Toole County, Montana

Transcription

1 Toole County, Montana Frontier Medicine Better Health Partnership Community Health Needs Assessment Report Survey conducted by Marias Medical Center Shelby, Montana In cooperation with The Montana Office of Rural Health & The National Rural Health Resource Center July 204

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3 Marias Medical Center Community Health Needs Assessment Table of Contents I. Introduction... 2 II. Health Assessment Process... 2 III. Survey Methodology... 2 IV. Survey Respondent Demographics... 4 V. Survey Findings... 8 VI. Focus Group Methodology VII. Focus Group Findings VIII. Summary Appendix A Steering Committee Members Appendix B Public Health and Populations Consultation Appendix C Survey Cover Letter Appendix D Survey Instrument Appendix E Responses to Other and Comments Appendix F Focus Group Questions Appendix G Focus Group Notes Appendix H Secondary Data... 8

4 Marias Medical Center Community Survey & Focus Groups Summary Report July 204 I. Introduction Marias Medical Center (MMC) is a 25-bed Critical Access Hospital in Shelby, MT with a service area of just over,900 square miles serving the Toole County population of roughly 5,324 people. Other health services available include the Marias Care Center, a 63-bed nursing home, and Marias Heritage Center, a licensed 40-unit retirement and assisted living facility. In addition, Marias Healthcare Services, Inc., a Federally Qualified Health Center (FQHC) clinic look-a-like, is a community partner located on MMC s campus. MMC participated in the Community Health Services Development (CHSD) process, a Community Health Needs Assessment (CHNA), conducted by the Montana Office of Rural Health and the National Rural Health Resource Center in Duluth, Minnesota. The CHNA was funded by the Frontier Medicine Better Health Partnership (FMBHP) Project. Community involvement in steering committee meetings and focus groups enhanced the community s engagement in the assessment process. In the spring of 204, Marias Medical Center s service area was surveyed about its healthcare system. This report shows the results of the survey in both narrative and chart formats. A copy of the survey instrument is included at the end of this report (Appendix D). Readers are invited to familiarize themselves with the survey instrument and the subsequent findings. The narrative report touches on the highlights while the charts present data for virtually every question asked. Please note: we are able to compare some of the 204 survey data with data from previous surveys conducted in If any statistical significance exists, it will be reported. The significance level was set at II. Health Assessment Process A Steering Committee was convened to assist Marias Medical Center in conducting the CHSD assessment process. A diverse group of community members representing various organizations and populations within the community (ex. public health, elderly, uninsured) came together in January 204. For a list of all Steering Committee members and their affiliations, see Appendix A. The Steering Committee met twice during the CHSD process; first to discuss health concerns in the community and offer their perspective in designing the survey instrument and again to review results of the survey and focus groups. III. Survey Methodology Survey Instrument In April 204, surveys were mailed out to the residents in Marias Medical Center s service area. The survey was based on a design that has been used extensively in the states of Washington, Wyoming, Alaska, Montana, and Idaho. The survey was designed to provide each facility with information from local residents regarding: Demographics of respondents Hospitals, primary care providers, and specialists used plus reasons for selection Local healthcare provider usage Services preferred locally Perception and satisfaction of local healthcare 2

5 Sampling Marias Medical Center provided the National Rural Health Resource Center with a list of outpatient and inpatient admissions. Those zip codes with the greatest number of admissions were selected to be included in the survey. A random list of 800 residents was then selected from Prime Net Data Source. Residence was stratified in the initial sample selection so that each area would be represented in proportion to the overall served population and the proportion of past admissions. (Note: although the survey samples were proportionately selected, actual surveys returned from each population area varied which may result in slightly less proportional results.) Additionally, three focus groups were held to identify the motives of local residents when selecting healthcare providers and to discover reasons why people may leave the Shelby area to seek healthcare services. It was intended that this research would help determine the awareness of local programs and services, as well as the level of satisfaction with local services, providers, and facilities. Information Gaps: Data It is a difficult task to define the health of rural and frontier communities in Montana due to the large geographic size, economic and environmental diversity, and low population density. Obtaining reliable, localized health status indicators for rural communities continues to be a challenge in Montana. There are many standard health indices used to rank and monitor health in an urban setting that do not translate as accurately in rural and frontier areas. In the absence of sufficient health indices for rural and frontier communities in Montana, utilizing what is available is done with an understanding of access to care in rural and frontier Montana communities and barriers of disease surveillance in this setting. The low population density of rural and frontier communities require regional reporting of many major health indices including chronic disease burden and behavior health indices. The Montana BRFSS [Behavioral Risk Factor Surveillance System], through a cooperative agreement with the Center for Disease Control (CDC), is used to identify regional trends in health-related behaviors. The fact that many health indices for rural and frontier counties are reported regionally makes it impossible to set the target population aside from the five more-developed Montana counties. Information Gaps: Limitations in Survey Methodology A common approach to survey research is the mailed survey. However, this approach is not without limitations. There is always the concern of non-response as it may affect the representativeness of the sample, thus a mixture of different data collection methodologies is recommended. Conducting community focus groups and key informant interviews in addition to the random sample survey allows for a more robust sample and, ultimately, these efforts help to increase the community response rate. Partnering with local community organizations such as public health, community health centers, and senior centers, just to name a few, helps to reach segments of the population that might not otherwise respond to a survey or attend a focus group. 3

6 Survey Implementation In April 204, the community health services survey, a cover letter from the National Rural Health Resource Center with Marias Medical Center s Chief Executive Officer s signature on Marias Medical Center letterhead, and a postage paid reply envelope were mailed to 800 randomly selected residents in the hospital s service area. A news release was sent to local newspapers prior to the survey distribution announcing that Marias Medical Center would be conducting a community health services survey throughout the region in cooperation with the Montana Office of Rural Health. One hundred eighty-five surveys were returned out of 800. Of those 800 surveys, 6 were returned undeliverable for a 25% response rate. From this point on, the total number of surveys will be out of 739. Based upon the sample size, we can be 95% confident that the responses to the survey questions are representative of the service area population, plus or minus 6.27%. IV. Survey Respondent Demographics. A total of 739 surveys were distributed amongst Marias Medical Center s service area. One hundred eighty-five were completed for a 25% response rate. The following tables indicate the demographic characteristics of the survey respondents. Information on location, gender, age, and employment is included. Percentages indicated on the tables and graphs are based upon the total number of responses for each individual question, as some respondents did not answer all questions. Place of Residence (Question 3) While there are some large differences in the percentages below, the absolute differences are small. The returned surveys are skewed toward the Shelby population which is reasonable given that this is where most of the services are located Area Zip code Count Percent Count Percent Shelby % % Sunburst % 7 9.4% Valier % 3 7.2% Cut Bank % 7 3.9% Kevin % 3.7% Oilmont % 2.0% Chester % 0.6% Conrad % 0.6% Galata % 0.6% Sweet Grass % 0 0 Browning % Not Asked in 204 Other 5 2.4% 0 0 TOTAL % 80 00% Significantly more respondents were from Shelby in 204 than in

7 Gender (Question 32) 204 N= N= 26 Of the 85 surveys returned, 69.8% (n=29) of survey respondents were female, 27% (n=50) were male, and 3.2% (n=6) chose not to answer this question. The survey was distributed to a random sample consisting of 50% women and 50% men. It is not unusual for survey respondents to be predominantly female, particularly when the survey is healthcare-oriented since women are frequently the healthcare decision makers for families. 5

8 Age of Respondents (Question 33) 204 N= N= 206 Thirty-two percent of respondents (n=57) were between the ages of Eighteen percent of respondents (n=33) were between the ages of and 5.5% of respondents (n=28) were between the ages of This statistic is comparable to other Critical Access Hospital (CAH) demographics. The increasing percentage of aging residents in rural communities is a trend which is seen throughout Montana and will likely have a significant impact on the need for healthcare services during the next 0-20 years. However, it is important to note that the survey was targeted to adults and therefore, no respondents are under age 8. Older residents are also more invested in healthcare decision making and therefore, are more likely to respond to healthcare surveys, as reflected by this graph. 6

9 Employment Status (Question 34) 204 N= N= 95 Forty-eight percent (n=85) of respondents reported working full time while 3.% (n=55) are retired. Eleven percent of respondents (n=20) indicated they work part time. Respondents could select all that apply so percentages do not equal 00%. Eight respondents chose not to answer this question. 7

10 V. Survey Findings Community Health Impression of Community (Question ) 204 N= N= 208 Respondents were asked to indicate how they would rate the general health of their community. Fifty-five percent of respondents (n=95) rated their community as Somewhat healthy. Thirtyfive percent of respondents (n=6) felt their community was Healthy and 8.7% (n=5) felt their community was Unhealthy. No respondents felt their community was Very healthy and twelve respondents chose not to respond to this question. Significantly fewer respondents rated their community as very healthy or healthy in 204 than in

11 Health Concerns for Community (Question 2) 204 N= N= 28 Respondents were asked what they felt the three most serious health concerns were in their community. The number one health concern identified by respondents was Alcohol abuse/ substance abuse at 5.9% (n=96). Obesity/poor nutrition was also a high priority at 33% (n=6) then Cancer at 3.4% (n=58). Respondents were asked to pick their top three serious health concerns so percentages do not equal 00% Health Concern Count Percent Count Percent Alcohol abuse/substance abuse % % Obesity/poor nutrition % % Cancer % % Illegal drug abuse Not asked in % Diabetes % % Heart disease % % Lack of exercise % 28 5.% Tobacco use 35 6.% % Depression/anxiety % % Lack of access to healthcare 2 9.6% % Mental health issues 8 8.3% 2.4% Prescription drug abuse Not asked in % Child abuse/neglect 26.9% 8 9.7% Accidents/injuries Not asked in % Motor vehicle accidents 5.0% 9 4.9% Domestic violence 2 5.5% 5 2.7% Lack of dental care 4 6.4% 5 2.7% Stroke 3 6.0% 4 2.2% Other 4.8% 7 3.8% Respondents were significantly less likely to cite depression and anxiety as a serious community health concern in 204 than in Other comments: - All of the above - Keeping good doctors - Administration (2) - Lack of competent leadership - Too much legalistic thinking - Lack of doctor with most patients unable to use the hospital 9

12 Components of a Healthy Community (Question 3) 204 N= N= 28 Respondents were asked to identify the three most important things for a healthy community. Fifty-six percent of respondents (n=04) indicated that Access to healthcare and other services is important for a healthy community. Good jobs and a healthy economy was the second most indicated component at 47.6% (n=88) and third was Healthy behaviors and lifestyles at 29.7% (n=55). Respondents were asked to identify their top three choices, thus the percentages do not add up to 00% Important Component Count Percent Count Percent Access to healthcare and other services % % Good jobs and a healthy economy % % Healthy behaviors and lifestyles % % Strong family life % % High quality healthcare services Not asked in % Religious or spiritual values % % Good schools % % Emergency services Not asked in % Low crime/safe neighborhoods % 26 4.% Affordable housing % 2.4% Clean environment % 8 9.7% Community involvement % 2 6.5% Parks and recreation/fitness 5.0% 5.9% Immunized children Not asked in % Low level of domestic violence 5.0% 5 2.7% Tolerance for diversity 3 6.0% 4 2.2% Low death and disease rates 9 4.% 3.6% Arts and cultural events 3.4% 0 0 Other 4.8% 3.6% Respondents indicated that good schools were an important component of a healthy community significantly less often in 204 than in Low crime and safe neighborhoods was indicated by respondents significantly less often in 204 than in Respondents indicated that affordable housing was an important component of a healthy community significantly less often in 204 than in Significantly fewer respondents indicated that a clean environment was an important component of a healthy community in 204 than in Community involvement was indicated by respondents significantly less often in 204 than in Other comments: - We need more happy lifestyles with each other - Equality in the healthcare system 0

13 Survey Findings Awareness of Services Overall Awareness of Health Services (Question 4) 204 N= N= 205 Respondents were asked to rate their knowledge of the health services available at Marias Medical Center. Forty-six percent (n=84) of respondents rated their knowledge of health services as Good. Twenty-eight percent (n=50) rated their knowledge as Fair and 8.8% of respondents (n=34) rated their knowledge as Excellent. Four respondents chose not to answer this question.

14 How Respondents Learn of Healthcare Services (Question 5) 204 N= N= 28 The most frequent method of learning about available services was Word of mouth/reputation at 70.8% (n=3). Friends/family was the second most frequent response at 60.5% (n=2) and Healthcare provider was reported at 43.2% (n=80). Respondents could select more than one method so percentages do not equal 00% Method Count Percent Count Percent Word of mouth/reputation % % Friends/family Not asked in % Healthcare provider % % Newspaper % % Radio % % Public health Not asked in % Website/internet 3 4.8% 6 8.6% Presentations 0 4.6% 9 4.9% Senior center Not asked in % Other 5 6.9% 5 2.7% Respondents in 204 were more likely to learn of healthcare services through word of mouth/reputation than in In 204, significantly more respondents reported learning about community healthcare services via radio than in Respondents were significantly more likely to use the internet to learn of healthcare services in 204 than in Other comments: - Postal services - By using the services 2

15 Cross Tabulation of Service Knowledge and Learning about Services Analysis was done to assess respondents knowledge of services available at Marias Medical Center with how they learn about services available in their community. The chart below shows the results of the cross tabulation. How respondents learned of healthcare services was a multiple response item, thus totals do not add up to 00%. KNOWLEDGE RATING OF MARIAS MEDICAL CENTER SERVICES BY HOW RESPONDENTS LEARN ABOUT HEALTHCARE SERVICES Word of mouth/reputation Friends/family Healthcare provider Newspaper Radio Public Health Website/internet Presentations Senior center Other Excellent Good Fair Poor Total (5.4%) (46.2%) (3.5%) (6.9%) (7.%) (50.5%) (28.8%) (3.6%) (20.5%) (59%) (9.2%) (.3%) (4.5%) (48.7%) (30.3%) (6.6%) (3.3%) (50%) (26.7%) (0%) (29.4%) (47.%) (7.6%) (5.9%) (37.5%) (3.3%) (25%) (6.3%) (25%) (75%) (57.%) (28.6%) (4.3%) (60%) (40%) 3

16 Other Community Health Resources Utilized (Question 6) 204 N= N= 28 Respondents were asked which community health resources, other than the hospital or clinic, they had used in the last three years. Pharmacy was the most frequently utilized community health resource cited by respondents at 75.% (n=39). Eye doctor was also a highly utilized resource at 70.8% (n=3) followed by Dentist at 6.6% (n=4). Respondents could select more than one resource so percentages do not equal 00% Resource Count Percent Count Percent Pharmacy % % Eye doctor % % Dentist % 4 6.6% Chiropractor % % Civic center Not asked in % Public health department % % Massage therapy 33 5.% % Senior center % 2.4% Alternative Medicine % % Transportation services Not asked in % WIC Not asked in % Mental health 7 3.2% 4 2.2% Chemical dependency services Not asked in Other 0.5% 5 2.7% Significantly more respondents saw an eye doctor in the past three years in 204 than in The public health department was used significantly more often by respondents in 204 than in In 204, respondents used alternative medicine significantly more often than in Other comments: - Dr. Clary s office (2) - Walking trail 4

17 Improvement for Community s Access to Healthcare (Question 7) 204 N= N= 28 Respondents were asked to indicate what they felt would improve their community s access to healthcare. Fifty-eight percent of respondents (n=07) reported that More primary care providers would make the greatest improvement. Forty-two percent of respondents (n=77) indicated Improved quality of care and 30.8% (n=57) indicated More specialists would improve access to care. Respondents could select more than one method so percentages do not equal 00% Improvement Count Percent Count Percent More primary care providers % % Improved quality of care % % More specialists (OB/GYN, pediatrician, etc.) % % Expanded outpatient hours % % Health education services % % Health fair 9 8.7% % Transportation assistance % 9 0.3% Telemedicine 7 3.2% 3 7.0% Cultural sensitivity Not asked in % Other % % In 204, respondents indicated that more primary care providers would improve access to healthcare significantly more often than in Respondents indicated that improved quality of care would improve access to healthcare significantly more often in 204 than in Health education services was indicated as a method to improve access to healthcare by more respondents in 204 than in In 204, respondents were more likely to indicate other improvements not listed as options. Other comments: - Affordable (5) - Better administration (2) - Quality doctors - A new hospital - Less drama with doctor, nurses, and staff (3) - Extended days of service outside of Shelby - Not to lose so many doctors - Honesty within the system - Alternative Medicine - Doctors that know their jobs - Better hospital decisions - Better primary care providers - Home Health Care - Getting to know the doctors will increase trust in doctors - Access to doctors of your choice - Totally new management. Trust is gone; local costs exorbitant - Removal of Dr. Clary (4) - Change CEO and CFO - Allow Dr. Clary access to the ER (2) 5

18 Interest in Educational Classes/Programs (Question 8) 204 N= N= 28 Respondents were asked if they would be interested in any educational classes/programs if offered locally. The most highly indicated class/program indicated was Weight loss at 30.3% of respondents (n=56). Health and wellness was selected by 28.% of respondents (n=52) and Women s health followed at 22.7% (n=42). Respondents could select more than one method so percentages do not equal 00% Class/Program Count Percent Count Percent Weight loss % % Health and wellness % % Women s health Not asked in % Nutrition Not asked in % First aid/cpr Not asked in % Chronic pain management Not asked in % Diabetes % 28 5.% Living will/advanced directive Not asked in % Alzheimer s Not asked in % Cancer % % Heart disease Not asked in % Grief counseling Not asked in % Support groups Not asked in % Parenting 8 3.7% 4 7.6% Men s health Not asked in % Child wellness Not asked in % Mental health 5.0% 2 6.5% Suicide awareness/prevention Not asked in % Alcohol/substance abuse Not asked in % Smoking cessation Not asked in % Prenatal/birthing Not asked in % Other 6 2.8% 8 4.3% Respondents were more likely to express interest in a weight loss program in 204 than in Respondents indicated an interest in health and wellness programs more often in 204 than in Respondents were more likely to express interest in diabetes programs in 204 than in In 204, respondents were more likely to express interest in classes regarding cancer than in Other comments: - Dr. Clary s office - Financial/estate planning - Alternative Medicine - How to treat people fairly and with respect 6

19 Economic Importance of Local Healthcare Providers and Services (Question 9) 204 N= N= 22 The majority of respondents (84%, n=52) indicated that local healthcare providers and services (i.e.: hospitals, clinics, nursing homes, assisted living, etc.) are Very important to the economic well-being of the area. Sixteen percent of respondents (n=29) indicated they are Important. No respondents indicated Not important or Don t know and four respondents did not choose to answer this question. In 204, respondents rated the economic importance of local healthcare providers significantly higher than in

20 Survey Findings Use of Healthcare Services Utilization of Preventative Services (Question 0) 204 N= N= 28 Respondents were asked if they had utilized any of the preventative services listed in the past year. Flu shot was selected by 53% of respondents (n=98). Forty-eight percent of respondents (n=88) indicated they received a Routine health checkup/birthday lab and 46.5% of respondents (n=86) had a Routine blood pressure check. Respondents could select all that apply, thus the percentages do not equal 00% Service Count Percent Count Percent Flu shot Not asked in % Routine health checkup/birthday lab % % Routine blood pressure check % % Cholesterol check 50.9% % Mammography % % Pap smear Not asked in % Immunizations Not asked in % Prostate (PSA) % % Colonoscopy % % Children s checkup/well baby Not asked in % None % 7 9.2% Other 7 3.2% 8 4.3% In 204, significantly more respondents reported having a routine health checkup in the past year than in Other comments: - Diabetic test - Lab for INR s [International Normalized Ratio blood test] - Sports Physical (2) 8

21 Needed/Delayed Hospital Care During the Past Three Years (Question ) 204 N= N= 204 Thirty-seven percent of respondents (n=62) reported that they or a member of their household thought they needed healthcare services but did not get it or had to delay getting it. Sixty-four percent of respondents (n=08) felt they were able to get the healthcare services they needed without delay and fifteen respondents chose not to answer this question. Respondents were more likely to delay care in 204 than in

22 Reasons for NOT Being Able to Receive Services or Delay in Receiving Healthcare Services (Question 2) 204 N= N= 54 For those who indicated they were unable to receive or had to delay services (n=62), the reasons most cited were: It costs too much (38.7%, n=24), Don t like doctors (25.8%, n=6), and Too long to wait for an appointment (2%, n=3). Respondents were asked to indicate their top three choices, thus percentages do not total 00% Reason Count Percent Count Percent It costs too much % % Don t like doctors 3 24.% % Too long to wait for an appointment 0 8.5% 3 2.0% Could not get an appointment 3 5.6% 2 9.4% Privacy concerns Not asked in % No insurance % 8 2.9% Office wasn t open when I could go 4 7.4% 8 2.9% My insurance didn t cover it 5 9.3% 7.3% Not treated with respect 20.4% 6 9.7% Could not get off work 5 9.3% 5 8.% Too nervous or afraid 3 5.6% 4 6.5% Unsure if services were available 2 3.7% 4 6.5% Didn t know where to go 2 3.7% 3 4.8% Had no one to care for the children 2 3.7% 2 3.2% It was too far to go.9%.6% Transportation problems.9%.6% Language barrier Other 7 3.0% % In 204, significantly more respondents indicated they did not receive medical services because they could not get an appointment than in Significantly fewer respondents in 204 reported they delayed receiving care because they had no insurance than in Other comments: - Did not feel I needed care - Needed specialist - Doctors change too often (2) - No local provider - Doctor canceled appointment - Don t like specific doctor on call (2) - Couldn t see my own doctor - Management of clinic and hospital - The hospital board should work for the people not their own likes or 20 dislikes. The hospital board got rid of a very well-liked doctor. The board should not be so judgmental, and treat people fairly. - Family doctor not allowed on premises (2) - Main caregiver/doctor was fired (3) - Do not want to support hospital under current administration

23 Desired Local Healthcare Services (Question 3) 204 N= N= 28 Respondents were asked to indicate which healthcare professionals or services presently not available would they use if available locally. Respondents indicated the most interest in having Dermatology services available at 26.5% (n=49) followed by Senior well checks at 22.2% (n=4), then Podiatry (foot care) at 8.4% (n=34). Respondents were asked to select all that apply so percentages do not equal 00% Service Count Percent Count Percent Dermatology % % Senior well checks Not asked in % Podiatry (foot care) Not asked in % Chronic pain specialist Not asked in % Pulmonary/cardiac rehab Not asked in % Home health/hospice Not asked in % Orthopedics 22 0.% 7 9.2% Oncology Not asked in % Family planning Not asked in % Other % 3 7.0% Significantly more respondents would like dermatology services available locally in 204 than in Other comments: - Dermatologist - Endocrinology - Alternative Medicine - Allergist - Reflexology - Mental health 2

24 Hospital Care Received in the Past Three Years (Question 4) 204 N= N= 206 Seventy-three percent of respondents (n=29) reported that they or a member of their family had received hospital care (i.e. hospitalized overnight, day surgery, obstetrical care, rehabilitation, radiology, or emergency care) during the previous three years. Twenty-eight percent (n=49) had not received hospital services and seven respondents chose not to answer this question. 22

25 Hospital Used Most in the Past Three Years (Question 5) 204 N= N= 47 Of the 29 respondents who indicated receiving hospital care in the previous three years, 59.3% (n=67) reported receiving care at Marias Medical Center in Shelby. Twenty-one percent of respondents (n=24) went to Benefis in Great Falls and 9.7% of respondents (n=) utilized services at Kalispell Region Medical Center in Kalispell. Sixteen of the 29 respondents who reported they had been to a hospital in the past three years did not indicate which hospital they had utilized Hospital Count Percent Count Percent Marias Medical Center (Shelby) % % Benefis (Great Falls) % % Kalispell Regional Medical Center (Kalispell) 8 5.4% 9.7% Pondera Medical Center (Conrad) 7.5% 3 2.7% Northern Rockies Medical Center (Cut Bank) 6 4.0% 2.8% Liberty Medical Center (Chester) 0.7% 0.9% VA (Helena) Other 2.4% 5 4.4% TOTAL 47 00% 3 00% Other comments: - Depends on services needed - Flathead Orthopedics - Billings - Out of state - St. Patrick Hospital in Missoula, MT - Lack of doctor with most patients unable to use the hospital 23

26 Reasons for Selecting the Hospital Used (Question 6) 204 N= N= 60 Of the 29 respondents who had a personal or family experience at a hospital within the past three years, the primary reason given for selecting the facility used most often was Closest to home at 60.5% (n=78). Prior experience with hospital was selected by 45.7% of the respondents (n=59) and 4.9% (n=54) selected Referred by physician. Note that respondents were asked to select the top three answers which influenced their choices; therefore the percentages do not equal 00% Reason Count Percent Count Percent Closest to home % % Prior experience with hospital % % Referred by physician % % Hospital s reputation for quality % % Emergency, no choice % % Recommended by family or friends 6 0.0% 3 0.% Closest to work % 2 9.3% Cost of care 7 0.6% 9 7.0% VA/Military requirement 5 3.% 4 3.% Required by insurance plan 0.6% 2.6% Other 5 9.4% 3 0.% Other comments: - Where services are available - Doctor we chose - Competent doctors - Attention to service - Services not available closer to home - Specialist availability/care procedures not available locally - Not comfortable with quality of local doctors 24

27 Cross Tabulation of Hospital and Residence Analysis was done to examine where respondents utilized hospital services the most in the past three years with where they live by zip code. The chart below shows the results of the cross tabulation. Hospital location is across the top of the table and residents zip codes are along the side. LOCATION OF MOST OFTEN UTILIZED HOSPITAL BY RESIDENCE Shelby Sunburst Valier Cut Bank Conrad Chester Oilmont Kevin Galata Sweet Grass TOTAL Marias Medical Center (Shelby) 53 (64.6%) 9 (75%) 3 (30%) (00%) (00%) 67 (59.8%) Benefis (Great Falls) 4 (7.%) 2 (6.7%) 5 (50%) 2 (50%) 23 (20.5%) Kalispell Regional Medical Center (Kalispell) 9 (%) (8.3%) (0%) (9.8%) Pondera Medical Center (Conrad) (.2%) (0%) (00%) 3 (2.7%) Northern Rockies Medical Center (Cut Bank) 2 (50%) 2 (.8%) Liberty Medical Center (Chester) (00%) (0.9%) Other 5 (6.%) 5 (4.5%) Total (00%) 25

28 Cross Tabulation of Hospital and Reason Selected Analysis was done to assess respondents most utilized hospital with why they selected that hospital. The chart below shows the results of the cross tabulation. Reason hospital was selected was a multiple response item, thus totals do not add up to 00%. Hospital location is across the top of the table and reason for selection is along the side. LOCATION OF MOST UTILIZED HOSPITAL BY REASONS HOSPITAL SELECTED Cost of care Closest to home Closest to work Emergency, no choice Hospital s reputation for quality Prior experience with hospital Recommended by family or friends Referred by physician Required by insurance plan VA/Military requirement Other Marias Medical Center (Shelby) 6 (84.7%) 9 (8.8%) 22 (73.3%) 0 (27.8%) 32 (62.7%) (0%) 20 (4.7%) (50%) 2 (00%) 6 (54.5%) Benefis (Great Falls) 4 (80%) 4 (5.6%) (9.%) 6 (20%) 3 (36.%) 9 (7.6%) 2 (20%) 7 (35.4%) (50%) 4 (36.4%) Kalispell Regional Medical Center (Kalispell) (20%) 2 (2.8%) 9 (25%) 4 (7.8%) 4 (40%) 5 (0.4%) Pondera Medical Center (Conrad) (.4%) (3.3%) (2.8%) 3 (5.9%) 2 (20%) (2.%) Northern Rockies Medical Center (Cut Bank) 2 (2.8%) (3.3%) (2.8%) (2%) Liberty Medical Center (Chester) (.4%) (9.%) Other (.4%) 2 (5.6%) 2 (3.9%) (0%) 5 (0.4%) (9.%) Total

29 Overall Quality of Care at Marias Medical Center (Question 7) 204 N= N= 28 Respondents were asked to rate a variety of aspects of the overall care provided at Marias Medical Center using the scale of 4=Excellent, 3=Good, 2=Fair, =Poor, and Don t know. The sums of the average scores were then calculated with Ambulance service receiving the top average score of 3.7 out of 4.0. Radiology received a score of 3.5 and Dentistry received a 3.4 out of 4.0. The total average score was 3.2, indicating the overall services of the hospital to be Excellent to Good. Excellent Good Fair Poor Don t No 204 (4) (3) (2) () know Ans. N Avg Ambulance service Radiology Dentistry Laboratory Physical therapy Speech therapy Assisted living Occupational therapy Visiting specialists Emergency room Ophthalmology services General surgery Obstetrics Extended care (nursing home) Hospice Sleep studies TOTAL Ambulance service received a significantly higher rating in 204 than in Occupational therapy received a significantly higher rating in 204 than in Sleep studies received a significantly lower rating in 204 than in Question 7 continued on the following page 27

30 Question 7 continued Excellent Good Fair Poor Don t No 2009 (4) (3) (2) () know Ans. N Avg Ambulance service Dentistry Laboratory Obstetrics Radiology General surgery Ophthalmology services Physical therapy Emergency room Hospice Visiting specialists Assisted living Sleep studies Occupational therapy Extended care (nursing home) TOTAL *Please see corresponding significance statements on previous page 28

31 Primary Care Received in the Past Three Years (Question 8) 204 N= N= 23 Ninety-eight percent of respondents (n=74) indicated that they or someone in their household had been seen by a primary care provider (such as a family physician, physician assistant, or nurse practitioner) for healthcare services in the past three years. Two percent of respondents (n=4) had not seen a primary care provider and six respondents chose not to answer this question. 29

32 Location of Primary Care Provider (Question 9) 204 N= 53 Of the 74 respondents who indicated receiving primary care services in the previous three years, 69.3% (n=06) reported receiving care in Shelby at Marias Healthcare Services, Inc. Five percent of respondents (n=8) went to Benefis in Great Falls and 3.7% of respondents (n=2) utilized primary care services at a location not listed. Twenty-one of the 74 respondents who reported they had utilized primary care services in the past three years did not indicate where they received those services. 204* Clinic Location Count Percent Marias Healthcare Services, Inc. (Shelby) % Benefis (Great Falls) 8 5.2% Northern Rockies Medical Center (Cut Bank) 5 3.3% Great Falls Clinic (Great Falls) 4 2.6% Kalispell Regional Medical Center (Kalispell) 4 2.6% Pondera Medical Center (Conrad) 2.3% VA Clinic (Helena) 2.3% Liberty Medical Center (Chester) 0.7% Other 2 3.7% TOTAL 53 00% *Responses from 2009 are not comparable to 204 data because respondents could choose multiple locations for primary care in Other comments: - Dr. Clary (5) - Private clinic in Great Falls, MT - Sunburst, MT (2) - Glacier Community Health Center (3) - Private practice - Marias Healthcare Services until they fired my doctor after he had given over 30 years of his life [working at Marias Medical Center] 30

33 Reasons for Selection of Primary Care Provider (Question 20) 204 N= N= 2 Those respondents who indicated they or someone in their household had been seen by a primary care provider within the past three years were asked to indicate why they chose that primary care provider. Prior experience with clinic (49.4%, n=86) was the most frequently cited factor followed by Closest to home (47.7%, n=83) and Appointment availability at 23% (n=40). Respondents were asked to select all that apply so the percentages do not equal 00% Reason Count Percent Count Percent Prior experience with clinic % % Closest to home % % Appointment availability % % Clinic s reputation for quality % % Recommended by family or friends % 28 6.% Referred by physician or other provider 2 0.0% 20.5% Length of waiting room time % 3 7.5% VA/Military requirement 5.2% 5 2.9% Required by insurance plan 0.5% 4 2.3% Cost of care % 3.7% Indian Health Services 2 0.9% 0 0 Other % % In 204, respondents were significantly less likely to choose a primary care provider because they were located close to home. 2 Cost of care was cited significantly less often by respondents in 204 than in Other comments: - Dr. Clary s knowledge and experience (7) - Because he [primary care provider] had treated me since he came here [Marias Medical Center]. He knows me inside and out. I trust him with my life. - Nice people who actually acted like they cared - Family Doctor (5) - Costs in Shelby are too high - Privacy concerns - Only available specialist - Experience with physician - Doctor s reputation (3) - Our family physician (2) - Woman - Not Robert Clary 3

34 Cross Tabulation of Primary Care and Residence Analysis was done to examine where respondents went most often for primary care with where they live by zip code. The chart below shows the results of the cross tabulation. Clinic location is across the top of the table and residents zip codes are along the side. LOCATION OF PRIMARY CARE PROVIDER MOST UTILIZED BY RESIDENCE Marias Healthcare Services, Inc. (Shelby) Northern Rockies Medical Center (Cut Bank) Benefis (Great Falls) Great Falls Clinic (Great Falls) Pondera Medical Center (Conrad) Liberty Medical Center (Chester) Kalispell Regional Medical Center (Kalispell) VA Clinic (Helena) Other Total Shelby Sunburst Valier Cut Bank Oilmont Kevin Conrad Chester Galata Sweet Grass TOTAL 84 (7.8%) 2 (85.7%) 6 (66.7%) 2 (00%) (50%) (00%) 06 (70.2%) (0.9%) 3 (75%) 4 (2.6%) 6 (5.%) (7.%) (.%) 8 (5.3%) 4 (3.4%) 4 (2.6%) (0.9%) (00%) 2 (.3%) (00%) (0.7%) (0.9%) (7.%) 2 (22.2%) 4 (2.6%) (0.9%) (50%) 2 (.3%) 9 (6.2%) (25%) 20 (3.2%)

35 Cross Tabulation of Clinic and Reason Selected Analysis was done to examine where respondents went most often for primary care services with why they selected that clinic/provider. The chart below shows the results of the cross tabulation. Reason clinic/provider was selected was a multiple response item, thus totals do not add up to 00%. LOCATION OF PRIMARY CARE PROVIDER BY REASONS CLINIC SELECTED Marias Healthcare Services, Inc. (Shelby) Northern Rockies Medical Center (Cut Bank) Benefis (Great Falls) Great Falls Clinic (Great Falls) Pondera Medical Center (Conrad) Liberty Medical Center (Chester) Kalispell Regional Medical Center (Kalispell) VA Clinic (Helena) Other Total Appointment availability Clinic s reputation for quality Closest to home Cost of care Length of waiting room time Prior experience with clinic Recommended by family or friends Referred by physician or other provider Required by insurance plan VA/Military requirement Indian Health Services Other 27 (77.%) 3 (44.8%) 68 (94.4%) 3 (33.3%) 46 (63.9%) 2 (50%) 3 (8.3%) 3 (00%) (42.3%) 2 (5.7%) (3.4%) 2 (2.8%) 3 (4.2%) 2 (8.3%) (3.8%) (2.9%) 3 (0.3%) (50%) (.%) 4 (5.6%) 2 (8.3%) (6.3%) 2 (7.7%) 2 (6.9%) 3 (4.2%) (4.2%) (50%) (3.8%) (.4%) 2 (2.8%) (.4%) (.4%) 3 (0.3%) (50%) 2 (22.2%) 3 (4.2%) 3 (2.5%) (6.3%) (2.9%) (3.4%) (.%) (.4%) (50%) 4 (.4%) 6 (20.7%) 2 (22.2%) 9 (2.5%) 4 (6.7%) (6.3%) (42.3%)

36 Use of Healthcare Specialists during the Past Three Years (Question 2) 204 N= N= 206 Eighty-four percent of respondents (n=43) indicated they or a household member had seen a healthcare specialist during the past three years. Sixteen percent (n=27) indicated they had not seen a specialist and fifteen respondents chose not to answer this question. 34

37 Type of Healthcare Specialist Seen (Question 22) 204 N= N= 73 The respondents saw a wide array of healthcare specialists in the past three years. The most frequently indicated specialist was a Dentist at 45.5% of respondents (n=65) having utilized their services. Chiropractor was the second most utilized specialist at 22.4% (n=32) and both Cardiologist and OB/GYN were third at 20.3% (n=29). Respondents were asked to choose all that apply so percentages do not equal 00% Healthcare Specialist Count Percent Count Percent Dentist 64.2% % Chiropractor % % Cardiologist % % OB/GYN % % Radiologist % % General surgeon 3 7.9% % Orthopedic surgeon % % Gastroenterologist Not asked in % Dermatologist 7 9.8% 23 6.% Oncologist % 2 4.7% Ophthalmologist % 9 3.3% Urologist % 8 2.6% ENT (ear/nose/throat) 6 9.2% 4 9.8% Neurologist 2 2.% 9 6.3% Podiatrist 9 5.2% 9 6.3% Pulmonologist 8 4.6% 8 5.6% Endocrinologist Not asked in % Neurosurgeon Not asked in % Mental health counselor 6 3.5% 6 4.2% Psychologist 5 2.9% 5 3.5% Dietician 3.7% 4 2.8% Rheumatologist 9 5.2% 4 2.8% Allergist Not asked in % Pediatrician 6 3.5% 3 2.% Psychiatrist (M.D.) 2.2% 3 2.% Substance abuse counselor % Other 7 9.8% 3 9.% 204 respondents were significantly less likely to have visited a dentist than in Significantly fewer people saw a radiologist in 204 than in In 204, respondents were significantly more likely to have seen an oncologist. 4 In 204, significantly fewer people reported utilizing an ophthalmologist than in Question 22 continued on following page 35

38 Question 22 continued Other comments: - Seizure disorder specialist - Hematologist - Plastic surgeon (2) - Rheumatologist - Pain management - Naturopath - Cancer specialist (2) - Kidney doctor - Ultrasound - Colonoscopy - Eye doctor (2) - Flight physician - Bladder infection - Anesthesiologist - Orthopedic surgeon 36

39 Location of Healthcare Specialist (Question 23) 204 N= N= 73 Of the 43 respondents who indicated they saw a healthcare specialist in the past three years, 67.8% (n=97) saw one in Great Falls. Shelby was utilized by 39.9% (n=57) of respondents for specialty care and Kalispell was reported by 27.3% (n=39). Respondents could select more than one location; therefore percentages do not equal 00% Location Count Percent Count Percent Great Falls % % Shelby % % Kalispell % % Cut Bank % 7.9% Conrad 9.0% 7.7% Helena 6 3.5% 7 4.9% Missoula 0 5.8% 6 4.2% Other 20.6% 5 0.5% Other comments: - Phoenix, AZ - Billings (5) - Browning - Chicago, IL - Chester 37

40 Survey Findings Personal Health Prevalence of Depression (Question 24) 204 N= 85 Respondents were asked to indicate if there were periods of at least three consecutive months in the past three years where they felt depressed on most days, although they may have felt okay sometimes. Fourteen percent of respondents (n=25) indicated they had experienced periods of feeling depressed and 80% of respondents (n=48) indicated they had not. Seven percent of respondents (n=2) chose not to answer this question. 38

41 Physical Activity (Question 25) 204 N= 85 Respondents were asked to indicate how frequently they had physical activity for at least twenty minutes over the past month. Thirty-five percent of respondents (n=65) indicated they had physical activity of at least twenty minutes Daily over the past month and 34.6% (n=64) indicated they had physical activity 2-4 times per week. Four percent of respondents (n=7) indicated they had No physical activity and five respondents chose not to answer this question. 39

42 Survey Findings Cost and Health Insurance Medical Insurance (Question 26) 204 N= 55 Respondents were asked to indicate what type of medical insurance covers the majority of their medical expenses. Fifty-four percent (n=83) indicated they have Employer sponsored coverage. Twenty-four percent (n=37) indicated they have Medicare then Private insurance/private plan was indicated by % of respondents (n=7). Thirty respondents chose not to answer this question. 204* Insurance Type Count Percent Employer sponsored % Medicare % Private insurance/private plan 7.0% Medicaid/Healthy MT Kids Plus 4 2.6% VA/Military 4 2.6% State/other 2.3% None/Pay out of pocket 2.3% Health Insurance Marketplace 0.6% Health Savings Account 0.6% Indian Health 0.6% Other 3 2.0% TOTAL 55 00% *In 2009, respondents could select more than one type of insurance so the results are not comparable to 204 responses. 40

43 Insurance and Healthcare Costs (Question 27) 204 N= N= 96 Respondents were asked to indicate how well they felt their health insurance covers their healthcare costs. Fifty percent of respondents (n=89) indicated they felt their insurance covers a Good amount of their healthcare costs. Twenty-seven percent of respondents (n=48) indicated they felt their insurance is Excellent and 6.4% of respondents (n=29) indicated they felt their insurance coverage was Fair. 4

44 Barriers to Having Health Insurance (Question 28) 204 N= N= 20 Those respondents who indicated they did not have medical insurance (n=2) were asked to indicate why they did not. Fifty percent (n=) reported they did not have health insurance because they could not afford to pay for it and 50% (n=) indicated they did not have medical insurance for Other reasons. Respondents were asked to mark all answers that applied, thus the percentages may not equal 00% Reason Count Percent Count Percent Cannot afford to pay for medical insurance % 50.0% Employer does not offer insurance % 0 0 Cannot get medical insurance due to medical issues % 0 0 Other 2 0.0% 50.0% Other comments: - IHS [Indian Health Services] 42

45 Awareness of Health Payment Programs (Question 29) 204 N= N= 203 Respondents were asked to indicate their awareness of programs that help people pay for healthcare bills. Sixty-one percent of respondents (n=92) indicated they were aware of these types of programs, but did not qualify to utilize them. Twenty percent (n=30) indicated that they were not aware or did not know of these programs and 8.6% of respondents (n=3) indicated they were aware of and utilized health payment assistance programs. Thirty-four respondents chose not to answer this question. 43

46 Cost and Prescription Medications (Question 30) 204 N= 68 Respondents were asked to indicate if medication costs had prohibited them from getting a prescription or taking their medication regularly. Eighteen percent of respondents (n=30) indicated that, in the last year, cost had prohibited them from getting a prescription or taking their medication regularly. Eighty-two percent of respondents (n=38) indicated that cost had not prohibited them, and seventeen respondents chose not to answer this question. 44

47 VI. Focus Group Methodology Three focus groups were held in Shelby, Montana in June 204. Focus group participants were identified as people living in Marias Medical Center s service area. Forty-one people participated in the three focus group interviews. The focus groups were designed to represent various consumer groups of healthcare including senior citizens and local community members. Focus groups were held at Marias Medical Center, Marias Electric, and the senior center. Each group meeting lasted up to 90 minutes in length and followed the same line of questioning in each session (Appendix F). The questions and discussions at the focus groups were led by Kailyn Dorhauer with the Montana Office of Rural Health. Focus group notes can be found in Appendix G of this report. 45

48 VII. Focus Group Findings The following key findings, themes, and health needs emerged from the responses which participants gave to the line of questioning found in Appendix F. Improve health of the community: Wellness programs/classes Affordable and high-quality healthy food Community connectedness Educating community members regarding the importance of preventative care Most important local healthcare issues: Lack of home healthcare Alcohol, tobacco, prescription/other drug abuse Lack of volunteerism Mental health services Nutrition High doctor turnover rates at Marias Medical Center Opinion of hospital services: Quality of care at Marias Medical Center is great A recent transition in providers has affected the entire community Participants felt that Marias Medical Center provides a large number of services, especially in comparison to other rural hospitals More specialists are needed at Marias Medical Center Participants felt that the hospital board is lacking leadership and does not effectively communicate with community members Distinguishing whether healthcare bills are from the clinic or hospital can be confusing to community members Signs and a main desk in the hospital would help direct patients to their destination Privacy issues were voiced regarding the waiting room The dentist is great, but it is difficult to make an appointment because he is so busy Reasons for using local providers: Some participants prefer to use local providers to support their community, for convenience, and to minimize travel 46

49 Opinion of local services: The Emergency Room staff are quick, efficient, and provide excellent care Ambulance services are great, but more volunteers would be beneficial The rural clinics are very helpful for those who live in Sunburst and Valier Marias Medical Center does a good job assisting those in the area who cannot afford to pay for healthcare through Hill-Burton funds The Public Health Department is a valuable resource for the community, but participants mentioned that more marketing regarding the services they offer would be useful The Heritage Center provides outstanding care and is perceived very highly by community members The Care Center also provides great care and community members are pleased with the recent additions to the Alzheimer s Disease wing Reasons to leave the community for healthcare: Planned parenthood services, Obstetric (OB) services, and pediatric care because they are not offered locally The recent transition in providers and leadership style of the Hospital Board have caused some community members to seek care elsewhere Privacy concerns Participants mentioned that some community members choose to follow their provider if the provider begins working elsewhere Needed healthcare services in the community: Bringing back the Health Fair Pediatric care Obstetric (OB) services 47

50 VIII. Summary One hundred eighty-five surveys were completed in Marias Medical Center s service area for a 25% response rate. Of the 85 returned, 69.8% of the respondents were females, 6.9% were 56 years of age or older, and 48% work full time. Respondents rated the overall quality of care at the hospital as excellent to good, scoring 3.2 out of 4.0 on a scale of 4.0 being excellent and.0 being poor. Over half of the respondents (54.9%) feel the Shelby area is a somewhat healthy place to live. Significantly fewer respondents rated the Shelby area as very healthy or healthy in 204 than in Respondents indicated their top three health concerns were: alcohol abuse/substance abuse (5.9%), obesity/poor nutrition (33%), and cancer (3.4%). When respondents were asked which health related educational programs or classes they would be most interested in, the top choices were: weight loss (30.3%), health and wellness (28.%), and women s health (22.7%). Overall, the respondents within Marias Medical Center s service area are seeking hospital care at a rate that is typically seen in rural areas. Area residents recognize the major impact the healthcare sector has on the economic well-being of the area, with 84% of respondents identifying local healthcare services as very important to the economic well-being of the area. The majority of participants appeared to have very favorable opinions of the services with most praising the care received. Participants were appreciative of the care available while identifying additional services or needs. In summary, respondents report support for local healthcare and many prefer to seek care locally whenever possible for convenience and out of trust for local providers. 48

51 Appendix A Steering Committee Members Steering Committee Name and Organization Affiliation. Anna Clark Marias Medical Center 2. Brenda Gilmore Social Services Director, Marias Medical Center 3. Jessica Brusven Toole County Health Foundation Director & Better Health Improvement Specialist, Marias Medical Center 4. Judy Richman Director, Marias Heritage Center 5. Julia Drishinski RN/Director of Education and Infection Control, Marias Medical Center 6. Justin Perry DPT/Director of Rehabilitation Services, Marias Medical Center 7. Kim Schilt Director of Nursing, Marias Medical Center 8. Kristi Aklestad RN, Toole County Health Department 9. Leorra Nickol Youth Dynamics 0. Lorette Carter Community Economic Development Director, City of Shelby. Marcia Heydon Business Office Manager, Marias Medical Center 2. Peggy Taylor Shelby Elementary School 3. Rikki James MTUPP/CIAA Coordinator, Toole County Health Department 4. Tressa Keller IT Tech, Marias Medical Center 5. Toni Moberly RN/Montana Cancer Control Program, County Health Department 6. Vicky Warila Youth Dynamics 49

52 Appendix B Public Health and Populations Consultation Public Health and Populations Consultation Worksheet. Public Health a. Name/Organization Kristi Aklestad RN, Toole County Health Department Rikki James Montana Tobacco Use Prevention Program/Clean Indoor Air Act Coordinator, Toole County Health Department Toni Moberly RN/Montana Cancer Control Program, Toole County Health Department b. Date of Consultation First Steering Committee Meeting: January 28, 204 c. Type of Consultation (Interview, Steering Committee, Focus Group, etc.) Steering Committee d. Input and Recommendations from Consultation - Look at Benefis community health needs assessment survey data - Many people don t know what services the health department offers - Have other questions they would like to include in the survey (referred to as Appendix B) 2. Populations Consultation (a leader or representative of populations such as medically underserved, low-income, minority and/or populations with chronic disease) Population: Low-Income, Underinsured a. Name/Organization Kristi Aklestad RN, Tool County Health Department b. Date of Consultation First Steering Committee Meeting: January 28, 204 c. Type of Consultation (Interview, Steering Committee, Focus Group, etc.) Steering Committee d. Input and Recommendations from Consultation - Noted that Healthy Montana Kids Plus is different than Health Montana Kids - People use both options in this area - Healthy Montana Kids is like Medicaid for kids 50

53 Population: Seniors a. Name/Organization Brenda Gilmore Social Services, Marias Medical Center b. Date of Consultation First Steering Committee Meeting: January 28, 204 c. Type of Consultation (Interview, Steering Committee, Focus Group, etc.) Steering Committee d. Input and Recommendations from Consultation - There is a need for senior wellness checks Population: Youth a. Name/Organization Peggy Taylor Principal, Shelby Elementary School Vicky Warila Youth Dynamics Leorra Nickol Youth Dynamics b. Date of Consultation First Steering Committee Meeting: January 28, 204 c. Type of Consultation (Interview, Steering Committee, Focus Group, etc.) Steering Committee d. Input and Recommendations from Consultation - Schools have been trying to provide more suicide prevention information - Prenatal, birthing, and breastfeeding classes would be beneficial to have in Shelby Population: Tribal/American Indian a. Name/Organization No Specific Representatives b. Date of Consultation First Steering Committee Meeting: January 28, 204 c. Type of Consultation (Interview, Steering Committee, Focus Group, etc.) Steering Committee d. Input and Recommendations from Consultation - Marias Medical Center can accept Indian Health Service (IHS) patients if they are referred 5

54 Appendix C Survey Cover Letter 52

55 Appendix D Survey Instrument 53

56 54

57 55

58 56

59 57

60 58

61 Appendix E Responses to Other and Comments 2. In the following list, what do you think are the three most serious health concerns in our community? All of the above Keeping good doctors Administration (2) Lack of competent leadership Too much legalistic thinking Lack of doctor with most patients unable to use the hospital 3. Select the three items below that you believe are most important for a healthy community. We need more happy lifestyles with each other Equality in the healthcare system 5. How do you learn about the health services available in our community? Postal services By using the services 6. Which community health resources, other than the hospital or clinic, have you used in the last three years? Dr. Clary s office (2) Walking trail 7. In your opinion, what would improve our community s access to healthcare? Affordable (5) Better administration (2) Quality doctors A new hospital Less drama with doctor, nurses, and staff (3) Extended days of service outside of Shelby Not to lose so many doctors Honesty within the system Alternative Medicine Doctors that know their jobs Better hospital decisions Better primary care providers Home Health Care Getting to know the doctors will increase trust in doctors Access to doctors of your choice Totally new management. Trust is gone; local costs exorbitant Removal of Dr. Clary (4) Change CEO and CFO Allow Dr. Clary access to the ER (2) 59

62 8. If any of the following classes/programs were made available to the Shelby community, which would you be most interested in attending? Dr. Clary s office Financial/estate planning Alternative Medicine How to treat people fairly and with respect 0. Which of the following preventative services have you used in the past year? Diabetic test Lab for INR s [International Normalized Ratio blood test] Sports Physical (2) 2. If yes, what were the three most important reasons why you did not receive healthcare services? Did not feel I needed care Needed specialist Doctors change too often (2) No local provider Doctor canceled appointment Don t like specific doctor on call (2) Couldn t see my own doctor Management of clinic and hospital The hospital board should work for the people not their own likes or dislikes. The hospital board got rid of a very well-liked doctor. The board should not be so judgmental, and treat people fairly. Family doctor not allowed on premises (2) Main caregiver/doctor was fired (3) Do not want to support hospital under current administration 3. What additional healthcare services would you use if available locally? Dermatologist Endocrinology Alternative Medicine Allergist Reflexology Mental health 5. If yes, which hospital does your household use the MOST for hospital care? Depends on services needed Flathead Orthopedics Billings Out of state St. Patrick Hospital in Missoula, MT Lack of doctor with most patients unable to use the hospital 60

63 6. Thinking about the hospital you use most frequently, what are the three most important reasons for selecting that hospital? Where services are available Doctor we chose Competent doctors Attention to service Services not available closer to home Specialist availability/care procedures not available locally Not comfortable with quality of local doctors 9. Where was that primary healthcare provider located? Dr. Clary (5) Private clinic in Great Falls, MT Sunburst, MT (2) Glacier Community Health Center (3) Private practice Marias Healthcare Services until they fired my doctor after he had given over 30 years of his life [working at Marias Medical Center] 20. Why did you select that primary care provider? Dr. Clary s knowledge and experience (7) Because he [primary care provider] had treated me since he came here [Marias Medical Center]. He knows me inside and out. I trust him with my life. Nice people who actually acted like they cared Family Doctor (5) Costs in Shelby are too high Privacy concerns Only available specialist Experience with physician Doctor s reputation (3) Our family physician (2) Woman Not Robert Clary 22. What type of healthcare specialist was seen? Seizure disorder specialist Hematologist Plastic surgeon (2) Rheumatologist Pain management Naturopath Cancer specialist (2) Question 22 continued on following page 6

64 Question 22 continued Kidney doctor Ultrasound Colonoscopy Eye doctor (2) Flight physician Bladder infection Anesthesiologist Orthopedic surgeon 23. Where was the healthcare specialist seen? Phoenix, AZ Billings (5) Browning Chicago, IL Chester 28. If you do NOT have medical insurance, why? IHS [Indian Health Services] Additional Comments: Will not do business with Marias Medical Center. Screw them after what they did to Dr. Clary. Marias Healthcare needs to be more competitive. Costs are too high here and billing is poor. Doctors are weird and seem incompetent. I do not use any Shelby medical services because of the extremely poor medical service that is available. The city of Shelby needs to look into programs to attract decent doctors. Right now we get doctors that cannot get jobs anywhere else. 62

65 Appendix F Focus Group Questions Purpose: The purpose of the focus groups was to identify motives of local residents when selecting healthcare providers and why people may leave the community to seek health services. This market research will help determine the awareness of local programs and services, as well as satisfaction or dissatisfaction with local services, providers, and facilities.. What would make this community a healthier place to live? 2. What do you think are the most important local healthcare issues? (Probe question: What do you think are the biggest issues facing local healthcare services?) 3. We are now going to ask you for your views about the hospital. What do you think of the hospital in terms of: Quality of care Number of services Hospital staff (style of care, competence) Hospital board and leadership (good leaders, trustworthy) Business office Condition of facility and equipment Financial health of the hospital Cost Office/clinic staff Availability 4. Are any of the local providers your personal provider or personal provider to your family members? Why? 5. What do you think about these local services: Emergency Room Ambulance service Healthcare services for Senior Citizens Public/County Health Department Healthcare services for low-income individuals/families Nursing Home/Assisted Living Facility Pharmacy 6. Why might people leave the community for healthcare? 7. What other healthcare services are needed in the community? 63

66 Appendix G Focus Group Notes Focus Group # Tuesday, June 24, 204 2pm-pm Marias Medical Center Shelby, MT 2 participants ( male, female). What would make this community a healthier place to live? - Wellness programs - Actual wellness programs not just go get your blood drawn and computer-based stuff. We [Marias Medical Center] do have some employer-based programs, but we need local wellness programs. A lot of employers do no offer them. - Yes, there are many small businesses that cannot afford to do that [offer wellness programs for employees]. - We just lost our weight loss program, and we do not have any sort of Weight Watchers programs here [in Shelby]. - What about that program the Physical Therapy Department [at Marias Medical Center] was doing with the kids? - We [Physical Therapy Department] didn t do it this year. It was a speed and agility program. The first time we did the program it was totally free, and then we had to start charging $25 to cover the costs. This year there just weren t enough kids signed up. - There are fitness classes at the Civic Center, but usually the hours are 9am to5pm and are not compatible with most people s work schedules. - More opportunities for nontraditional active populations. Maybe something for kids who aren t typically active, not just sports, or for programs for seniors. - Better fruits and vegetables, basically access to healthy food. - Affordable healthy food - Bio Tune Up [grocery store] used to try to have healthy food but no one was going there. - You can drive to Cut Bank and buy way better groceries. - Connectedness. More and more people are talking about not feeling connected to the community. People used to seek out more services, like joining a church, but now they do not do as much. 2. What do you think are the most important local healthcare issues? - Diabetes education would be nice, and cardiac rehab would be nice. People have to drive long distances to seek these services. - I think smoking is huge. I think it is huge in communities lacking wellness programs. - We [Marias Medical Center staff] have tons of calls about people who aren t ready to go into assisted living, but they need home health care. - There is a lot of that. We hear about it at the Public Health Department a lot, too. - Could the Senior Center offer services for them [elderly living in their homes]? - I think there is a huge need for home health. There is an actual grant funded through the Senior Center. The grant is for full-time caregivers who need a little break. Someone will come into the home, do light 64

67 housekeeping, respite care, and other things to give the caretaker a break. 3. What do you think of the hospital in terms of: Quality of Care - I think we [Marias Medical Center] are in crisis. We have had issues with a doctor that has split us wide open. - Even though there are outlying issues, our-day-to day care is great. - I know from personal experience, from when my mom was here [Marias Medical Center], she was not getting her medications on time, and she was staying at the hospital because the Heritage Center [Assisted Living Facility] was booked. We had an incident where one of the doctors was very inappropriate, and I asked him to leave after I took her into the ER. - I have never had any problem here [Marias Medical Center]. I get in, and I get my stuff. I live in Valier and can even see the doctor once a week if I want, which is very nice. - I did take my son to the doctor, and he told my son to buck up. I thought that was very insensitive. The bed-side manner here [at Marias Medical Center] could use some improving. - Confidentiality gets breached from some of the nursing staff. Someone from here [Marias Medical Center] is talking about private stuff out in the community. - The CNA was being nosy, just to be nosy. - We [staff at Marias Medical Center] actually talked about that in a customer service meeting. - I think a lot of the gossip has been eliminated after they quit allowing smoking on hospital grounds. They [staff] aren t just gossiping away while smoking anymore. - Quality of care is great. We need quality physicians though. We are in a transition. I think it is getting better than it previously was, but we don t want quantity over quality. Number of Services - I think for our size we [Marias Medical Center] offer a lot. We offer more than the surrounding small hospitals. - I think we are a leader in the field. - It would be so nice to have Pediatric Care here. - It would be awesome to have an orthopedic surgeon, but we are just dreaming here. - Yeah, cost of equipment is too pricey. Hospital Staff - Recruitment is so difficult for a rural hospital. It is difficult no matter what. We can t compete with Benefis [hospital in Great Falls] and cannot offer services competitively. - Our staff must hold each other responsible. - The staff doesn t really work well together. But, that is a time thing, I think. 65

68 - I think for the most part we [Marias Medical Center staff] do okay! However, I may see things differently. - We [Marias Medical Center] need more specialists. It s hard as a nurse. We have to wear many hats. When we are expected to do too many things it sets the standards too high. It is really hard. I m sure physicians feel the same way. [In a rural hospital] you are expected to be an expert in every field. That is really hard. - Could we [Marias Medical Center] get more physicians? I think it has been discussed but I do not know what direction we are going. Hospital Board and Leadership - We [Marias Medical Center staff] are in transition. The board is also in transition. - In regards to the new hospital board members, I appreciate that they are posting more updates [for the public s awareness]. Business Office - I think they are really on top of it. We had a procedure done and bills were sent very fast. - The way hospitals are billed, and then reimbursed, is just difficult. - Our billing department is doing things differently, things are changing. - We [billing department] are auditing high dollar services. They are being flagged and looked into. - Should we advertise how we restructured our pricing? - Distinguishing the difference between hospital and clinic bills is confusing. - Patients must pay these separate. But they [patients] usually lump them together. - That is confusing. However, it is no different than what other places [clinics and hospitals] do. - Shelby Clinic bills are much easier to decipher. Condition of Facility and Equipment - I think it [condition of facility] has gotten better and better. Better than surrounding areas anyways. - Nursing home [Care Center] needs a little attention. - Physical Therapy moved over here [Maris Medical Center], which is good. - Customers liked PT [Physical Therapy] where it was before, but [now having] more space is nice. Finding a parking spot is annoying for customers. And coming up a ramp to enter the clinic is an issue. - Some more visible signs would be nice for the PT [Physical Therapy] department. And a sign in [space] for the hospital and clinic. I think they [patients] get to the ER and then stop. More signs would be nice. - The Care Center could look a little nicer. Maybe someday they could get an OB [Obstetrics services] room? - I think the [hospital] layout makes it very hard to check-in. To even find a nurses station is difficult. The layouts of the offices are difficult to navigate. - We [Marias Medical Center] do not have a main desk. One central point is needed. 66

69 Financial Health of the Hospital - The community probably feels that it [financial health of the hospital] isn t particularly stable. They may also feel that it costs more compared to other places, like Billings. Cost of care is perceived to be higher here. Cost - We [Marias Medical Center] have done adjustments [in lowering pricing for services], and we are trying to work with each department. - When you consider driving [to a surrounding hospital], it s more cost effective to come here [Marias Medical Center] versus driving somewhere else and taking a whole day off from work. Office/Clinic Staff - The admissions office has no privacy. They [patients] have to stand against the wall [while waiting to check in]. You can hear the person checking people in. - If you come here [Marias Medical Center] early [in the morning], a nurse will send you to the lab, but do you stand or sit down? Where do I go? We need a waiting room. You just stand there. It s awkward. I felt like I was not supposed to be there. Should I even be waiting? - We [Marias Medical Center staff] don t want that. But there is no true main desk. - As for privacy, should we give them [patients] a number? Utilize other waiting areas and call over an intercom [when we are ready for them]? Availability - It is not hard to get an appointment. - The dentist is difficult to get a hold of. - [Dental services] are billed from the clinic. - I do not choose to use services here [Marias Medical Center] because I know there are privacy issues. - We [Marias Medical Center] had to recruit a dentist for years. He [dentist] books about three months in advance. And we [Marias Medical Center] are hiring a dental hygienist. - He [dentist] is awesome. If you are miserable, he gets you in. He is really good in the ER. It cleans up the ER traffic. The equipment [used by the dentist] is very nice. He [dentist] also does OR in the surgery center. 4. Are any of the local providers your personal provider or personal provider to your family members? Why? - I use Marias Medical Center most of the time but when I do seek care elsewhere it is because the service is unavailable. We do not have a OBGYN here, and therefore you must find it elsewhere - We have one [OBGYN] who comes here. - Yeah, but there was no OB when I needed it. 67

70 5. What do you think about these local services: Emergency Room - Only good! - Never had to use it [ER]. - Quick. All is good except the waiting room experience. It is too open. People can walk in and watch. It is not private but the quality of care is great. 68 Ambulance Service - Great! - I wish we could have paramedics, speaking of dreams. For ACLS [Advanced Cardiovascular Life Support] and other services, we need to call Conrad. Healthcare Services for Senior Citizens - I think we excel in this area [healthcare for seniors]. We have a rural Sunburst Clinic that helps keep folks in their homes longer. - We have life lines, transportation, and an assisted living center. Public/County Health Department - They [health department] are a valuable resource to use in the Clinic. - They [health department] offered free screenings to woman, providing mammograms and colonoscopies. - I don t think the community knows what all they offer, maybe they should market more. - We [Toole County Health Department] are perceived as the last resort call. I wish people knew more about us. Healthcare Services for Low-Income Individuals/Families - The clinic has a sliding fee scale [for low-income patients]. The Health Department has WIC [Women, Infants and Children] and [lower] immunization fees [available for low-income patients]. - Hill Burton funds [Federal program that provides free and reduced cost healthcare] are used up in four months. They [low-income patients] know to get in right away on July st [so they are eligible to receive funds before the funds are used up]. Nursing Home/Assisted Living Facility - Heritage Center [Assisted Living Facility] fills up, so what can we do differently to make our Care Center [Nursing Home] where patients want to stay? - If you can stay at the Heritage Center as long as possible, that s good. Not many [patients] want to go to the nursing home. - If you [as an elderly patient] do not have a family member to advocate for you, you will not get good quality of care. - I think it s cultural. Nobody wants to go to a nursing home. If they can afford the Heritage Center, that is certainly the [preferred] option. [Our aging population holds] the old rancher mentality, [but there are] the safety issues [at stake] which is why we need to educate [the public about] why these centers exist!

71 69 - There has been a shift in the whole industry [long-term care]. Care is way too expensive. They [family members] will keep them [person needing care] at home as long as possible, which is much cheaper. When we [Care Center staff] finally get them [patients], they are train wrecks. We do not have the funds to care for these highdemand patients. - AD [Alzheimer s Disease] units are re-done, with locks, better floors and railings [in the Care Center]. Pharmacy - Two pharmacies are available in town. - People use them [pharmacies] and seem to be happy. - Nothing is available at night or on the weekend. - But, the hospital gives a few pills to those people until pharmacy is open. - They [local pharmacies] do a great job! 6. Why might people leave the community for healthcare? - We do not have any planned parenthood or other services like that. - They can come get a pregnancy test [at Marias Medical Center]. - Because Shelby is a small community, some care is just a bit too personal! Could you imagine getting a colonoscopy from your neighbor? - I know of two patients that have just recently gone to Great Falls to deliver their babies because of the nurses in the hospital [at Marias Medical Center]. Both noted that they love Dr. Hardy and will return for her care after their babies are born. - A recent transition in providers has caused a lot of folks to choose other [care] options. It is really split. - I wonder if I am going to have to change physicians in 6 months. Developing a relationship with a provider is challenging, and it is difficult during this current transition of providers. - Sometimes I think people just do not know what is fact or fiction. The gossip is bad. - OB [Obstetrics services] has been sought outside of the community. - OB [Obstetrics services] is offered here [Marias Medical Center] now, but it hadn t been previously. - I heard instruments were being dropped on the floor in the Operating Room, [which created] a stigma that things were dirty [when performing Obstetric services.] - How do you know if that is true or not? - I feel like any issue now has become a paramount issue. Everything seems more negative than positive. - It is affecting our [Marias Medical Center] volunteers. They are either on one side or the other. We need more volunteerism, and a sense of community. 7. What other healthcare services are needed in the community? - Having a Health Fair is really important. It provides education to the public, which is great! It also teaches us [community members] about the hospital.

72 Focus Group #2 Tuesday, June 24, 204 6pm-7:45pm Marias Medical Center Shelby, MT 4 participants ( male, 3 female). What would make this community a healthier place to live? - To make our hospital healthier, because right now it is not. I think we are working on that. There are a lot of people outside the hospital that I feel are almost like a poison. A group of them [community members] want the CEO to fail. This group has been super crude to the CEO and his family, and for those who are against keeping this doctor. Community members have lost business, it s getting insane. I have lived here most of my life, minus ten years, I have raised three kids here and am really proud of this town, but I am not proud right now. - It s not just outside of this community, but also inside the hospital. There have been staff members here who have gotten shunned. - I think there is a poison within this building that needs to be eliminated. It is keeping our facility from growing. - We [Shelby community] are getting a lot of negative perceptions from the surrounding communities. - I think this hospital is spot on. We are working on physical fitness, getting new doctors and we are spot on where a lot of rural hospitals are not. But there is a big road block. - Trying to get people to recognize how important preventative care is. People must exercise, get their blood work checked. I guess trying to get better awareness about what they [community members] can do to help themselves. We should teach them to recognize what they can do to help themselves before they get sick. 2. What do you think are the most important local healthcare issues? - Prescription drug abuse - Teen drinking and selling too much over-the-counter medications, causing abuse. - I do think there is a drug problem, but I think it is in all these little towns, not just Shelby. - Mental health services and parenting is a real problem. There are a lot of issues with parents not providing good care to their kids, nutritionally and prenatally. - Tobacco and alcohol within the youth. Mental health is a big issue which affects physical health for the whole family. 3. What do you think of the hospital in terms of: Quality of Care - Personally, I would rate it [quality of care] pretty high. - Four years ago my colon ruptured and the ER was great. They sent me to Great Falls. Just for them [Marias Medical Center ER staff] to react so quickly, they have a physician who comes in off-site who is wonderful. Even the regular doctors are great. The radiology department is great too. - I hear good things, the only negative is that Dr. Clary could be here all day and now he can t. But the quality of care is good. 70

73 - There has been a big turnover in help [staff at Marias Medical Center] and in a little community, people do not like that. That makes it tough to give it 00% when turnover is high. - I ve seen both extremes. I was an EMT for 22 years. I have been all over the state. There were times when I transported patients here [Shelby] and have worried about the care the providers were providing. On the other hand, there have been times when I have been upset with other hospitals. I convinced the people in Billings to take my mother here [Marias Medical Center], and she got wonderful quality of care here. I ve seen both extremes as a provider and user. Overall, given the remoteness, it s phenomenal. Number of Services - I think it [services available] is pretty good. We [Marias Medical Center] have a big helicopter, just in case something goes wrong. We also have a lot of specialty doctors who come in. - As long as it is cost effective, we [Marias Medical Center] can do it [medical procedures]. - The services are appropriate for the size of the facility. Some [facilities] do not have the advanced specialty care, but that is expected. [The services are] very adequate for where we are. We chose to live here, and therefore we chose to not have all those specialists. Hospital Staff - Usually I do not hear about the actual care. Most people rate care very high no matter what department it is. - Other than once or twice depending on the ER doctor, I have never had a problem [with hospital staff]. - There are negative perceptions about Marias Medical Center in the community right now and incorrect information has been shared, particularly on the radio recently. - We had two traumas, and the care delivered was great. Thirty to forty kids were in an accident, and in the end we [Marias Medical Center] treated over 20 patients. Everyone came together and we all got through it. We [staff] react well and pull together. Also some outside agencies helped out. I felt a great sense of community after that trauma. Hospital Board and Leadership - The CEO is wonderful. I m sure he won t be here much longer because he is so good. The hospital board has no leadership. They cannot even control their own meetings. When they [hospital board] think about trying to keep this facility up and running it makes me sick. - I used to trust our [hospital] board about six months ago, when everything used to seem like it was on track but after the recent provider transitions, a few [hospital] board members moved [away from Shelby] and I feel like no one knows the new ones [hospital board members]. The new ones [hospital board members] have gone in a new direction, the CFO has resigned, and I cannot even call the new board members, so 7

74 who can I call to ask? Who is going to lead us and guide us? Where will we [Marias Medical Center] be in a month? - I think they [hospital board] are not making the best decisions. The board members have an agenda. - And the sad thing is, is that they [hospital board] are very public about this. To the point that even our local pharmacy is affected. No one is friendly. No one wanted to wait on me [at the local pharmacy] because now they [pharmacy staff] know exactly what side of the recent transition of providers I am on. The pharmacist is very involved in this transition. I think the pharmacist has not distinguished business from personal life. - That is why we need an active hospital board committee. I do not feel comfortable asking them [hospital board] what is going on. - As an employee [at Marias Medical Center], you do not feel like they are protecting you. - Is the [hospital] board looking at the big picture? No. There is no support. - They [hospital board] are making their decisions based off emotions. The county commissioners can override whatever decision they do. That makes me feel a little safer, so we must trust the county commissioner. - The [hospital] board consists of all volunteers. When a big issue comes up, they need to have more personal involvement. They [hospital board members] only know what they hear from the board meetings. Those are their only perceptions [what they hear in the hospital board meetings]. - I have never dealt with them [hospital board]. I felt bad when certain staff felt he had to resign because of everything that was going on. I know what it feels like when the public wrongly accuses board members of doing something they didn t. Business Office - [Community members are] probably not happy with the Billing Department. They [community members] do not understand what is going on with the billing department. - When doctors take a long time to dictate, it influences the billing process. - People may not understand the [billing] statements. - We [Marias Medical Center] are overpriced, but we have started to reduce the prices of some things. Condition of Facility and Equipment - I think they [Marias Medical Center staff] are always working on it [condition of the facility]. Our Auxiliary has added a lot to the rooms. The nurses will come visit with us [Auxiliary] and tell us what they need. So we [Auxiliary] work on a budget and try to get them [nurses] what they ask for. We just bought two new items for the Physical Therapy Department. I think Mark [CEO at Marias Medical Center] does a fabulous job. - The landscape is really nice, we repainted the parking lot. - The donations and Auxiliary donations are nice. - There are limitations on staff [at Marias Medical Center]. Our maintenance is also our ambulance volunteers. 72

75 - They [ambulance volunteers] get pulled in so many directions. Sometimes that is why there is a delay in receiving services. - The hospital is in great shape for a rural medical center. Financial Health of the Hospital - It [financial health of the hospital] is bad from what I know. And I m sure I do not see the whole picture. I see what we need for payroll, but the months that you do not hit payroll, the county has helped our hospital. Financially, it is a huge concern. - EMR [Electronic Medical Records] was just a huge hit financially, and we are still working on that, for over two years now. Cost - A lot of people in the community say that cost of care is high. - I always tell them that our [Marias Medical Center] costs are no different from costs down the road. - We have reduced ambulance, radiology, and lab charges, and I m hoping that will eliminate the negative perceptions [about cost]. - Everyone compares us [Marias Medical Center] to Great Falls, but that is not realistic. - [The cost of care is] no different than anywhere else. It is outrageous. They have to charge that much in order to pay for those who do not pay. Dropping prices will not change this country-wide crisis. Office/Clinic Staff - I have never heard a negative thing about checking in here [Marias Medical Center]. - A friend of ours from Canada got a bloody nose, he came in here, and the girl at the front desk asked about 40 questions. He thought she asked too many questions, instead of providing care in a timely manner. - There are so many questions that we [staff] are required to ask right now, it is a bit ridiculous and it is hard to get through it quickly. - They [staff] talk so loud when you check in! As you are talking to them [check-in staff], there is no privacy. You can hear everything! - When they [check-in staff] repeat things to clarify, such as social security numbers and all sorts of personal information, everyone else can hear, and there is no privacy. - Check-in staff are welcoming. No problems. Availability - I think it [availability of services] goes through streaks. The clinic tries to keep a few openings per day. - I have never had any problems [getting an appointment]. - Quick and effective. - It s okay. I recognize that when there is an ambulance, sometimes you need to pull people from another job. 73

76 4. Are any of the local providers your personal provider or personal provider to your family members? Why? - Yes. The only reason we would leave the area is for specialty care. My son did his physical therapy here [Marias Medical Center]. We support what is here. - I choose local providers to support my local community. I went to Great Falls to see my old provider who was bullied out of here [Marias Medical Center] and now she practices in Great Falls. - The drive gets old. But just when I think I ll try one of the physicians here [Marias Medical Center], they [physicians] seem to rotate out and a new one comes along. But supporting the new ones [physicians] are better than driving elsewhere. - I know we have good staff. I can trust whoever is on call. I don t care about the personal difference. I want care here [at Marias Medical Center]. 5. What do you think about these local services: Emergency Room - Pretty good services. If someone comes in with an agenda and the provider doesn t follow through, it makes them [patients] mad. When it is a true emergency the providers do whatever is necessary. - The time I came in they [Marias Medical Center ER staff] were absolutely wonderful. Very time effective, they did an awesome job. - Tough at times, depending on the time of the day. They [Marias Medical Center ER] know when the crew is coming in via EMS [Emergency Medical Service], so why is there a delay? If we [EMS] are coming from Sunburst I wish the MD would be waiting for us. The timelines would have been nice to have. If we [EMS] tell them [ER] what we need in advance, you would think there is a quicker response. From a professional stand point, they [ER] should take us [EMS] more seriously. Ambulance Service - Great! - The level of care is right there with any other rural agency. The training they [ambulance crew] receive is as good as they come. - I think our ambulance crew is awesome. They are always training, and our volunteer Auxiliary [Marias Medical Center Auxiliary club] is always giving them money and they are putting those funds to great use. Healthcare Services for Senior Citizens - There is a physical fitness program for seniors, which is nice. - The ER offers free blood pressure screenings for everybody. Many seniors take advantage of that. - The Heritage Center is an extended care facility. - Do they have programs for any seniors not staying there? - They are financially under the hospital, all bundled together with the same tax ID number. - I am curious about home healthcare options because that is something I need personally. 74

77 Public/County Health Department - I think she [public health nurse] does great. I think they are busy and do well. - I think they [health department] are always trying to expand and educate. - They [health department] are easy to work with. The collaboration is wonderful. - I always wonder what they [health department] do. They formed a ReACT group [Montana youth advocating against tobacco use], but I m not too sure what else. They deal with WIC [Women Infants Children] but I have never had a need to interact with them. Healthcare Services for Low-Income Individuals/Families - I do not know. - Clinic is FQHC [Federally Qualified Health Center], with a sliding fee scale. The hospital has Hill Burton funds [Federal program that provides free and reduced cost healthcare], which you can also apply for. - We have people [Marias Medical Center staff] who help them [low-income families] with Healthy Montana kids, who basically fill out the application for them. - They [Marias Medical Center] will not turn you away from services no matter what. - There is a very short form that we [Marias Medical Center staff] can fill out that allows coverage for 30 days through Medicaid. We [Marias Medical Center staff] are certified to do that. It depends on your income, so we approve it if it falls below a certain level. That way, the facility doesn t have to pay for that [care received by patients who cannot pay their bill]. Nursing Home/Assisted Living Facility - The Heritage Center [assisted living facility] is wonderful. - As for the Care Center [nursing home] side, when people call you rarely hear complaints. - We [Care Center staff] do Patient Satisfaction Reports with residents and their families. They [residents] have care plan options for family and all that. The Care Center is our nursing home, which is a part of our hospital. It is a licensed facility with 65 beds. - They [Care Center] have an AD [Alzheimer s Disease] wing, and I ve heard lots of great things. - We [Care Center] just got a $4,000 new tub! It accommodates seniors better. - I have heard nothing but positive things. The care my mother received was phenomenal. Everyone was great for her. As far as people I know with family members at the Heritage Center [assisted living facility], all was positive. Pharmacy - I think they [pharmacists] do amazing things. She [pharmacist] delivers [medications] to people who are home bound. Shopko will do some deliveries too. I think she [pharmacist] picks and chooses who she wants to deliver to. She [pharmacist] stopped delivering to me, so I pulled my account and went to Shopko. 75

78 - It s been great. Anna [pharmacist] is unbelievable to work with, really good and easy to work with. - The pharmacist is very involved in this provider transition. 6. Why might people leave the community for healthcare? - Because of the high emotion revolving around this doctor [at Marias Medical Center]. If we [community members] had an effective [hospital] board then that would have been taken care of. If we could just send him [doctor] on his way it would solve a lot of problems. - We go out of town for pediatric care because we don t expect to have that service here [Marias Medical Center]. - Some people have followed providers who now practice in Great Falls, and some providers went to [work in] Conrad. - Because of all the misinformation and what they [community members] perceived has gone on with the [hospital] board, employees, and doctors. People see all of that and just want to go elsewhere. I found the provider to be very knowledgeable, but his personal relationships have spilled over. Community members do not like that. 7. What other healthcare services are needed in the community? - It is important to bring young families back to Shelby. My daughter-in-law is very interested in this facility [Marias Medical Center] and she doesn t want to have babies with providers in Great Falls. We want to make these little towns grow! That is what happens in rural towns. This hospital needs to correlate with the rest of the growing buildings in Shelby. I want OB [Obstetrics] resources, and the Auxiliary is very supportive of that. None of our [Marias Medical Center] staff have their babies here [Marias Medical Center]. I think that is really sad. People say not to have their babies here [at Marias Medical Center]. Do they not trust them [Marias Medical Center staff] enough to have their babies? There were a couple incidents, one resulting in the loss of a child. Because of confidentiality issues, we [community members] do not know what is true. - One of the problems facing all of rural Montana is the lack of volunteerism needed to keep EMS [Emergency Medical Services] alive. After over two decades of service, I was forced to retire due to inflexible rules established by Toole County EMS that mandated that I could only miss two meetings per year; meetings that always occurred on the first Thursday of every month. This worked out for me most of the time, but due to other obligations, I ended up in a situation this past year where I missed more than two meetings. Everywhere else I ve served as an EMT [Emergency Medical Technician] have understood that I had a very busy schedule and were willing to work with me to take what time I could give, but the inflexibility of the EMS administration in Toole County resulted in me having to give it up after 22 years. As it is now, we have no EMT serving in Sunburst and the only two left in the northern part of the County have to drive quite a distance, and this certainly affects patient care. 76

79 Focus Group #3 Wednesday, June 25, 204 2:5pm-pm Senior Center Shelby, MT 25 participants (2 male, 3 female). What would make this community a healthier place to live? - I ve felt pretty healthy all of my life, until all these politics and [hospital] boards came into play. - The feedlot smells. - Maybe they [Shelby community workers] should fumigate the sewage system. - If everyone could live in harmony, the whole community would benefit. - Yeah, take the politics out! 2. What do you think are the most important local healthcare issues? - Nutrition - Good people to get back to the Senior Center. - It s hard to get people to volunteer. - We keep losing our doctors. - It is very difficult getting people to volunteer anywhere, including the hospital and the Senior Center. 3. What do you think of the hospital in terms of: Quality of Care - Very good - Good Number of Services - Exceptional. They [Marias Medical Center] have specialists who come in once a month. Hospital Staff - The crew is only as good as the leader. - [Hospital staff] are nice and provide good care. - There are administrative problems. - Nurses do not get paid enough. - The comments from [hospital] board meetings that are broadcasted over the public radio are skewed and the information is not correct. Hospital Board and Leadership - I think they [Marias Medical Center s hospital board] have a big job to do, and I think sometimes they are not awarded for what services they put in. - They [hospital board] have a tough job. - We tried to ask all these questions to our board members, and they wouldn t answer because they said it was none of our business. Yet our tax dollars are paying for it and no one answers our questions. We cannot get an answer out of them [board members]! I feel that there is a big issue with our community and their leadership. 77

80 - There needs to be better communication between the [hospital] board and the community. - The community has no input. - They [hospital board] need to improve communication with the community. Business Office - Billing [department] is bad and late. - When I get a bill from six months later from Medicare, I approach Medicare, not the billing office. - There is a lot of miscommunication between Medicare and the hospital. - The billing department is not great. Condition of Facility and Equipment - The upkeep [of the facility] is okay. Financial Health of the Hospital - I do not know [about the financial health of the hospital]. - They [Marias Medical Center] want 400-some thousand dollars. - I heard that they [Marias Medical Center] were in the hole last year. - Hill Burton funds [Federal program that provides free and reduced cost healthcare] and Medicaid helped pay my bills. - If they [Marias Medical Center] keep losing patients, they will go broke. - They [Marias Medical Center] have lost a lot of patients over the last year. Cost - [Costs are] pretty high. - Higher than Great Falls. - Higher than most places. Office/Clinic Staff - Good - They [office and clinic staff] do fine. Availability - It [availability of services and appointments] is okay. 4. Are any of the local providers your personal provider or personal provider to your family members? Why? - Yes. My family uses Shelby [Marias Medical Center]. - My family left because my doctor moved! - We left because of all the turmoil [at Marias Medical Center]. - Doctors [at Marias Medical Center] seem to be leaving so people [patients] leave too. It s hard to see a doctor, and then they [doctors] leave. The turnover rate makes it difficult. - It s hard to travel out of town. Most people try to stay because of that. 78

81 5. What do you think about these local services: Emergency Room - Never used it [ER]! - It [ER] has been okay. - It [ER] was good when I broke my hip. 79 Ambulance Service - Good ambulance personnel. - Very rough ambulance ride. - That isn t their [ambulance service] fault it s the rough roads! Healthcare Services for Senior Citizens - I m basically well, so things [services for seniors] are fine. - Okay. Public/County Health Department - Good! - The hospital would be healthier if they sold local food. - Don t know much [about the health department]. - Never used them [the health department]. Healthcare Services for Low-Income Individuals/Families - Veteran services could be improved nationally. - Obama is going to fix that [Veteran health services]! - Medicaid takes care of patients. - These types of people [low-income individuals/families] are living better than me! Obama takes too good of care of them! - I haven t heard anything. Nursing Home/Assisted Living Facility - The Heritage Center [assisted living facility] is nice. - I have heard complaints but that s it. - They [Care Center staff] take care of people the best they can. - They [Care Center staff] seem to get residents out and take them on trips. They treat them [residents] well. - They do not have enough nurses for the nursing home. Pharmacy - They [pharmacies] are adequate. - So good. 6. Why might people leave the community for healthcare? - When you have something seriously wrong, you have to go elsewhere. My wife has RA [rheumatoid arthritis] and we have to leave for infusion treatments. - I wish the doctors [at Maris Medical Center] would stick around a bit longer. - Doctors leaving [Marias Medical Center] makes us [local patients] leave.

82 - Doctors [at Marias Medical Center] are moving all the time. - Leadership is bad here [at Marias Medical Center]. - It [leadership] is not going to change, therefore I leave. - Yeah, there is too much bullying. - Leadership [at Marais Medical Center] must change! - But the city and county work well together. - No they don t. - It is split. - But we have a record of all the projects they ve worked together on. - Each side must treat each other with respect. 7. What other healthcare services are needed in the community? - I wish we could have them all, but that s not realistic. 80

83 Appendix H Secondary Data County Profile 8

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85 83

86 Economic Impact Assessment Demographic Trends and Economic Impacts: A Report for Marias Medical Center William Connell Brad Eldredge Ph.D. Research and Analysis Bureau Montana Department of Labor and Industry Introduction This report responds to requests by MHA for the location quotient of the hospital sector in Toole County and for information on the county s demographics. In addition, the report includes analysis of the economic impact of the hospital sector on Toole County s economy. Section I gives location quotients for the hospital sector in Toole County using both state and national employment as the basis of comparison. Section II looks at the demographic profile of Toole County. Section III presents the results of an input-output analysis of the impact of Marias Medical Center on the county s economy. Section I Location Quotients A location quotient measures how the level of employment concentration in a geographic area compares with that of another geographic area. For example, if 20 percent of workers in county A worked in manufacturing and 0 percent of the workers in that county s state worked in manufacturing, then the location quotient for county A would be: County A Percent employed in manufacturing = 20% = 2. State Percent employed in manufacturing 0% Intuitively, county A s location quotient of 2 indicates that its employment in manufacturing is about double what one would expect given the size of manufacturing employment in the state. Two location quotients for hospital employment in Toole County were calculated. The first compares Toole County s hospital employment concentration to that of the State of Montana, and the second compares it to hospital employment in the United States. The calculations use 200 annual averages. Hospitals Location Quotient (compared to State of MT) =.74 Hospitals Location Quotient (compared to U.S.) = 2.0 A location quotient near indicates that the employment concentration in the county mirrors that of the larger geographic region. In the case of Toole County, the location quotient of.74 indicates that hospital employment in the county about 75 percent higher than one would expect given statewide employment patterns. When compared to the nation, the location quotient is an even higher 2.0. Toole County probably has such high location quotients because staffing a full-service hospital requires a base number of employees regardless of the overall population of the county. 84

87 Many rural hospitals have high location quotients because, unlike their urban counterparts, they cannot take advantage of economies of scale. Another way to look at the location quotient is to ask how many employees would be employed in the hospital sector if Toole County s employment patterns mirrored the state or the nation. Marias Medical Center averaged 9 employees in 200. This is 8 more than expected given the state s employment pattern and 96 more than expected given the national employment pattern. In 200, Marias Medical Center accounted for 9.3% of county nonfarm employment and 8.7% of the county s total wages. (Source of Employment Data: Quarterly Census of Employment and Wages, Research and Analysis Bureau, Montana Department of Labor and Industry) Section II Age Demographics The 200 Census reported that there were 5,324 residents of Toole County. The breakdown of these residents by age is presented in Figure. Toole County s age profile is similar to that of many of Montana s rural counties. In 200, baby boomers were between the ages of 44 and 60 and their presence is evident in the graph. Following the baby boom came the baby bust, which is evidenced by the lack of 25 to 44 year olds in the county. In many rural Montana counties, the baby bust is exacerbated by out-migration of young adults. Figure : Age Distribution of Toole County Residents 85

88 Figure 2: Percent of the population by age groups, Toole County vs. Montana Figure 2 shows how Toole County s population distribution compares to Montana s. A careful examination of Figure 2 and the underlying data reveals that, compared with the State as a whole, Toole County has a much higher percentage of people aged 30 to 59 (45.0 percent vs percent) and a lower percentage of children under 0 (0.2 percent vs. 2.4 percent). Overall, the county and state age profiles are very similar. According to the 200 Census, Toole County had a median age of 4.5, which was slightly higher than the state median age of These demographics are important when planning for healthcare delivery now, and in the future. Section III Economic Impacts Businesses have an economic impact on their local communities that exceeds the direct amount of people they employ or wages they pay. For example, individuals employed at Marias Medical Center spend a portion of their salary on goods and services produced in Toole County, thus supporting jobs and income in those local businesses. Likewise, the hospital itself may purchase goods and services from local suppliers. These businesses and employees then spend a portion of their income on local goods and services which, in turn, supports other local jobs and companies. Thus, the effect of one dollar of wages is multiplied as it circulates through the community. The amount of jobs and income in a local community attributable to a particular industry sector can be determined by calculating its employment and income multipliers. Industries with the highest multipliers generally are those who buy supplies, services, and labor from the local community, sell products and services outside the local community, and pay a high income to their employees. Although hospitals in rural areas do not usually sell their services to non-residents, they can still generate significant multiplier effects for their communities given that much of their funding comes from outside the region in the form of public and private insurance reimbursements. The relatively high wages earned by hospital employees also tend to boost hospital s multipliers. 86