By: Kim Scifres and Luke Lamb
Indiana law now requires nonprofit hospitals to develop a Community Benefits Plan report and file it annually with the Indiana Department of Health (IDOH).
Under IC § 16-21-9-6, this plan must address how the hospital will meet identified community health needs. Under IC § 16-21-9-7, the hospital is required to submit an annual report that includes the hospital’s mission statement, the community health needs considered, the amount and types of community benefits actually provided, and, crucially, the community benefits plan itself.
Within that plan, two elements receive particular scrutiny: mechanisms to evaluate its effectiveness, including a method for soliciting the views of the communities served and measurable objectives to be achieved within a defined time frame.
The IDOH does not define a specific form, metric set, survey instrument, or minimum response rate, but they do require a credible, well-documented plan.
This plan should allow a reviewer to follow the progression from the identified need to intervention, measurement, community input, and, finally, to the hospital’s results.
The IDOH expects a structured document that demonstrates active management of community health priorities, measurable accountability for results, and authentic engagement with the communities the hospital serves.
Hospitals that treat the IDOH filing as a last-minute Schedule H attachment often discover too late that their internal documentation does not demonstrate how interventions are evaluated, how community views shaped the plan, or whether objectives were met on a defined timeline.
To prevent delays and requests for additional information at the filing deadline, hospitals should review their community benefit plans now to ensure they include the following critical components.
Documenting Plan Effectiveness and Community Input for IDOH Annual Community Benefit Reports
IDOH requires nonprofit hospitals located in Indiana to demonstrate how they determine whether health interventions are truly working rather than merely listing programs and dollars spent. A strong annual report makes the evaluation mechanism visible for each priority initiative and demonstrates that community views were actively solicited and considered.
The report should discuss the following elements for each priority area or initiative:
- The need addressed: Identify the health need or disparity from the communitywide needs assessment that the initiative addresses.
- The intervention or activity: Briefly describe the service, program, partnership, grant, outreach effort, or access initiative.
- The performance measurements: Include measurements at more than one level where feasible, such as:
- Outputs: What was delivered?
Examples of this might include the number of screenings, classes, referrals, transportation rides, participants, or financial-assistance applications completed. - Outcomes: What changed?
Examples of this might include the percentage of participants connected to primary care, who completed a follow-up visit, improved knowledge, received a recommended screening, or reported reduced barriers to care. - Equity/access measures: Who benefited?
When possible, share demographic information such as geography, age, race/ethnicity, income proxy, insurance status, language, disability, or other population characteristics.
- Outputs: What was delivered?
- Evaluation method and data source: Explain how results are measured. These measurements might be tracked through various sources including electronic health record data, program enrollment records, claims data, referral tracking, pre- and post-participant surveys, public health data, or partner reports.
- Review cadence and accountability: Identify who reviews the results, how often they review them, and what happens if a program is off track.
A strong cadence and accountability statement might read: “The Community Benefit Steering Committee reviews the dashboard quarterly and approves corrective actions or resource reallocations annually.” - Annual progress narrative: Report the current-year result against the target goals. Use this section to explain any material variances, program changes, discontinuations, or new actions. This level of detail makes the evaluation mechanism visible in the annual report.
Community Input Documentation
Nonprofit hospitals located in Indiana must demonstrate that they actively solicited the community’s views rather than simply making their report available.
Each Community Benefits Plan report should document each of the following elements:
- Who was engaged: This may include residents, patients, community-based organizations, local public-health agencies, schools, faith organizations, employers, social-service providers, and/or groups representing populations experiencing barriers to care.
- How input was obtained: This may include surveys, focus groups, listening sessions, advisory councils, interviews, public meetings, partner meetings, patient/family advisory councils, and/or feedback collected through program delivery.
- When and how often: Hospitals should distinguish the inputs used for the original needs assessment and those obtained during implementation and annual evaluation.
- How participation was accessible & representative: This may include outreach to priority populations, language access, virtual/in-person options, accessible meeting locations, compensation and/or any other participation mechanisms employed.
- What was heard: This may include themes, concerns, barriers, service gaps, and/or priorities.
- How it affected decisions: This may include specific examples of an objective, intervention, outreach method, budget, partner arrangement, and/or performance measure that changed because of community feedback.
- How results were provided to the community: Hospitals should explain how participants were informed about findings and actions taken.
For example, a useful annual-report statement would be a statement such as: “Community feedback was collected through [methods] from [groups] during [time period]. Feedback identified [themes]. In response, the hospital [specific action], and will assess its effect through [measure] in [time frame].”
Developing Measurable Objectives for IDOH Annual Community Benefit Reports
IDOH’s statutory language calls for objectives that can be assessed by a defined date.
For hospitals to comply with this requirement, a clear approach that may be employed to define objectives and deadlines are SMART-style goals. SMART goals in this instance would be defined as specific, measurable, achievable, relevant to an identified community need, and time-bound.
Vague aspirations will not satisfy the statute, and objectives should state who will benefit, what will change, by how much, and by when. Therefore, for each objective, the hospital needs to outline the following elements to demonstrate measurable objectives within a defined time frame:
| Objective Element | Information to Outline |
| Priority need | The need identified through the community-wide assessment |
| Population/community | Who and where the hospital intends to serve |
| Objective | The intended, measurable improvement |
| Baseline | Starting value and measurement period |
| Target | Numeric or otherwise objectively verifiable result |
| Deadline | Fiscal year-end, calendar date, or multi-year completion date |
| Strategy/activity | The intervention expected to achieve the objective |
| Measure/data source | How the result will be calculated and documented |
| Responsible owner/partners | Hospital department and key collaborators |
| Budget/resources | Funding and resources tied to the objective |
| Annual status | Actual result, variance, and corrective action, if needed |
Annual reporting for multi-year plans should also outline the following elements:
- The baseline and final target
- The annual milestone for the reporting year
- Actual performance
- Whether the objective remains on schedule
- Any justified revision to the strategy, timeline, target, or budget
A weak objective example would be a statement such as: “Improve access to behavioral-health care.”
A stronger objective example would be a statement such as: “By the end of FY 2027, increase the percentage of referred adults in the hospital’s identified service area who complete an initial behavioral-health appointment within 30 days from 42% in FY 2025 to 55%, measured through referral-partner follow-up data.”
Filing Deadline and Preparation Timeline
The annual Community Benefits Plan report is due when the hospital timely files its annual IRS Form 990 with Schedule H attached, including any extension. For calendar year filers with a valid extension, this deadline is quickly approaching on November 15, 2026. However, hospitals should not wait until the Form 990 filing deadline to begin compiling their report.
Assembling community input documentation, performance data, and SMART objective progress requires significant lead time.
Evaluations, data gathering, and community engagement summaries should be underway well in advance of the report’s filing deadline to demonstrate a full year of activity.
Preparing Early for IDOH Annual Community Benefit Reports
As scrutiny surrounding nonprofit hospitals continues to escalate, having a comprehensive and well-documented community benefit strategy has never been more important.
Blue & Co. has worked with health systems nationwide to strengthen community benefit reporting, improve reporting methodologies, conduct operational assessments, develop reporting policies and procedures, calculate the value of tax-exempt status, and provide education to community benefit professionals, finance teams, executive leadership, and governing boards.
Our teams are available to help ensure that your IDOH Community Benefits Plan report is both compliant and a clear reflection of your hospital’s impact on the communities you serve.
Connect with your local Blue & Co. advisor or contact one of our experts listed below if your organization needs more information about the IDOH Community Benefits Plan report.
Kim Scifres, CPA, Principal
kscifres@blueandco.com
502-992-3511
Luke Lamb, CPA, Senior Manager
llamb@blueandco.com
502-461-8543
Emilie Knieriem, CPA, Senior Manager
eknieriem@blueandco.com
502-461-8512
