Community Health Needs Assessment

The Community Health Needs Assessment was supported by a generous $249,000 grant from the Robert Wood Johnson Foundation’s New Jersey Health Initiatives Program.The purpose of the Community Health Needs Assessment was to identify critical health issues affecting Middlesex and Somerset County residents and plan future health initiatives to address them.

More information about the Community Health Needs Assessment, can be found by clicking on the below links:



2022 Community Health Needs Assessment

2019 Community Health Needs Assessment

2016 Community Health Improvement Plan

2016 Community Health Needs Assessment

2012 Community Health Needs Assessment Toolbox

In 2020, a Middlesex and Somerset County Community Health Improvement Plan was published.

DSRIP Community Partner Letter
Download the DSRIP Community Partner Letter

Information Collected Through

  • Bilingual telephone interviews with county residents
  • Bilingual focus groups
  • Interviews with key “informants” and partners such as local health departments and community-based organizations

Key Findings & Trends

  • Lack of trained medical staff and health care providers in areas such as cultural competency, mental health, substance abuse, domestic violence and developmental disabilities
  • Multiple language and cultural barriers due to diverse population within areas surveyed; lack of providers who speak the languages of patient populations
  • Lack of health insurance
  • Emergency room overuse
  • Inconvenient medical office/clinic hours; lack of knowledge regarding navigation of health care system; long wait times for appointments

Healthy Behaviors

  • “Risky” behaviors identified (lack of seat belt use, binge drinking, smoking, lack of sleep
  • Increased tobacco use (especially among youths, the poor and uninsured populations)
  • Lack of HIV/AIDS testing
  • Overuse/inappropriate use of prescription medication; high incidence of prescription medication use by children
Disease-Specific Issues of Concern
  • Asthma
  • Mental health
  • Diabetes
  • Dental health services
  • Obesity (adult and childhood)
  • Cardiovascular disease
What’s Next?
  • Integrate assessment findings into both health care systems’ strategic plans
  • Use information to target and develop new community outreach efforts
  • Address needs through development of key hospital services
  • SPUH and RWJ Health System will continue to meet jointly and with community partners to develop new programs that address priority areas
  • Develop joint programming among all partners to address diabetes, obesity, access to reliable health information and access to preventive health services/screenings
  • Expand existing outreach programs with the survey areas

Community Health Needs.

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