum


Social services (e.g., food shelves, supportive housing programs, employment training programs) to help lower-income families afford safe housing, healthy food and access to employment opportunities

Mental Health and Developmental Well-Being

Supporting mental health and developmental well-being for all children and families is important, but certain populations may be more likely to have unmet needs due to barriers to obtaining mental health services, lack of appropriate services, exposure to adverse childhood experiences (ACEs), and other environmental conditions that contribute to or exacerbate mental health concerns. Stakeholders identified specific populations who have unmet mental health needs including children under five, persons of color and American Indian communities, immigrant and refugee families, children living in poverty and adolescents in need of intensive mental health services.

While systemic factors contribute to a child’s exposure to ACEs, it is important to note that some children are more likely to report experiencing four or more ACEs including children who are: American Indian, African American, Hispanic/Latino, low-income or homeless.

We see kids being diagnosed with developmental needs, but they are put on waitlists and that causes implications. Families may not get the support they need during a critical time, and the child could struggle to stay in school. There is a need for more therapeutic mental health services as we see more children suffering from the effects of trauma. We have a capacity issue.”
– Community-based organization staff


Community stakeholders and Children’s Minnesota staff saw mental health and developmental well-being as critical health issues that need continued focus. The following specific concerns were identified through the assessment:

  • Overall, there is a lack of clinical and community services to address children’s mental health. There are concerns that this leads to youth mental health issues going unaddressed until there is a crisis; youth not getting an appropriate level of services; and youth and parents using drugs and alcohol to self-medicate in the absence of appropriate mental health services.
  • There are not enough culturally-appropriate mental health services or service providers, while providers not specializing in mental health do not have adequate information to proactively identify potential mental health issues early.
  • Generational trauma among communities such as American Indians and African Americans contributes to chronic stress, which negatively impacts children’s mental health and development.
  • The current climate around immigration is exacerbating mental health issues and overall stress.

How we plan to respond ( Full Strategy)

Identify opportunities for enhanced and more coordinated mental health support for children with an emphasis on early childhood services, early intervention and culturally informed care.

  • Identify and develop specific services in follow-up clinics for at-risk early childhood patient populations
  • Improve access by expanding integrated behavioral health into primary care clinics
  • Implement suicide screening across behavioral health and primary care programs


Integrated behavioral health specialists in all of our primary care clinics and inpatient specialty care areas

Implementation of the HealthySteps program in Children’s Minnesota primary care clinics

Participation in the Harvard Center for the Developing Child’s Pediatric Innovation Cluster (Children’s Minnesota is one of eight national practice sites)

Expertise in brain science and impacts of adverse childhood experiences on health shared with educators and advocates through presentations


Culturally-competent social workers and mental health providers

Organizations and faith-based institutions that encourage culturally-specific healing practices and coping strategies

Trauma-informed training programs for providers, teachers and others who work with children and youth in the community

Access to Resources

Accessing critical resources is often most challenging for lower-income families, immigrant and refugee families, and communities that have been intentionally excluded or not taken into consideration when service systems are designed.

In neighborhoods of concentrated poverty, resources that support health and wellness are often limited, making it more difficult for residents to make choices that promote health. All of the CHNA’s focal neighborhoods within Minneapolis and St. Paul are areas of concentrated poverty; 60-81% of children experience poverty in these neighborhoods.

There are a lot of barriers to accessing resources or accessing them equitably. This includes providing necessary resources in areas of the community that really need them, making it possible for families to receive these services and helping them use what they have to improve their family’s condition.”
— Public school staff


Community stakeholders and Children’s Minnesota providers and staff believe supporting family access to resources needs to remain a priority. It can be difficult for families to get services, even through referrals, due to a variety of barriers including time, unreliable transportation options, limited financial resources and a lack of knowledge or experience navigating service systems. The “access to resources” priority area is intentionally broad and requires Children’s Minnesota to use a holistic approach to understand and address the needs and concerns of youth and families, including the following health needs identified as emerging issues through the assessment process:

  • The basic need for adequate housing was a significant concern identified by Children’s Minnesota providers and staff, community stakeholders and parents alike. There is currently a lack of affordable housing in the Twin Cities metro, leading to housing instability. Housing quality was also a concern, as issues including mold, pests, a lack of proper heating and cooling and neighborhood safety can be detrimental to a child’s health. While the Children’s Minnesota Healthcare Legal Partnership has some capacity to address these issues, staff felt more support is necessary.
  • Food access remains a persistent issue among youth and families. While Children’s Minnesota already has some services available to address food insecurity, all contributors felt that hunger will be difficult to solve by providing short-term food resources alone. Additional education about nutrition, as well as addressing fundamental issues (e.g., income) are needed.
  • Parent and caregiver education is of vital importance for kids and their families. For that reason, all contributors felt there is a need to provide more education for families so they are better able to make decisions for their children and access the services they need. Staff identified a number of topics where education could be improved including connections between environmental factors and health conditions (e.g. secondhand smoke and asthma), how to administer medications, obtaining and managing health insurance and a family’s legal rights to access services and make decisions about their child’s care.

Children’s Minnesota wants to ensure that insurance and health care costs are considered as part of this priority area. Families experience barriers to getting and keeping the affordable health care insurance necessary to guarantee they can access the medical services they need. Even with insurance, health care can be unaffordable for them due to costs from deductibles, co-pays and prescription medications.

How we plan to respond ( Full Strategy)

Expand programming and partnerships that connect patients and families to essential resources that can positively impact overall health, development and well-being.

  • Extend Community Connect model to serve additional patient populations
  • Promote continued organization-wide awareness and utilization of the Children’s Minnesota Healthcare Legal Partnership
  • Build upon existing relationships and explore new partnerships to foster mutually-beneficial collaborations with community-based organizations, schools and other key entities to streamline communication, service delivery and information sharing


Continued funding support for Children’s Minnesota Community Connect and Healthcare Legal Partnership programs

Ongoing development of cross-sector patient referral partnerships

Family resource centers in Minneapolis and St. Paul hospitals with information for families and food shelf access

Participation on the Hennepin County Community Health Improvement Partnership (CHIP) Housing Action Team – a cross-sector group focused on improving housing access and stability

Ongoing public awareness and advocacy efforts focused on increasing access to high quality early childhood development and educational opportunities as well as increased funding for school nutrition programs

Advocacy partnership between Children’s Minnesota, Hennepin County and the City of Minneapolis focused on
finding funding for programs that help families address the environmental factors associated with asthma


Community centers, community-based organizations and faith centers that connect residents to resources

Technology designed to link residents to key resources (e.g., computers and smart phones)

Mobile services that bring resources and support directly to residents

Progress Since the 2016 Assessment


  Screening patients to identify families’ needs

  Multi-lingual, multi-cultural resource navigators connecting families to social support resources

  Extending and increased availability for walk-in appointments

  Tracking disparities so providers can reach out to families proactively to ensure they have what they need

  New clinician process to assist local school nurses when they work with children who have poor asthma control


school nurses and teachers trained on asthma care thanks to generous Kohl’s grant

Mental Health and Well-Being

  Embedding behavioral health workers into primary care clinics

  Testing patients for toxic stress and screenings for adverse childhood experiences as participant in the Harvard Center on the Developing Child’s Pediatric Innovation Cluster

  Training pediatric behavioral residents to address the shortage of practicing providers

  Implementing HealthySteps program which focuses on positive parenting, supportive resources and parent well-being

  Screenings for symptoms of postpartum depression in new mothers

  Partnering with Fraser and the Minnesota Autism Center to create a seamless approach to autism care for patients and families

  Implementing telehealth services within psychiatry and eating disorder clinics to meet needs in rural Minnesota

  Working with the Emily Program to support patients with eating disorders

Access to Resources


families enrolled in Community Connect

  Launched Community Connect to improve access to support resources and to empower family decision making, while respecting cultural traditions

Income and Employment

CEO Marc Gorelick joined the

CEO Action Network

for diversity and
inclusion in the

  Offer equity and inclusion internships to students in local programs and colleges

  Created employee resource groups (ERGs) that promote retention, recruiting and professional development

  Our ERGs collaborate with leading local companies to bolster community enrichment throughout the metro area

  Leaders are given scorecards to measure specific equity and inclusion metrics

Structural Racism

  Established a Health Equity Council at Children’s Minnesota to help build equity practices

  Breaking down patient data by race, ethnicity and language to better address issues in patient experience

  Developing tools to analyze the patient experience through an equity lens

  Equity and social work departments have partnered to set equity goals and address individual bias

The urban American Indian population living in the Twin Cities metro area is one of the largest in the country and experiences some of the highest health disparities.

The Children’s Minnesota American Indian Collaborative builds relationships and drives better health outcomes with the American Indian community. One example is the First Gift program:


  Continuing to work with the St. Paul and Minneapolis school districts to identify intervention opportunities based on health conditions, geography, absenteeism and improved information sharing

Submit Your Feedback

We welcome input and comments from members of our community on the needs assessment process and implementation strategy.

Questions? Please contact a member of our team if you’d like to learn more about our work.

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