Community Health Needs Assessment

A community survey was administered online and in-person in English, Spanish, Chinese, Russian, and Haitian Creole. The survey collected 31,792 responses from patients and community members. 

Community Profile

In addition to the community survey, local, state and federal data were reviewed to create a community profile to provide essential information and insight on a broad range of health issues in our community. The data below represents the population of New York City.

1. U.S. Census Bureau. (n.d.). New York City, New York. data.census.gov. Retrieved April 16, 2025.
2. New York City Department for the Aging. (2024, September). 2024 Annual Plan Summary: Covering April 1, 2024 – March 31, 2025 . (PDF)
3. Gundersen, C., Strayer, M., Dewey, A., Hake, M., & Engelhard, E. (2023). Map the Meal Gap 2023: A Report on County and Congressional District Food Insecurity and County Food Cost in the United States in 2021. (PDF) Feeding America. 
4. NYC Health + Hospitals. (2022). Community Health Needs Assessment. (PDF) 
5. New York City Department of Health and Mental Hygiene. Community Health Survey [2019]; public use dataset accessed on [29 August 2022].
6. Mayor’s Office for Economic Opportunity. (2024, May). New York City Government Poverty Measure 2021. (PDF) The City of New York. 
7. Health Resources and Services Administration. (n.d.). MUA Find. U.S. Department of Health and Human Services. Retrieved April 16, 2025

Throughout the CHNA process, HSS engaged various constituents in data collection and to guide the selection of the health needs and services to address in its community programming. Input was obtained from the following groups:

• HSS CHNA Steering Committee: The Education Institute led an eight-member CHNA Steering Committee that helped shape and oversee the entire CHNA process by deciding what questions to explore, developing the survey, identifying community partners, and ensuring the work reflected HSS’s priorities.
• HSS internal stakeholders: Key staff from departments across HSS contributed to the community health needs assessment by reviewing the survey, offering feedback based on their areas of expertise, and helping ensure the questions were clear, meaningful, and grounded in trusted measurement tools.
• Public Health Departments and other experts: HSS worked closely with the New York City Department of Health and Mental Hygiene and the Greater New York Hospital Association, gathering their input to strengthen our survey, guiding best practices for the CHNA, and participating in a community forum. We also contributed to GNYHA’s Prevention Agenda Priorities Survey to help shape New York State’s public health priorities for 2025–2030.
• Community partners: HSS invited 72 community organizations to participate in the CHNA, with several offering feedback that strengthened the survey’s clarity, relevance, and accessibility. Community partners also joined a forum to review the results, share their perspectives, and help rank key health needs, confirming that the findings reflected the real experiences of the communities they serve. See list of community partners involved in our CHNA process:
  
  
  • Americares Free Clinics
  • Arthritis Foundation – Greater NY Area
  • Brooklyn Cyclones
  • Brooklyn Nets
  • Building One Community
  • Concerned Home Managers for Elderly (COHME)
  • Columbia University Mailman School of Public Health
  • DOROT
  • FC Monmouth
  • Jefferson Health
  • Lenox Hill Neighborhood House
  • Lupus Foundation of America

  • Lupus Research Alliance
  • Mount Sinai Hospital
  • New York City Department of Health and Mental Hygiene
  • New York Knicks
  • New York Red Bulls
  • New York Road Runners
  • Over 60 Senior Center
  • Rethink Food
  • Spondylitis Association of America
  • Touro College Graduate School of Social Work
  • VNS Health
  • Weill Cornell Clinical and Translational Science Center
• General public: HSS gathered input from the general public by piloting the survey in five languages with 63 community members, which helped ensure the questions were clear, culturally relevant, and easy to understand.

The 2025 CHNA gathered responses from 31,792 patients and community members. These results guide the development and implementation of community healthcare programs.

The results of the CHNA were shared with community members and stakeholders through a series of 6 community forums and 1 digital outreach campaign reaching 1,307 community members. Community members learned about the CHNA results then were asked to rank a list of health indicators in order of importance.

Top 10 Health Needs

1. Osteoarthritis
2. Chronic Pain
3. Pain Management
4. Lack of sleep
5. Osteoporosis
6. Lack of exercise
7. Poor physical function
8. Falls
9. Some other form of arthritis
10. Mental Health

To address the health needs identified through community forums, HSS offers a diverse range of targeted, culturally-relevant, evidence-based programming. Please click on each program below for more information.

Aging with Dignity

• Support groups and creative workshops to target social isolation and improve coping skills
• Health Needs Addressed: Lack of sleep, falls, mental health, social isolation

Asian Community Bone Health Initiative

• Community-based exercise and education program to help Asian older adults manage their chronic musculoskeletal conditions and increase access to care
• Health Needs Addressed: Osteoporosis, falls

Charla de Lupus/ Lupus Chat^®

• A free national peer health education and support program to increase knowledge of lupus among Hispanic/Latino and African American communities
• Health Needs Addressed: Mental health, Lupus, inability to manage chronic conditions

Eat & Move Better with Rethink Food

• A program that distributes meals as well as health and wellness resources to families in underserved communities in New York and New Jersey
• Health Needs Addressed: Lack of exercise, poor nutrition

Inflammatory Arthritis (IA) Support and Education Programs

• A support and education program for community members and families living with rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA) and gout
• Health Needs Addressed: Some other form of arthritis, social isolation, inability to manage chronic conditions

LANtern^® (Lupus Asian Network)

• A free national bilingual peer support and education program for Asian Americans with lupus and their families
• Health Needs Addressed: Mental health, Lupus, inability to manage chronic conditions

Leon Root, MD, Pediatric Outreach Program

• A community-based screening and education program to detect, treat, and prevent sports related injuries in young athletes
• Health Needs Addressed: Poor physical function

Pain and Stress Management Program

• A program comprised of educational and mindfulness-based coping techniques to improve the ability to cope with chronic pain and stress.
• Health Needs Addressed: Chronic pain, pain management

Musculoskeletal Health & Wellness Initiative

• Exercise and education programs to raise awareness, educate and reduce the impact of musculoskeletal conditions
• Health Needs Addressed: Osteoarthritis, chronic pain, pain management, lack of exercise

On the Move

• An exercise program that aims to provide children with a fun and engaging way to learn about fitness to help combat obesity
• Health Needs Addressed: Lack of exercise

Youth Athlete Health Program

• A primary and secondary sports injury prevention program for young adults, coaches, teachers, and parents
• Health Needs Addressed: Poor physical function

VOICES 60+ Senior Advocacy Program

• An advocacy program to help low income, culturally diverse patients aged 60+ years, with arthritis and related chronic illnesses, with accessing services and support to improve quality of life
• Health Needs Addressed: Some other form of arthritis, Other needs identified (rheumatoid arthritis)