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Community Benefit / Community Health Needs Assessment
Not-for-profit hospitals, in order to maintain their tax-exempt, or "charitable," status, under section 501(c)(3) of Federal Internal Revenue Code, have long been required to provide benefit to the community that they serve. Recent changes in legislation now require that such hospitals explicitly and publicly demonstrate community benefit by conducting a community health needs assessment (CHNA) and adopting an implementation strategy to meet the identified community health needs. (IRS).
Section 9007 of the Patient Protection and Affordable Care Act, Public Law 111-148 (the "Affordable Care Act"), created section 501(r) of the Code adding new requirements effective beginning with the first tax year on or after March 23, 2012, that 501(c)(3) hospitals must conduct a CHNA at least once every three years in order to assess community need and annually file information (by means of Schedule H (Form 990)) regarding progress toward addressing identified needs. (IRS). This can involve partnerships with other clinical, public health, and population health focused organizations. Section 9007 furthermore established tax penalties for hospitals that do not comply, as well as reporting requirements regarding national compliance on the IRS. (IRS) .
The IRS has provided initial guidance concerning the CHNA requirement (see legislative and tax information); this guidance has been further augmented by individual states to accommodate their state-specific requirements for tax-exempt status (Hilltop). A growing set of tools, examples, and analyses are provided below to assist both those tasked with preparing a CHNA, as well as those interested in reviewing national progress.
- HSRProj (Health Services Research Projects in Progress): Projects on Community Benefit/Community Health Needs Assessment - (National Library of Medicine (NLM) U.S.)
- PubMed : Search for Community Benefit/Community Health Needs Assessment - (National Library of Medicine (NLM) U.S.)
For a broad set of quality sources of data and statistics related to health care, health services and health status, readers are directed to the following resource and topic pages on HSRInfo Central and PHPartners.org:
- Data, Tools and Statistics (HSR Info Central)
- Health Data, Tools and Statistics (PHPartners)
- Public Health Systems and Services Research (HSR Info Central)
- AHRQ Health Care Innovations Exchange - (Agency for Healthcare Research and Quality (AHRQ)) - The Innovations Exchange offers health professionals and researchers the opportunity to share, learn about, and ultimately adopt evidence-based innovations and tools suitable for a range of health care settings and populations.
- Assessing and Addressing Community Health Needs - (Catholic Health Association of the United States (CHAUSA) USA) - This web page assembles a number of different resources to assist hospitals in understanding the IRS requirements that went into effect on December 31, 2014, the differences between the proposed and final regulations, and resources that will assist in the CHNA planning and implementation processes.
- CDC Community Health Improvement Navigator - (Centers for Disease Control and Prevention (CDC)) - This website is aimed at those who participate in CHI work within hospitals and health systems, public health agencies, and other community organizations. It provides vetted tools and resources for community health improvement.
- CHNA Data Platform - (Kaiser Permanente US) - Registration is required to use this web-based tool, which includes a focused set of community health indicators to assist in the CHNA process.
- Community Benefit - (National Association of County and City Health Officials (NACCHO)) - NACCHO provides a section devoted to information on community benefit.
- Community Benefit (CHA) - (Catholic Health Association of the United States (CHAUSA) USA) - This website features a selection of tools, reports and forms to assist organizations in fulfilling the community benefit requirements. News feeds alert users to new data, relevant to the area.
- Community Health Assessment & Health Improvement Planning - (Center to Reduce Cancer Health Disparities, NCI (CRCHD)) - This site helps state, tribal, local, and territorial (STLT) health departments as they develop community health assessments and health improvement plans, whether for accreditation preparation, nonprofit hospital collaboration, or other reasons.
- Community Health Assessment and Improvement Planning - (National Association of County and City Health Officials (NACCHO)) - This website provides access to resources in support of both assessment of community benefit and accreditation, from from the perspective of Local Health Departments.
- Community Health Assessment Clearinghouse - (New York State Department of Health) - Intended as a resource for community health planners, practitioners, and policy developers both in counties and hospitals in New York State but relevant to other states and settings, this website contains health data, local health planning, and examples of Community Health Assessments and Hospital Community Service Plans (CHNAs).
- Community Health Improvement Process and Community Health Assessment Resources - (Centers for Disease Control and Prevention (CDC)) - This webpage provides links to a selection of guides, handbooks, and resources, focusing on state, tribal, local, and territorial (STLT) health departments.
- Community Health Needs Assessment (CHNA) - (Community Commons USA, Institute for People, Place & Possibility (IP3)) - Web-based platform designed to assist hospitals, non-profit organizations, state and local health departments, and other organizations seeking to identify assets and potential disparities in their communities.
- Community Health Needs Assessment Toolkit (2012) - (Oklahoma State University, National Center for Rural Health Works USA) - Designed for state level professionals, this toolkit facilitates the community health assessment process in rural hospitals at no or low cost to the hospitals.
- Community Health Status Indicators (CHSI) - (Centers for Disease Control and Prevention (CDC)) - Interactive web application that produces health profiles for all counties in the United States. Each profile includes key indicators of health outcomes, which describe the population health status of a county and factors that have the potential to influence health outcomes, such as health care access and quality, health behaviors, social factors, and the physical environment.
- Community Needs Assessment Online Tool - (University of Missouri-Columbia USA) - The Center for Applied Research and Environmental Systems (CARES) provides basic data on counties and states through an online data retrieval system and provides you with a downloadable, and editable, Microsoft Word document which can serve as a basis for conducting a more detailed CCNA.
- Community Tool Box - (Community Tool Box, Work Group for Community Health and Development, University of Kansas U.S.) - The Community Tool Box is a global resource for free information on essential skills for building healthy communities. Its goal is to promote community health and development by connecting people, ideas and resources
- County Health Rankings & Roadmaps - (Robert Wood Johnson Foundation (RWJF), University of Wisconsin) - Provides county-by-county health rankings for each of the 50 states and Washington DC, explanations of each health factor, and actionable strategies to improve the health of communities across the nation.
- Data, Tools and Statistics - (National Library of Medicine, National Information Center on Health Services Research and Health Care Technology) - A compendium of resources to assist in the research process.
- Health Indicators Warehouse (HIW) - (National Center for Health Statistics, CDC (NCHS)) - The Health Indicators Warehouse serves as the data hub for the HHS Community Health Data Initiative by providing a single source for national, state, and community health indicators.
- Hospital-based Strategies for Creating a Culture of Health - (Health Research and Educational Trust (HRET), Robert Wood Johnson Foundation (RWJF)) - This report presents the results of an analysis of the community health needs assessments from 300 tax-exempt hospitals. It outlines the key drivers to community health needs, including: access to care, lack of health insurance, socioeconomic factors, limited preventive and screening services, limited care coordination, and inadequate chronic condition management.
- How can Community Commons help you with your Community Health Needs Assessment Report? - (Community Commons USA) - This toolkit includes a series of webinars to assist in the CHNA development, an instructional video on creating a report with this tool, and a map creation tool (or use an existing map).
- HSRProj - (National Library of Medicine, National Information Center on Health Services Research and Health Care Technology) - Database of ongoing health services research projects. Search for studies relating to access, cost, and quality of health care, including patient outcomes, health services research methods, community needs assessments, etc.
- HSRR (Health Services and Sciences Research Resources) - (National Library of Medicine, National Information Center on Health Services Research and Health Care Technology) - HSRR is a searchable database of information about research datasets, instruments/indices and software employed in Health Services Research, the Behavioral and Social Sciences and Public Health. The database includes brief descriptions of research resources and links to PubMed.
- Implementing Healthy People 2020: MAP-IT: A Guide to Using Healthy People 2020 in Your Community - (Department of Health and Human Services (HHS) U.S.) - This framework was developed to help organizations create a community needs assessment in conjunction with the Healthy People 2020 goals.
- Kaiser Permanente Community Health Needs Assessment: Data Platform - (Kaiser Permanente US) - This web-based resource was designed to assist KP hospitals with conducting CHNAs; free registration is required to use the platform.
- Leading Health Indicators - (Department of Health and Human Services (HHS) U.S.) - Healthy People 2020 provides a comprehensive set of 10-year, national goals and objectives for improving the health of all Americans.
- Maps and Data - (Kaiser Permanente US) - This tool will allow you to browse maps created by Community Commons members, or build state specific reports for Community Health Needs Assessment and Vulnerable Populations Footprint.
- Public Health Quality Improvement Exchange (PHQIX) - (RTI International, Robert Wood Johnson Foundation (RWJF)) - Searchable site for public health professionals interested in learning and sharing information about quality improvement (QI) in public health.
- Resources for Implementing the Community Health Needs Assessment Process - (Centers for Disease Control and Prevention (CDC)) - CDC has compiled a selection of resources to assist hospitals in conducting a community needs assessement.
- Tools for Community Action - (Centers for Disease Control and Prevention (CDC)) - This website includes links to The Guide to Community Preventive Services, Community Health Resources Database, Community Health Assessment aNd Group Evaluation (CHANGE) Tool and Action Guide, several actions guides, and a series of reports focusing on health education
State and Special Population Resources
- Assessing Your Community's Health: A Needs Assessment Toolkit for Health Care for the Homeless (HCH) Grantees - (National Health Care for the Homeless Council USA) - Designed primarily for Health Center Program grantees, this toolkit explains the process and tools for conducting a CHNA.
- Iowa Community Indicators Program (ICIP) - Iowa State University has created a resource that examines regional economic and demographic change.
- New York State Community Health Indicator Reports (CHIRS) - (New York State Department of Health) - Mission is to protect, improve and promote the health, productivity and well being of all New Yorkers.
- State and State/Local Resources: Data, Tools, Statistics - (National Library of Medicine (NLM) U.S.) - Website provides links to high quality resources and analyses from a broad set of sources, identified by the National Library of Medicine
- Tri-State Community Wellness Indicators - This website provides information on demographics, health, and societal risk factors for fourteen counties in southwestern Indiana, southeastern Illinois and northwestern Kentucky.
- Vermont Indicators - (University of Vermont) - A searchable resource created by the University of Vermont. It is divided by Vermont cities, towns, and villages, with information on demographics, transportation, education, and health resources in Vermont.
- Additional Requirements for Charitable Hospitals; Community Health Needs Assessments for Charitable Hospitals; Requirement of a Section 4959 Excise Tax Return and Time for Filing the Return - (Internal Revenue Service (IRS) USA) - This document from 12/31/14 represents the final regulations that provide guidance regarding the requirements for charitable hospital organizations added by the Patient Protection and Affordable Care Act of 2010.
- Additional Requirements for Charitable Hospitals; Community Health Needs Assessments for Charitable Hospitals; Requirement of a Section 4959 Excise Tax Return and Time for Filing the Return : 2015 Addendum - (Internal Revenue Service (IRS) USA) - This document, dated February 5, 2015, contains final regulations that provide guidance regarding the requirements for charitable hospital organizations.
- Community Health Needs Assessments for Charitable Hospitals: Proposed Rule by the Internal Revenue Service on 4/05/2013 - (Internal Revenue Service (IRS) USA) - The proposed rule, and actions related to the rule, are described in this Federal Register posting. Subsequent correction are also listed here.
- New Requirements for 501(c)(3) Hospitals Under the Affordable Care Act - (Internal Revenue Service (IRS) USA) - This fact sheet outlines the requirements for community benefit, and the tax implications for not-for-profit institutions.
- Requirement of a Section 4959 Excise Tax Return and Time for Filing the Return - (Internal Revenue Service (IRS) USA) - This document contains final and temporary regulations that provide guidance to charitable hospital organizations regarding the requirement of a return to accompany payment of the excise tax, enacted as part of the Patient Protection and Affordable Care Act of 2010, for failure to meet the community health needs assessment requirements for any taxable year.
- Requirement of a Section 4959 Excise Tax Return and Time for Filing the Return (8/15/2013) - (Internal Revenue Service (IRS) USA) - Final and temporary regulations (identical to NPRM also published on 8/15/2013) establishing filing requirements for hospital organizations liable for excise tax as a consequence of failure to meet the community health needs assessment requirements for any taxable year.
- Schedule H (Form 990) - (Internal Revenue Service (IRS) USA) - Not-for-profit hospitals are required to file this form, which demonstrates their compliance with ACA section 501(r). Link directs to IRS resource pages for form, instructions, notifications and other relevant tax documents,
- What Does the Affordable Care Act Say about Hospital Bills - (Community Catalyst USA) - This publication outlines the key elements of the final regulations in the Affordable Care act related to patient billing related to patient billing-financial assistance, charges, billing and collections.
- A 50-State Survey of State Community Benefit Laws through the Lens of the ACA - (Hilltop Institute USA) - This website provides issue briefs on each state's regulations related to the community benefit provision of the ACA. (Supported by Kresge Foundation and Robert Wood Johnson Foundation.)
- State Links - (Internal Revenue Service (IRS) USA) - The IRS has provided a set of links to the state government web sites, with information related to the tax regulations for tax-exempt organizations.
- Best Practices for Community Health Needs Assessment and Implementation Strategy Development: A Review of Scientific Methods, Current Practices, and Future Potential: Slides. - (Public Health Institute) - Slides from a July 2011 presentation on community health needs assessments are available.
- Community Health Assessment and Improvement Planning: The Unique Contribution of Public Health Institutes (2013) - (National Network of Public Health Institutes (NNPHI)) - This article looks at the need for public health institutes to contribute to the community health assessment process.
- Community Health Assessment for Population Health Improvement: Resource of Most Frequently Recommended Health Outcomes and Determinants - (Centers for Disease Control and Prevention (CDC)) - This document identifies the metrics that can help describe the health of a community.
- Community Health Needs Assessments - (Association of State and Territorial Health Officials (ASTHO)) - Included in this set of resources are several case studies looking at partnerships between hospitals and state public health departments.
- Connecting the Dots: A Healthy Community Leader's Guide to Understanding the Nonprofit Hospital Community Benefit Requirements - Arizona Health Futures has released a fact sheet, which provides basic information about the community benefit requirement, its relevance towards building healthy communities, and the steps necessary to begin a constructive conversation with a nonprofit hospital.
- Do Health Impact Assessments Make a Difference?: A National Evaluation of HIAs in the United States - (Robert Wood Johnson Foundation (RWJF)) - The methods by which to conduct and screen HIA targets effectively are discussed in this 2014 brief and supplement
- Hospital Community Benefit Expenditures: Looking Behind The Numbers - (Health Affairs) - This blog post provides a comprehensive overview of the major resources related to the issue of the Community Benefit and CHNA.
- Hospital Community Benefits after the ACA: Partnerships for Community Health Improvement (2012) - (Hilltop Institute USA) - This article discusses the many hospitals and state and local public health institutions have partnered to address the issues surrounding community health assessments and their implementation.
- Hospital Community Benefits after the ACA: The State Law Landscape (2013) - (Hilltop Institute USA) - This issue brief looks at States' regulations regarding community benefit, and its impact on health reform.
- Hospitals Building Healthier Communities: Embracing the Anchor Mission (2013) - (University of Maryland) - The report features a series of case studies, intended to serve as models for other hospitals planning to strengthen their community engagement model. Included in the paper are previous research on anchor institutions, the evolution of the hospital in the U.S. and trends and best practices in community building.
- Partner With Nonprofit Hospitals to Maximize Community Benefit Programs' Impact on Prevention (2013) - (Trust for America's Health (TFAH)) - This issue brief looks at the importance of the Community Benefit requirement, and how various hospitals are making it work.
- Principles to Consider for the Implementation of a Community Health Needs Assessment Process (2013) - (George Washington University) - This document outlines the procedures and requirements for creating a Community Health Needs Assessment, and suggests possible partnerships to successfully complete the process.
Analyses examining Pre-ACA Community Benefit Practices
- Community Benefit Information from Non-Profit Hospitals: Lessons Learned from the 2006 IRS Compliance Check Questionnaire (2006) - (American Hospital Association (AHA)) - This 2006 survey examined hospitals' about their community health assessment status. It provides historical context for this issue.
- Hospitals and Community Benefit - Interim "Hospital Compliance" Report - (Internal Revenue Service (IRS) USA) - This 2007 report examined implementation of the community benefit standard by hospitals and found lack of uniformity in definitions and reporting. It called for a separate schedule for hospitals on Form 990, the annual return filed by tax-exempt organizations, and proposed creation of Schedule H, where hospitals would report how they provide community benefit
- Nonprofit, For-Profit, and Government Hospitals: Uncompensated Care and Other Community Benefits (GAO-05-743T: Published: May 26, 2005) - (U.S. Government Accountability Office (GAO) US) - Congress requested that GAO examine whether nonprofit hospitals provide levels of uncompensated care and other community benefits that are different from other hospitals.
- Provision of Community Benefits by Tax-Exempt U.S. Hospitals (2013) - (New England Journal of Medicine (NEJM) US) - A landmark analysis of community benefit, the article is derived from submitted 990 and Schedule H reports for 2009, for more than 1800 non-profit hospitals nationwide.
- Results from 2009 & 2010 Tax-Exempt Hospitals' Schedule H Community Benefit Reporting (2013) - (American Hospital Association (AHA)) - This Ernst & Young benchmark report for the American Hospital Association examines the results of a survey from 2009 and 2010 of the Schedule H data filed by over 900 hospitals nationwide, identifying a baseline analysis of hospitals' pre-ACA compliance with their community benefit obligation.
- Variation in Standards and Guidance Limits Comparison of How Hospitals Meet Community Benefit Requirements (2008) - (U.S. Government Accountability Office (GAO) US) - This 2008 analysis of federal and state laws, standards and guidance from federal agencies and industry groups was performed to determine the definition of community benefit within the hospital community.
This is a list of representative samples of CHNA’s. These have been selected to provide examples of different types of institutions that would be doing CHNA’s. The list is not meant to be exhaustive.
- 2013 Community Health Needs Assessment and Implementation Strategy (2013) - Bellevue Hospital in New York City provides an example of a large city municipal hospital's CHNA.
- Building Healthier Communities: 2013 Community Benefit Report (2013) - From the Minnesota Hospital Association, this community needs assessment reflects the partnership of individual hospitals, health systems, and local public health and community leaders to create a consolidated CHNA for the state of Minnesota.
- Community Health Needs Assessment (OSF) - Order of St. Francis Healthcare has shared CHNAs from their affiliated hospitals, providing examples of hospitals in a religious environment.
- Community Health Needs Assessment and Community Health Strategic Plan (2013) - This 2013 document from Kane Community Hospital in Pennsylvania provides an example of a CHNA and Strategic Plan from a small, rural hospital.
- Community Health Needs Assessment Report (2013) - Brigham and Women's Hospital, provides an example of a report from an academic medical center.
- Greater New Haven Community Index (2013) - From a consortium of New Haven organizations, including the Yale-New Haven Hospital, this CHNA provides an example of work of a hospital in a small city.
- One Maine Health Collaborative StateWide Community Health Needs Assessment - (Eastern Maine Healthcare Systems (EHMS)) - This statewide report consolidates CHNA; information is presented in the context of related, ongoing forums and other activities.
- Rural Community Health and Needs Assessments - The Center for Rural Health at the Mel and Enid Zuckerman College of Public Health of the University of Arizona has assembled examples of the CHNAs for rural Arizona counties and hospitals.
- 2016 Association for Community Health Improvement Annual Conference - (National Network of Public Health Institutes (NNPHI)) - This conference, designed to assist public health institutes connections with non-profit hospital representatives engaging in Community Health Needs Assessments and population health improvement, will be held March 1 - March 3, 2016 in Baltimore MD.
- Addressing Hospital Needs and Goals in the Era of the Affordable Care Act and Meaningful Use: What Librarians Need to Know Webinar - (Medical Library Association (MLA)) - The original broadcast was held on November 20, 2013. The webinar (includes CE credits), looks at the librarian's role within the hospital in the era of the Affordable Care Act, meaningful use, and greater scrutiny of not-for-profit status. (Fee required)
- Best Practices for Community Health Needs Assessment and Implementation Strategy Development: A Review of Scientific Methods, Current Practices, and Future Potential Report of Proceedings from a Public Forum and Interviews of Experts (2012) - (Public Health Institute) - The summary of an expert panel discussion, held July 11-13, 2011 in Atlanta GA, this document looks at the Community Health Needs Assessment, and its Implementation Strategy Development and Execution.
- Community Benefit and Anchor Institutions: Linkages and Opportunities - (University of Maryland) - This webinar from December of 2013 looks at the community benefit requirements as a powerful and effective framework to drive community economic development. Also included are links to webinar slides and to slides that supplement the webinar information.
- Community Benefit: Moving Forward with Evidence-Based Policy and Practice: Proceedings of a National Conference (Fall 2009) - (Missouri Foundation for Health, St Louis University US) - Published by Saint Louis University and Missouri Foundation for Health, this report describes the results of a June 27, 2009, preconference to the Annual Research Meeting of Academy Health.
- Community Health Needs Assessments: Aligning Hospital Investments and Public Health Outcomes - (Network for Public Health Law) - Held on Wednesday, March 26 at 2 - 3:30 p.m. (ET), this webinar discusses the community health needs assessment requirements for not-for-profit hospitals.
- Community Health Status Indicators(CHSI) 2015 Webinar - (Centers for Disease Control and Prevention (CDC), National Library of Medicine (NLM) U.S.) - This CDC/NLM webinar provides an overview of the new features and redesign of CDC's CHSI online web application. Learn firsthand from experts who developed CHSI 2015 about how best to use this redesigned web application to support community health and health needs assessment and population health improvement. Originally presented on March 24 and March 26, 2015.
- County Health Rankings & Roadmaps 101 - (Robert Wood Johnson Foundation (RWJF)) - An overview of the program and tour of the website are included in the webinar from July 14, 2015
- Environmental Health and Community Health Benefits: Moving Upstream to Prevent Harm (Video) - (American Public Health Association (APHA)) - This webinar was broadcast May 27, 2014.
- Healthy People 2020 and Community Benefit - (National Association of County and City Health Officials (NACCHO)) - The meeting goals and objects and selected presentations from this April 9, 2013 meeting are available.
- Let's Go!: Participating in Community Health Initiatives - From the Massachusetts Library Association Annual Meeting, this panel presentation, held on May 7, 2014, discusses the community outreach work of three public librarians.
- NACCHO Performance Improvement Technical Assistance Webinar Series (2012) - (National Association of County and City Health Officials (NACCHO)) - Slides from a January 2012 webinar are available.
- Understanding the Hospital Community Benefit Requirement and the Community Health Needs Assessment - (Robert Wood Johnson Foundation (RWJF)) - In a July 16, 2013 webinar, the concept of community benefit, and the requirements for conducting a CHNA are discussed.
- American Hospital Association - The primary organization for hospitals, AHA's website contains a number of reports, presentations, and case studies relevant to organizations seeking to comply with the community benefit requirement.
- Association for Community Health Improvement - ACHI is a national association for community health, community benefit, and healthy communities professionals.
- Centers for Disease Control and Prevention (CDC) - The Centers for Disease Prevention and Control (CDC) is one of the operating components of the U.S. Department of Health and Human Services. CDC's mission is to promote health and quality of life by preventing and controlling disease, injury, and disability.
- Community Benefit Connect - The purpose of Community Benefit Connect is to support nonprofit hospitals by building a learning community of practitioners who will translate into action community benefit planning, implementation, reporting and evaluation. Included on the website are suggested links, webinars, and a blog.
- Community Health Assessment (CHA) and Community Health Improvement (CHIP) initiatives - (National Network of Public Health Institutes (NNPHI)) - NNPHI has assembled a webinars and case studies aimed at assisting public health institutes in becoming familiar with specific community health improvement tools and techniques.
- Community Indicators Consortium - The Community Indicators Consortium advances and supports the development, availability and effective use of community indicators for making measurable and sustainable improvements in quality of community life.
- Hospital Accountability Program - (Community Catalyst USA) - This website features news related to the CHNA regulations, as well as links to documents useful to organizations needing to comply with the regulations.
- Hospital Community Benefit Program - (Hilltop Institute USA, University of Maryland) - This website was developed to assist policymakers in locating the necessary resources to ensure continuation of their tax-exempt status.
- Internal Revenue Service: Tax Information for Charities & Other Non-Profits - Includes a calendar of events, newsletter, and training information for non-profit organizations.
- National Center for Rural Health Works - Funded through the Federal Office of Rural Health Policy (ORHP), the National Center for Rural Health Works provides tools and templates by which community residents can evaluate their health systems.
- Public Health Accreditation Board - (Public Health Accreditation Board (PHAB)) - Provides information about a national voluntary accreditation program for state, local, territorial and tribal public health departments. The goal of the accreditation program is to improve and protect the health of every community by advancing the quality and performance of public health departments.
- Robert Wood Johnson Foundation - (Robert Wood Johnson Foundation (RWJF)) - RWJF's mission is to improve the health and health care of all Americans.
- W.K. Kellogg Foundation - The Foundation provides grant support for projects that concentrate on early childhood (prenatal to age 8), within the context of families and communities.