Health Equity Impact Assessments: What New York Birth Centers Need to Know

Community birth centers are opening and growing across New York and with that growth comes a maze of regulatory requirements that can feel overwhelming, especially for smaller, midwifery-led teams. One requirement that’s still unfamiliar to many is the Health Equity Impact Assessment (HEIA).

I, Lauren McCullough, sat down with Andrea Mantsios, PhD, MHS, founder of Public Health Innovation & Action (Phia), to demystify HEIAs for birth center owners and those in the process of opening a new center. Andrea and her team have been conducting HEIAs across New York for years, working with hospitals, health centers and community-based providers.

In this Q&A, Andrea explains what an HEIA is, when a birth center is likely to need one, what the process looks like step by step and how it can actually become a tool to deepen your relationship with your community and strengthen your case with regulators, funders and policymakers. If you’re planning a new birth center, expanding services, relocating or changing ownership, this conversation is for you.

Andrea Mantsios, PhD, MHS, founder of Public Health Innovation & Action (Phia) (photo courtesy of Andrea Mantsios).

For those who may be hearing about it for the first time, what exactly is a Health Equity Impact Assessment (HEIA) and why is it an important part of health-related projects in New York?

Great question! A Health Equity Impact Assessment (HEIA) evaluates how a proposed project will affect health equity, delivery of services, and access to healthcare in a service area, specifically for medically underserved groups who live in that area. In New York State, certain healthcare facilities that will be making changes to the way they deliver healthcare services—like adding more beds or opening a new clinic location—are required to have an independent entity conduct an HEIA. The purpose of the assessment is to determine what impacts, negative or positive, the proposed project may have on medically underserved groups in the area.

In conducting an HEIA, we ask: What might those impacts be? How might the community experience the proposed change, and how could it affect them and their access to healthcare? The findings from this assessment are used to create a mitigation plan for how the facility can offset the possibility of unintended, potentially negative impacts on medically underserved groups because of their service change. HEIA findings can also help facilities understand how they can plan their project even better to increase care and access to care, and to improve health equity in the community.

How did HEIAs come about, and what problems are they designed to address within healthcare planning and policy, especially around healthcare disparities?

HEIAs are designed to ensure that community voices are considered in changes to healthcare services. They are used to assess the impact of a proposed project on medically underserved groups to ensure that a healthcare service change is not making it harder for these groups to access care. It's important that HEIAs are conducted by independent entities (not the facility itself) so they can be as objective as possible.

Before HEIAs were required by New York State, healthcare facilities were not required to consult the communities that would be impacted by changes they made to their services. Now, HEIAs ensure that community voices are heard and carefully considered in decisions that could potentially impact their access to care, how they receive care, and how easy or difficult it is for them to receive care.

Who typically requires an HEIA in New York State, and at what stage of a project should organizations like birth centers start thinking about?

HEIAs are typically required for hospitals, health centers, diagnostic and treatment facilities, assisted living facilities, and birth centers that are proposing a change to their services that could alter the landscape of care for communities in their service area. Certain criteria are used to determine whether an HEIA is required for a project. For example, an HEIA is required if a Certificate of Need (CON) application involves: 1) a significant change to services, such as an addition or reduction of 10% or more in certified beds, services, or operating hours; 2) a relocation, where there will be a change in the location of services or care; or 3) a change in the establishment or ownership of a healthcare facility. If the project meets the criteria requiring an HEIA, the HEIA must be submitted alongside the CON application.

When should birth centers start thinking about it? As early as possible in the planning stages of a project, including if it is a new birth center planning to open! I encourage birth centers to be thinking about whether an HEIA is needed from the beginning of a new project, before submitting a CON to the New York State Department of Health. That way, you won’t be caught off guard by the requirement.

What are some of the biggest misconceptions you see about HEIAs among healthcare providers or administrators?

First, I’ve seen that providers and administrators worry that the HEIA will take a really long time to complete. At Phia, our HEIA process takes about 10 weeks, depending on the complexity of the project and the specific community engagement plan.

Also, when planning a project, people often focus on the positive implications and don't think about potential negative impacts. I don't think anyone is actively trying to increase health disparities, but there can be so many unintended impacts as healthcare facilities plan new projects. The point of the HEIA is to uncover any unintended potential negative impacts, so facilities can be informed early on and plan before the project is implemented for measures they can take to ensure those potentially negative impacts do not occur.

In your experience, what makes for a truly impactful HEIA, one that goes beyond being a compliance checkbox and actually drives equity-informed decisions?

To me, one of the most valuable parts of an HEIA is the mitigation plan, which is developed in response to the findings uncovered through the independent entity's meaningful community engagement work. In proposing mitigation efforts, we take all the information that's been gathered from the community, including concerns or potential health equity issues, and we use that information to highlight opportunities to improve the proposed project to enhance health equity and access to services for medically underserved groups. We take potential problems and work with the healthcare facility to transform them into solutions.

That, to me, is the most action-oriented part of the assessment. That's where we can really drive equity-informed decisions, because the applicant now has specific actions they can take to ensure the project does not negatively impact medically underserved groups. It’s so valuable for healthcare facilities to have the opportunity to implement suggestions from the communities themselves around how a project could best meet their needs.

Can you walk us through the main steps involved in completing an HEIA in New York, and roughly how long the process usually takes from start to finish?

Absolutely! For our team at Phia, we always start by becoming oriented with the context of a project. So, our first step in conducting an HEIA is to get a deep understanding of the context of that service area. Speaking with the applicant about some of the key characteristics of the populations they serve is a good starting point, but from there, we do a deep dive into data and additional resources to paint a more complete picture, often by using community health needs assessments for that city or county. We learn everything we can about sociodemographic data and social determinants of health data for the specific area served by the facility.

Next, we develop tailored data collection instruments, adapting our interview and focus group guides to capture the nuance necessary for assessing impact in the community in question. We may also develop a survey if needed. Then, we conduct our data collection using the interviews, focus groups, and surveys we’ve developed. We ensure the data collection includes a diverse sample of people from medically underserved groups in the area.

Once data collection is done, we analyze and synthesize the data to highlight key themes. And finally, we integrate and amplify community perspectives on the identified project impacts throughout the assessment. The projects generally take about 10 weeks to complete, depending on how extensive the proposed project is (for example, adding beds to a hospital unit is less complex than opening a new site).

What advice would you give to smaller organizations or community birth centers that might feel intimidated by the HEIA process?

Regulatory processes can absolutely feel intimidating, especially for smaller healthcare facilities! I want to reassure folks that the HEIA process itself is actually very straightforward and formulaic. You’re required to work with an independent entity, and whether you choose to work with Phia or another organization for your HEIA, that independent entity will provide you with a clear stepwise process to follow to complete the HEIA. The independent entity will work with you to ensure that all of what the state requires is included in your assessment.

At Phia, we always have a project kickoff call where we provide our clients with a clear roadmap of how we’ll get it all done and respond to any questions or concerns they may have. My team and I love that HEIAs provide an opportunity to engage community voices and thoughtfully use data to look at a proposed project through the lens of health equity. We work hand-in-hand with our clients to unpack any potential impacts on communities in the service area and create a plan to mitigate those impacts.

How do HEIAs apply specifically to community birth centers or midwifery-led models in New York, and what unique equity considerations come up?

Birth centers will be required to complete an HEIA if they are submitting a Certificate of Need for a project and the criteria checklist determines that an HEIA is required. In thinking about HEIAs for community birth centers, one of the key equity considerations is the birthing individuals that are serviced by the birth center. What medically underserved populations does the birth center serve? In building a new birth center or changing the services provided, how would those changes impact underserved groups in terms of being able to access services? Who might struggle to access the services and supports provided at the birth center, and is there anything that can be done to increase access to care?

How can birth centers use the HEIA process as an opportunity to strengthen relationships with their communities or communicate their value to funders and policymakers?

Wow, I love this question! I earnestly believe that HEIAs are an excellent tool for healthcare facilities, including birth centers, to meaningfully engage with the communities they serve. In fact, that is the most valuable opportunity the HEIA process provides for facilities!

When we're conducting meaningful engagement for applicants, we're learning about the key community organizations and individuals in the community who help underserved groups navigate getting care and access to important healthcare services. We’re also gaining an understanding of unique community concerns and considerations, as well as the obstacles people face in accessing healthcare services.

At the end of our assessment at Phia, we provide a list of community groups we suggest the facility connect with to further develop relationships with medically underserved groups in their service area. Through these connections, the healthcare facility can make sure these groups are aware of the healthcare services provided and how to get access to those services.

These connections also lay the foundation for a deeper relationship with the community, so the facility can continue to engage community members in ongoing assessments of the services they're providing. It’s invaluable for a healthcare facility to gain ongoing insights from the community on what the facility is doing well and how they can continue to improve access to care and service delivery to even better meet the needs of medically underserved groups.

For those who may want to partner with you, what does collaboration with Phia typically look like, and how can birth center leaders get in touch with you and your team?

Collaboration with Phia is a great way to take on your HEIA! We have been doing these assessments for several years now, and we have a refined system and efficient, robust, insight-driven processes that help us collect and analyze data in a thoughtful, intersectional way. We support our applicants by providing the most comprehensive, thoughtful HEIA we can.

If you’re planning a new birth center or a change in your services, we'd love to connect and learn more about your birth center and how we may be able to support you in completing an HEIA. Please reach out to us at info@phiaconsulting.com, or you can reach out to me directly at amantsios@phiaconsulting.org. We would love to hear from you!

Thanks so much, Lauren, for the opportunity to talk about these important assessments with a community of individuals working on birth centers here in New York. As a mom of two and a strong advocate for women’s health, I thank you all so much for the important work you do!

Public Health Innovation & Action (Phia) logo (courtesy of PHIA Consulting).