Step 1: Needs Assessment

A needs assessment means collecting information that provides a complete picture of the following parts of your community:

  • Demographics
  • LTSS needs
  • Strengths and resources

The assessment helps you identify your community's needs and decide which are the most important. This step is crucial to your success, because it reduces your risk of investing valuable resources into services that may be unnecessary or are not a good fit for your situation.

Watch a video about Menominee Indian Tribe of Wisconsin's Model of Long-Term Care to see an example of how the tribe conducted a needs assessment.

Conducting a needs assessment will provide you with:

  • A picture of your community's current LTSS situation and needs
  • Information that helps you decide what your funding priorities should be
  • Guidance for developing your program and making policy decisions
  • Data to include when writing grant proposals

See Who Pays for LTSS? for more on grant funding

Expert Assistance

When planning your needs assessment, consider working with an expert researcher. An educated and experienced researcher can help ensure a reliable assessment process and accurate results, which are important to building an effective program.

Need more information on how to design a needs assessment? See Intro to Evaluation.

Needs Assessment Model

This model recommends steps to take when conducting your needs assessment.

Identify Initial Needs

First, you need to determine what problems and needs your community has. This initial identification is key because you will measure future progress against it.

Define Problems

Identify the services you need. Also, identify problems that could stand in your way to implementing a program or service.

Sample Needs

Sample Problems

  • Home- and community-based care on the reservation
  • Training for caregivers
  • A home- and community-based care model that fits your budget
  • Small staff
  • Lack of funding
  • Lack of space to build or renovate

Identify Stakeholders

Stakeholders are people who have needs or wants that relate to your planning process. They can include people directly affected by a program and people or organizations who have interest in the program, such as tribal leaders.

Read more on the importance of tribal leader support for your program and how to gain that support.

Kinds of Stakeholders

Stakeholder Examples

  • Individuals
  • Organizations
  • Tribal elders who receive care from an LTSS program
  • Tribal elders or people with disabilities who need care and don't currently have a way to receive it
  • The families of tribal elders or people with disabilities
  • Tribal leaders
  • The tribal health department
  • A local nonprofit that provides disability services

Collect Data

Collect data to help identify the needs in your community. You can collect data by interviewing people or having them complete surveys or join focus groups. Good people to include are:

  • Elders
  • People with disabilities
  • Caregivers
  • Health care providers
  • Tribal officials
  • Title VI directors

You can also collect valuable data by reviewing reports or other research, such as:

  • Census data
  • Data on clinic users
  • State or county economic profiles
  • Electronic health records
  • RPMS numbers for communities served by IHS
  • Other reports related to your field

Organize and study the data you find.


Define LTSS Needs

After gathering information for your assessment, evaluate what you found to understand your community's LTSS needs. You may find that your early assumptions about needs or problems were correct. You may discover new issues that you didn't suspect. Follow these steps:

  • Uncover additional needs: Consider each issue, and break large issues into smaller pieces. Note any issues you can think of that didn't surface during the assessment.
  • Know the current facts: Become familiar with the data discovered during this assessment. This initial data forms the baseline, or the starting numbers, from which you can measure changes in the future.

Describe LTSS Needs

Based on your needs assessment results, identify:

  • Who needs LTSS?
    • Number of people
    • Age and gender breakdown
    • Disabilities in this population
    • Location (on or off reservation)
  • What types of services does your community need (e.g., transportation or caregiver respite)?
  • What services are available now?

Based on this information, create a plan for building services.

Future Uses for the Data Collected

You should use the information you discover during your needs assessment to ask questions about your program. As a future step, you'll need to conduct an evaluation to answer these questions. This is what the process looks like:

  1. A needs assessment determines your community's needs.
  2. Beginning in Step 2 of the roadmap, you'll design a program to meet those needs.
  3. When you get to Step 7 of the roadmap, you'll evaluate your program to see if it is meeting the needs effectively.


Using the information provided by your LTSS needs assessment, you are now ready to choose goals and objectives for your program. Proceed to Step 2.

Page Last Modified:
09/30/2020 10:56 AM