COMMUNITY HEALTH NEEDS ASSESSMENT ST. VINCENT MADISON COUNTY SERVICE AREA COMMUNITY HEALTH NEEDS ASSESSMENT REPORT 2016

Transcription

1 2016 COMMUNITY HEALTH NEEDS ASSESSMENT ST. VINCENT MADISON COUNTY SERVICE AREA COMMUNITY HEALTH NEEDS ASSESSMENT REPORT 2016

2 COMMUNITY HEALTH NEEDS ASSESSMENT - 2 CONTENTS EXECUTIVE SUMMARY... 5 DEMOGRAPHICS...5 IDENTIFYING COMMUNITY HEALTH NEEDS METHODOLOGY...5 Secondary Data... 5 Primary Data Community Input... 5 SIGNIFICANT COMMUNITY HEALTH NEEDS...5 PRIORITIZATION PROCESS & PRIORITY NEEDS...6 CONCLUSION...6 NOTE TO THE READER...6 INTRODUCTION... 7 ABOUT ST. VINCENT HEALTH...7 ABOUT ST. VINCENT ANDERSON REGIONAL & MERCY HOSPITALS...7 St. Vincent Anderson Regional... 7 St. Vincent Mercy... 7 ABOUT HEALTHY COMMUNITIES INSTITUTE...7 SERVICE AREA... 7 DEMOGRAPHICS... 8 POPULATION...8 Age... 8 Race/ethnicity... 8 ECONOMY...9 Income... 9 Poverty... 9 Unemployment EDUCATION TRANSPORTATION PRECEDING CHNA EFFORTS & PROGRESS PRIORITY HEALTH TOPICS IN PRECEDING CHNA COMMUNITY FEEDBACK ON PRECEDING CHNA & IMPLEMENTATION PLAN IDENTIFYING SIGNIFICANT COMMUNITY HEALTH NEEDS: METHODOLOGY SECONDARY DATA Overview Analyzing Disparities Identifying Geographic Areas of Highest Need PRIMARY DATA: COMMUNITY INPUT SIGNIFICANT COMMUNITY HEALTH NEEDS ASSESSMENT FINDINGS... 18

3 COMMUNITY HEALTH NEEDS ASSESSMENT - 3 GEOGRAPHICAL AREAS OF HIGHEST NEED QUALITY OF LIFE FINDINGS HEALTH NEEDS FINDINGS SIGNIFICANT HEALTH NEEDS PRIORITIZATION OF TOP HEALTH NEEDS PRIORITIZATION SESSION PARTICIPANTS PRIORITIZATION PROCESS HEALTH PRIORITIES FOR MADISON COUNTY ACCESS TO HEALTH SERVICES BEHAVIORAL HEALTH RESPIRATORY DISEASES DIABETES EXERCISE, NUTRITION, & WEIGHT OTHER SIGNIFICANT COMMUNITY HEALTH NEEDS CONCLUSION APPENDIX A: EVALUATION OF PRECEDING CHNA PRIORITIES APPENDIX B: SECONDARY DATA ANALYSIS SCORING METHOD Comparison to a Distribution of County Values: Within State and Nation Comparison to Values: State, National, and Targets Trend Over Time Missing Values Indicator Scoring Topic Scoring DISPARITIES SCORING RESULTS Data sources APPENDIX C: COMMUNITY INPUT KEY INFORMANT INTERVIEW QUESTIONS APPENDIX D: PRIORITIZATION TOOLS APPENDIX E: AUTHORS APPENDIX F: COMMUNITY INPUT REPORT FOR MADISON COUNTY METHODS RESULTS INTERPRETATION Health Needs Behavioral Health Access to Healthcare Services... 82

4 COMMUNITY HEALTH NEEDS ASSESSMENT - 4 Exercise, Nutrition, & Weight Strengths and Limitations of the Analysis CONCLUSION REFERENCES SUPPLEMENT - SURVEY: TAKE THE SURVEY YOUR INPUT COUNTS! ZIP CODES: MADISON COUNTY [2] APPENDIX G: MADISON COUNTY RESOURCE LIST For comments or questions about this report, please contact St. Vincent Community Development & Health Improvement: CommunityDevelopment@stvincent.org PRODUCED BY HEALTHY COMMUNITIES INSTITUT E, OCTOBER

5 COMMUNITY HEALTH NEEDS ASSESSMENT - 5 Executive Summary As part of the 2016 St. Vincent Community Benefit effort, St. Vincent Anderson Regional and Mercy hospitals are pleased to present the 2016 Community Health Needs Assessment (CHNA) for the Madison County Service Area. As federally required by the Affordable Care Act, this report provides an overview of the methods and process used to identify and prioritize significant health needs in Madison County, Indiana. St. Vincent contracted Healthy Communities Institute (HCI) to help facilitate their system-wide CHNA work and document all efforts into the 2016 reports for each hospital. DEMOGRAPHICS According to the 2015 County Health Rankings, Madison County ranks 79 th out of 92 Indiana counties in overall health outcomes. Roughly 4% of the population in Madison County are Hispanic/Latino, 8% Black/African American, and 88% White/Caucasian. The median household income is lower compared to the state of Indiana at about $44,500 annually; unemployment rates are higher in Madison County; and roughly 11% of Madison County families are living in poverty, which is roughly on par with the state. HCI s SocioNeeds Index identified the zip code of as having the greatest socioeconomic need. IDENTIFYING COMMUNITY HEALTH NEEDS METHODOLOGY SECONDARY DATA The secondary data used in this assessment were obtained and analyzed from the St. Vincent Health Community Dashboard ( which includes a comprehensive dashboard of over 100 community health and quality of life indicators covering over 20 topic areas. Indicator values for Madison County were compared to other counties in Indiana and nationwide to score health topics and compare relative areas of need. Other considerations for health areas of need included trends over time, Healthy People 2020 targets, and disparities by gender and race/ethnicity. PRIMARY DATA COMMUNITY INPUT The needs assessment was further informed by interviews with community members who have a fundamental understanding of Madison County s health needs and represent the broad interests of the community. Six key informants provided valuable input on the county s health challenges, the sub-populations most in need, and existing resources for county residents. SIGNIFICANT COMMUNITY HEALTH NEEDS Primary and secondary data were evaluated and synthesized to identify the significant community health needs in Madison County. These needs span the following topic areas and are often inter-related: Access to Health Services Exercise, Nutrition, & Weight Mental Health & Mental Disorders Respiratory Diseases Substance Abuse Economy Kidney & Urinary Tract Diseases Prevention & Safety Social Environment Wellness & Lifestyle

6 COMMUNITY HEALTH NEEDS ASSESSMENT - 6 PRIORITIZATION PROCESS & PRIORITY NEEDS St. Vincent Anderson Regional and Mercy hospitals called together hospital decision makers, Madison Health Partners, and community leaders to prioritize the significant community health needs of Madison County considering several criteria: alignment with Ascension Health strategies of healthcare that leaves no one behind and cares for the poor and vulnerable; opportunities for partnership; availability of existing programs and resources; opportunities for partnership; addressing disparities of subgroups; availability of evidence based practices; and community input. The following five health and/or quality of life topics were selected as the top priorities: Access to Health Services Behavioral Health Diabetes Exercise, Nutrition, & Weight Respiratory Diseases CONCLUSION This report describes the process and findings of a comprehensive health needs assessment for the residents of Madison County, Indiana. The prioritization of the identified significant health needs will guide the community health improvement efforts of St. Vincent Anderson Regional and Mercy hospitals. From this process, St. Vincent Anderson Regional and Mercy hospitals will outline how they will address the top five prioritized health needs in their Implementation Strategies. NOTE TO THE READER Your feedback is welcomed and encouraged. Please send any feedback and/or comments about this report to: CommunityDevelopment@stvincent.org.

7 COMMUNITY HEALTH NEEDS ASSESSMENT - 7 Introduction ABOUT ST. VINCENT HEALTH St. Vincent Health has been serving their Indiana communities for over 130 years. As a member of Ascension Health, the largest Catholic healthcare system in the country, the St. Vincent mission is to care for the body, mind and spirit of those in need, regardless of personal means or religious affiliation. St. Vincent is dedicated to providing spiritually centered, holistic care, that sustains and furthers both individual and community health - with 22 health ministries serving 47 counties in Central and Southern Indiana. ABOUT ST. VINCENT ANDERSON REGIONAL & MERCY HOSPITALS ST. VINCENT ANDERSON REGIONAL St. Vincent Anderson Regional Hospital is located in Anderson, Indiana, and serves Madison County and contiguous counties in Central Indiana. Anderson Regional is an acute-care facility with a comprehensive, integrated health system that includes many noted centers of excellence, and is dedicated to the Spirit of Caring, guided by Core Values that reflect a commitment to quality, compassion and affordability in healthcare. ST. VINCENT MERCY St. Vincent Mercy is located in Elwood, a rural community in the northwest section of Madison County in Central Indiana. For over 80 years, St. Vincent Mercy has been serving the healthcare needs of residents of Elwood and surrounding communities. Mercy offers expert care, never losing sight of their tradition of providing quality, compassionate care close to home. ABOUT HEALTHY COMMUNITIES INSTITUTE Healthy Communities Institute, now part of Midas+, a Xerox Company, was retained by St. Vincent Health to conduct the 2016 Community Health Needs Assessment (CHNA) for 11 of their service areas, and to author the subsequent CHNA reports for each service area. Based in Berkeley, California, HCI provides customizable, web-based information systems that offer a full range of tools and content to improve community health, and developed St. Vincent Community Health Needs Assessment Platform. The organization is composed of public health professionals and health IT experts committed to meeting clients health improvement goals. To learn more about Healthy Communities Institute please visit Service Area St. Vincent Anderson Regional and Mercy serve Madison and contiguous counties in Central Indiana. Madison County has an estimated population of 130,207 and, according to the 2015 County Health Rankings, ranks 79th out of 92 Indiana counties for overall health. The most common industries in Madison County are healthcare, manufacturing and retail.

8 COMMUNITY HEALTH NEEDS ASSESSMENT - 8 Demographics The demographics of a community significantly affect its health profile. Different race/ethnic, age and socioeconomic groups may have unique needs and require varied approaches to health improvement efforts. All estimates are sourced from the 2015 Nielsen Claritas data unless otherwise indicated. POPULATION Madison County has a population of 130,207. Figure 1 shows the population count by zip code, with St. Vincent Mercy Hospital being located in the northwestern city of Elwood. Anderson Regional is located in central city of Anderson and is in a more densely populated area of Madison County. Figure 1. AGE The age distribution of Madison County is quite similar to the rest of Indiana with the exception of some minor differences. Proportionally, there are slightly fewer children aged 0-17 years old, fewer young adults aged years old, and there are slightly more adults who are 65 and older when compared to Indiana state. Figure 2. RACE/ETHNICITY Madison County s population is similar by race and ethnicity to that of the statewide population, with roughly 87 percent of the population being white and 8 percent black/african American. The remaining population primarily consists of those of two or more races or other races. And 3.8 percent of the population is Hispanic/Latino.

9 COMMUNITY HEALTH NEEDS ASSESSMENT - 9 ECONOMY INCOME The median household income of Madison County is $44,551, which is approximately $5,000 less than the median for Indiana as a whole. At a more granular level, there are variations in income levels among Madison County zip codes. In Figure 3, zip code is shown as having the lowest median household income ($26,917) when compared to other zip codes, the county value, and the state value. Figure 3. Figure 4. POVERTY As shown in Figure 4, the family poverty rates in Madison County are similar to the rest of the state. But there appear to be slightly more families with children living below the poverty line in the county by a difference of about.2 percent.

10 COMMUNITY HEALTH NEEDS ASSESSMENT - 10 UNEMPLOYMENT The unemployment rate in Madison County ranges from 5.3% to 23% among the county s zip codes, with an overall county value of 12.3%. The map in Figure 5 shows zip code as having the highest unemployment rates in the county. At a rate of 13.3%, Madison County males have a higher unemployment rate both in the county and the state overall. Females in Madison County, while having a better unemployment rate than males in the county, are also faring worse than the state values (see Figure 6). Figure 5. Figure 6.

11 COMMUNITY HEALTH NEEDS ASSESSMENT - 11 EDUCATION High School Degree attainment in the adult population among Madison County residents is similar to the state at 77.6 percent, but Bachelor s Degree attainment in the county is about 8 percent lower than the state overall. Figure 7. Figures 7 and 8 show maps of High School Degree or Higher and Bachelor s Degree or higher by zip code for those 25 years and older in Madison County. Zip code and has the lowest High School Degree attainment within the county. Zip codes 46036, and are the areas of Madison County with the lowest Bachelor s Degree attainment. It is worth noting that zip code is also the zip code that has the highest unemployment rates, has the highest amount of households without a vehicle (Figure 9 below) and shows the greatest socioeconomic need according to HCI s SocioNeeds Index. Figure 8. TRANSPORTATION

12 COMMUNITY HEALTH NEEDS ASSESSMENT - 12 Zip code has the highest percentages of households without a vehicle when compared to other Madison County zip codes, with up to 20% of households not having a vehicle. Residents of zip code without a household car may be more likely to experience difficulties in accessing essential health services, grocery stores, schools, and work sites. Limited accessibility to these essentials have been proven to show poor health outcomes. Figure 9.

13 COMMUNITY HEALTH NEEDS ASSESSMENT - 13 Preceding CHNA Efforts & Progress The CHNA process should be viewed as a three-year cycle (Figure 10). An important piece of that cycle is revisiting the progress made on priority health topics set forth in the preceding CHNA. By reviewing the actions taken to address a priority health issue and evaluating the impact those actions have made in the community, it is possible to better target your resources and efforts during your next round of the CHNA cycle. PRIORITY HEALTH TOPICS IN PRECEDING CHNA Figure Year CHNA Cycle 3-Year Cycle St. Vincent Anderson Regional and Mercy s priority health topics for FY were: Obesity Tobacco Cessation/Substance Abuse Mental Health Access to Primary Care Each of the above health topics correlates well to the priority health topics selected for the current CHNA (detailed below), thus St. Vincent Anderson Regional and Mercy will be building upon efforts of previous years. A detailed table describing the strategies/action steps and indicators of success for each of the preceding priority health topics can be found in Appendix A. COMMUNITY FEEDBACK ON PRECEDING CHNA & IMPLEMENTATION PLAN St. Vincent Anderson Regional and Mercy s preceding CHNA was made available to the public via the website: stvincent.org. To collect comments or feedback on the report, a special address was created: CommunityDevelopment@stvincent.org. No comments had been received on the preceding CHNA at the time this report was being written.

14 COMMUNITY HEALTH NEEDS ASSESSMENT - 14 Identifying Significant Community Health Needs: Methodology Significant community health needs for Madison County were determined using a combination of secondary and primary data (community input). SECONDARY DATA OVERVIEW Secondary data used for this assessment were collected and analyzed with the St. Vincent Community Dashboard ( a web-based community health data platform developed by Healthy Communities Institute and sponsored by St. Vincent. The community dashboard brings non-biased data, local resources and a wealth of information to one accessible, user-friendly location. It includes a comprehensive dashboard of over 100 community indicators covering over 20 topics in the areas of health, determinants of health, and quality of life. The data is primarily derived from state and national public secondary data sources. The value for each of these indicators is compared to other communities, nationally or locally set targets, and to previous time periods. HCI s Data Scoring Tool was used to systematically summarize multiple comparisons across the Community Dashboard to rank indicators based on highest need. For each indicator, the community value was compared to a distribution of Indiana and US counties, state and national values, Healthy People 2020 and significant trends were noted. These comparison scores range from 0-3, where 0 indicates the best outcome and 3 the worst. Availability of each type of comparison varies by indicator and is dependent upon the data source, comparability with data collected for other communities, and changes in methodology over time. These indicators were grouped into topic areas for a higher level ranking of community health needs. More detailed methodology used by the Data Scoring Tool is described in Appendix B: Secondary Data Analysis. Figure 11. HCI Data Scoring Score range: Good Bad Table 1. Quality of Life and Health Topics Indicators were categorized into 23 topic areas, which were further classified as a quality of life or health topic.

15 COMMUNITY HEALTH NEEDS ASSESSMENT - 15 Quality of Life Economy Education Environment Public Safety Social Environment Transportation Access to Health Services Cancer Children s Health Diabetes Exercise, Nutrition, & Weight Heart Disease & Stroke Immunization & Infectious Diseases Kidney & Urinary Tract Diseases Maternal, Fetal & Infant Health Health Men s Health Mental Health & Mental Disorders Older Adults & Aging Prevention & Safety Respiratory Diseases Substance Abuse Women s Health Wellness & Lifestyle Please note that the most recent period of measure was used for all secondary data presented in this report (as publicly available on January 20, 2015). ANALYZING DISPARITIES Outside of topic area scoring, a separate analysis was conducted to determine if disparities exist among subpopulations within Madison County. If gender- or race/ethnicity-specific values were available, then the indicator was evaluated for the presence of substantial disparities. For details on the methods used to analyze disparities, please see Appendix B: Secondary Data Analysis. IDENTIFYING GEOGRAPHIC AREAS OF HIGHEST NEED The SocioNeeds Index developed by Healthy Communities Institute and available on the St. Vincent health data platform is a tool used to help determine which communities of Madison County are in most need of services and interventions. The Index summarizes multiple socioeconomic indicators, ranging from poverty to education, which may affect health or access to care. All zip codes in the United States are given an Index value from 0 (low need) to 100 (high need). Within Madison County, zip codes are ranked based on their Index value. These ranks are used to identify the relative level of need within the county. Figure 12. The SocioNeeds Index PRIMARY DATA: COMMUNITY INPUT To expand upon the information gathered from the secondary data, Healthy Communities Institute (HCI) conducted key informant interviews to collect community input. Interviewees who were asked to participate were recognized as having expertise in public health, special knowledge of community health needs and/or represented the broad interest of the community served by the hospital, and/or could speak to the needs of

16 COMMUNITY HEALTH NEEDS ASSESSMENT - 16 medically underserved or vulnerable populations. Eleven individuals were contacted for the service area, and six agreed to participate and scheduled an interview. The following organizations were contacted to provide community input through key informant interviews with HCI. Those in bold were able to provide an interview: Anderson Center Anderson Community School Corporation Madison County Health Department Madison County Minority Health Madison Health Partners Open Door Clinic St. Vincent Anderson Regional St. Vincent Medical Group Northeast Region United Automobile Workers United Way of Madison County Interviews were conducted during the months of February to April 2015 by telephone and ranged from minutes in length. During the interview, questions were asked to learn about the interviewee s background and organization, biggest health needs and barriers of concern in the community, as well as the impact of health issues on vulnerable populations. A list of the questions asked during the interviews can be found in Appendix C. Each interview included both an interviewer and a note taker from HCI, so much of the conversation was captured verbatim. Notes taken during the interviews were uploaded to a summary qualitative data analysis tool, TagCrowd.com, to create a word cloud. Word clouds help to identify the words or phrases mentioned most often in the interviews, and appear in the largest and darkest font in Figure 13 below. Figure 13. Primary Data Word Cloud The word cloud was used to get an initial sense of the major issues in the community. The interview notes were also uploaded to the web application Dedoose, a qualitative data analysis software. Using the major issues from the word cloud, themes from the interview questions (such as needs, barriers and advice), and secondary data health and quality of life topics, a code list was created. Interview notes were coded using this list, which allows for comparison and inclusion of the primary data with the secondary data throughout the report. Input from key

17 COMMUNITY HEALTH NEEDS ASSESSMENT - 17 informants is included in each relevant topic area. The code cloud below, Figure 14, was created from the key informant interview transcripts, where the size and darkness of the words reflect the relative number of times the word appeared. The figure provides an overall picture of the themes that were most prominent in the community input. Figure 14. Code Cloud

18 COMMUNITY HEALTH NEEDS ASSESSMENT - 18 Significant Community Health Needs Assessment Findings The secondary data summary and key informant interview findings are presented together to capture a more holistic assessment of health needs in Madison County. Quality of life topics are presented first, as they are key to understanding the barriers to health in the community. Furthermore, the availability of socioeconomic data for specific sub-populations and sub-county geographies provides a framework for identifying the populations most vulnerable to the poor health outcomes identified. GEOGRAPHICAL AREAS OF HIGHEST NEED Social and economic factors are well known to be strong determinants of health outcomes. The HCI SocioNeeds Index summarizes multiple socioeconomic indicators, ranging from poverty to education, which may affect health or access to care. All zip codes in the United States are given an Index value from 0 (low need) to 100 (high need). Within Madison County, zip codes are ranked based on their Index value (see Table 2). These ranks are used to identify the relative level of need within the county. Table 2. HCI s SocioNeeds Index Ranking for Madison County Figure 15. HCI s SocioNeeds Index for Madison County Zip Code Index Rank Geographically, there are parts of Madison County for which quality of life issues are of greater concern (Figure 15). The Index shows that zip code is the community with the highest socioeconomic need within Madison County and is more likely to be affected by poor health outcomes. As cited in the demographics section of this report, zip code also suffers from the highest unemployment rates, lowest educational attainment, and most number of households without access to a vehicle.

19 COMMUNITY HEALTH NEEDS ASSESSMENT - 19 QUALITY OF LIFE FINDINGS Socioeconomic indicators across the quality of life topic areas point to multiple barriers to health, and the effect of these drivers was noted in both the secondary data and key informant interviews (Table 3). Social Environment scored most poorly due to high rates of single-parent households, people 65+ living alone, and children below poverty level. Additionally key informants cited economy as an important issue to consider. Of specific importance was the need for new job creation in light of the loss of many major manufacturing jobs and a large working poor population. Table 3. Quality of Life Topics Topic Score Community Input Social Environment 2.19 Economy 2.15 Transportation 1.95 Education 1.67 Environment 1.58 Public Safety 1.44 Key Informant Total: HEALTH NEEDS FINDINGS The outcomes of the primary and secondary data analysis were combined to identify the significant community needs in Madison County. The analysis revealed that there were significant needs across the majority of the topic areas considered. Table 4 briefly summarizes the findings by topic area, where topics are sorted by secondary data summary score range, areas are identified with a high disparity score by category, and the number of times the area was identified as a top need by a key informant. Some topic areas which did not score high or did not have a score in the secondary data summary were identified as a top need by key informants, underlining the importance of considering both quantitative data and community input when assessing health issues. Table 4. Health Topics Disparities Topic Score Community Input Mental Health & Mental Disorders 2.55 Prevention & Safety 2.30

20 COMMUNITY HEALTH NEEDS ASSESSMENT - 20 Disparities Topic Score Community Input G Kidney & Urinary Tract Diseases 2.09 R G Respiratory Diseases 2.05 Wellness & Lifestyle 2.04 G Substance Abuse 1.93 R Older Adults & Aging 1.92 R Children s Health 1.87 R Maternal, Fetal, & Infant Health 1.81 R Diabetes 1.80 Exercise, Nutrition & Weight 1.72 G Immunizations & Infectious Diseases 1.63 Men s Health 1.62 G Heart Disease & Stroke 1.55 Access to Health Services 1.54 G Cancer 1.47 Women s Health 1.18 R indicates Disparity by Race G indicates Disparity by Gender Key Informant Total:

21 COMMUNITY HEALTH NEEDS ASSESSMENT - 21 The graph in Figure 16 below provides an overall synthesis of the primary and secondary data for all quality of life and health topics available for Madison County analysis. The X-axis demonstrates the evidence of need based on secondary data scores, and the Y-axis displays evidence of need based on the percentage of key informants indicating the topic as a health concern. The size of the circles provides another level of evidence larger circles indicate more indicators were available for that secondary data topic. Figure 16. Secondary and Primary Data Synthesis High Community Input & Low Secondary Data Scoring High Community Input & High Secondary Data Scoring Low Community Input & Low Secondary Data Scoring Low Community Input & High Secondary Data Scoring

22 COMMUNITY HEALTH NEEDS ASSESSMENT - 22 Taking the information displayed on the graph above, the Venn Diagram below shows the health topic areas demonstrating strong evidence of need in the primary data, secondary data or both. It is important to consider all three areas when determining a community s pressing health needs. Figure 17. Venn Diagram of Topic Areas and Data Support Strong Evidence of Need in Primary Data Strong Evidence of Need in Secondary Data Access to Health Services Exercise, Nutrition, & Weight Mental Health & Mental Disorders Prevention & Safety Social Environment Kidney & Urinary Tract Diseases Economy Substance Abuse Respiratory Diseases Wellness & Lifestyle Older Adults & Aging Children s Health Maternal, Fetal, & Infant Health Diabetes Weak Evidence of Need in Primary and Secondary Data: Immunizations & Infectious Diseases, Environment, Education, Heart Disease & Stroke, Men s Health, Cancer, Public Safety, Women s Health

23 COMMUNITY HEALTH NEEDS ASSESSMENT - 23 SIGNIFICANT HEALTH NEEDS The list of health needs in Table 5 below highlights the most significant health needs based on the analysis and synthesis of the primary and secondary data. This list represents 10 of the most pressing health and quality of life topics to be considered for the prioritization process. Table 5. Significant Health and Quality of Life Needs for Prioritization Secondary Data Primary Data Topic Score Health Topic Disparities in Data Community Input (Total N=6) Key Themes from Community Top 5 Health Needs/Concerns from Secondary Data 2.55 Mental Health & Mental Disorders Great need for mental health services in community; hard to keep up with volume of mental health referrals 2.30 Prevention & Safety N/a, not mentioned as a top health need/concern during community input process 2.09 Kidney & Urinary Tract Diseases 2.05 Respiratory Diseases 2.04 Wellness & Lifestyle Females ER & hospitalization due to urinary tract infections Females & African American children hospitalization rates due to asthma N/a, not mentioned as a top health need/concern during community input process Asthma is a big health concern, stemming from high rates of smoking Issues with lifestyle choice problems; lack of interest among residents in managing their own health Top Quality of Life 2.05 Social Environment High rates of child abuse and neglect in the community; poverty and working poor households affecting younger population Top 4 Needs/Concerns from Community Input

24 COMMUNITY HEALTH NEEDS ASSESSMENT Economy High number of unemployed and working poor after loss of GM factory jobs; capacity and funding barriers as a result of economic issues 1.93 Substance Abuse 1.72 Exercise, Nutrition, & Weight Men ER and Hospitalization Rates due to Alcohol Abuse Issues of substance and e-cigarette abuse especially among youth; high rates of prescription drug use and smoking among pregnant women Childhood and adult obesity; lack of nutrition and personal accountability with diet; food insecurity 1.54 Access to Health Services Many residents are uninsured, can t afford healthcare, or don't know what services are available; trust and language barriers among Hispanic population and others in community

25 COMMUNITY HEALTH NEEDS ASSESSMENT - 25 Prioritization of Top Health Needs To better target community resources on Madison County s most pressing health needs, St. Vincent Anderson Regional and Mercy hospitals participated in a group discussion facilitated by HCI to hone in on up to five health needs. Those health needs will be under consideration for the development of an implementation plan that will address some of the community s most pressing health issues. PRIORITIZATION SESSION PARTICIPANTS o o o o o o o o o o o o o o o o o o o o o o o o Ann Yates, St. Vincent Mercy, CNO and Director of Patient Care Teresa Saxton, St. Vincent Mercy, IP Organization Development Suzie Maier, ASPIRE, Director Madison City Karesa Knight, Intersect, Executive Director Marianne Spangler, Community Hospital Anderson, Director Roland Luciani, Hoosier Park, Director of Insurance & Benefits Rebecca Cook, St. Vincent Anderson, Director of Learning & Development Natalie Carter, MCCHC, Director of Internal Operations Sister Eileen Wrobleski, St. Vincent Anderson Hospital, VP Mission Integration Oz Morgan, St. Vincent Anderson Regional, Board Chair Sally DeVoe, MCCF, Executive Director Nancy Vaughn, United Way of Madison County, President Chris Bush, Jane Pauley CHC, Site Manager Marlita Williams, Madison County Community HC, Director of Research & Grants Ross Brochel, St. Vincent Anderson Regional, Executive Director of Human Resources Nicole Kowalski, St. Vincent Medical Group/RUAH, Health Access Manager Stephen Ford, Madison County Health Department, Administrator Ann Yeakle, Community Health Network, CB Coordinator Mike Casuscelli, Madison County Community HC, Director of Outreach & Enrollment Rick Zachary, United Auto Workers, Community Initiatives Francis Albarano, St. Vincent Mercy, Administrator Debbie Harmon, St. Vincent, Chaplain Charles Purdy, St. Vincent Medical Group, Regional Medical Officer Tom VanOsdol, St. Vincent Anderson, Regional President

26 COMMUNITY HEALTH NEEDS ASSESSMENT - 26 PRIORITIZATION PROCESS On July 31, 2015, the above participants convened at St. Vincent Anderson Regional to review and discuss the results of HCI s primary and secondary data analysis leading to the preliminary top 10 significant health needs highlighted in Table 5 above. From there, participants utilized a prioritization toolkit (Appendix D) to examine how well each of the 10 significant health needs met the criteria set forth by St. Vincent. The criteria for prioritization can be seen in Figure 18 below: Figure 18: St. Vincent System-Wide Criteria for Prioritization Alignment with Ascension Health Strategies Healthcare that Leaves No One Behind & Care for the Poor & Vulnerable Community Input Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Addresses Disparities of Sub-Groups Completion of the prioritization toolkit in Appendix D allowed participants to arrive at numerical scores for each health topic that correlated to how well each health topic met the St. Vincent system-wide criteria for prioritization. Participants then ranked the top 10 health needs according to their topic scores, with the highest scoring health needs receiving the highest priority ranking. Participants were encouraged to use their own judgment and knowledge of their community in the event of a tie score. After completing their individual ranking of the 10 health needs, participants submitted their ranking into an online polling platform that collates the submissions and results in an aggregate ranking of the health needs. The aggregate ranking can be seen below in Figure 19.

27 COMMUNITY HEALTH NEEDS ASSESSMENT - 27 Figure 19. Group Ranking of Madison County s Most Pressing Health Needs Upon seeing the group ranking above, prioritization participants had in-depth discussions about the needs that make most sense to prioritize for Madison County. As mental health and substance abuse are often linked together, the group decided to combine them into the topic of Behavioral Health to address root causes. The group also came to the conclusion that, from the hospital s perspective, economy was too large and complex of an issue to tackle, and thus excluded it from the priority list. Thus, the top five health priorities for Madison County to consider for subsequent implementation planning are: Access to Health Services Behavioral Health Respiratory Diseases Diabetes Exercise, Nutrition, & Weight These five health needs will be broken down in further detail below to understand how findings in the secondary data and community input led to each issue becoming a high priority health need for Madison County.

28 Health Priorities for Madison County COMMUNITY HEALTH NEEDS ASSESSMENT - 28 ACCESS TO HEALTH SERVICES SECONDARY DATA FINDINGS Access to Health Service s Poorest Performing Indicators and Rankings Madison County ranks in the third quartile in the US for Non-Physician Primary Care Provider Rate at 30 providers/100,000 persons. Primary care providers who are not physicians include nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists. Access to primary care providers increases the likelihood that community members will have routine checkups and screenings. Moreover, those with access to primary care are more likely to know where to go for treatment in acute situations. Since Access to Health Services made the initial short list for pressing health needs in Madison County due to community input evidence, the indicators available in the secondary data for this topic aren t quite as poor performing compared to some other topics that were presented for consideration. Table 6 below shows all Access to Health Services indicators that contributed to the topic receiving an overall topic score of The gauges illustrate how Madison County is faring compared to the following six comparisons: the Indiana State Value, Indiana County Value, US Value, US Counties Value, Healthy People 2020 if a target is available, and the Time Trend score. A gauge in the green received a score of 0-1 (good), yellow a score of 1-2 (fair), and red a score of 3 (poor). Table 6. Comparison Scores for Access to Health Services Indicators Access to Health Services Topic Score 1.54 Indicator: Madison County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Non-Physician Primary Care Provider Rate a Preventable b Hospital Stays Adults with Health Insurance 80% 80.1% 1.55 Primary Care Provider Rate a Children with Health Insurance 91.9% 91.3% 1.38

29 COMMUNITY HEALTH NEEDS ASSESSMENT - 29 Indicator: Madison County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Clinical Care c Ranking Dentist Rate a a Rates are expressed as the number of providers per 100,000 population b Indicates the hospital discharge rate for ambulatory care-sensitive conditions (ACSC) per 1,000 Medicare enrollees c From the County Health Rankings, this value is the Madison County Ranking out of 92 total Indiana Counties COMMUNITY INPUT All six key informants cited Access to Health Services as a need for Madison County. The most pressing issues in regard to access to health services, as cited by key informants were that low-income populations lack insurance or motivation to access health services, and that the cost of services is often a barrier for the working poor, that many working poor fall into the donut hole of eligibility for more affordable coverage, and that many providers cap the number of Medicare or Medicaid patients they can see. Key informants also provided insight into the experiences of poor and vulnerable populations pertaining to accessing health services. The figure to the right includes some direct quotes from key informants regarding accessing health services in their community and the populations most affected. Quotes from Key Informants Have to change the mindset that health insurance is important and it s not going to be free People in poverty live one crisis to the next. If a month comes up and they can t pay, even if it s low, they won t pay it because they want to make sure the rent is paid and food is on the table. When you re low income there are a lot of other issues. This is a lot of the working poor. They do not have health insurance even with ACA People tend to think that if they are uninsured that the ER is where they go for healthcare. A lot of people who fall through the cracks because they are not eligible for Medicaid and they have to offset their salary because they need to pay out of pocket for their medical costs. There is a high population of Medicaid and Medicare patients,

30 COMMUNITY HEALTH NEEDS ASSESSMENT - 30 BEHAVIORAL HEALTH SECONDARY DATA FINDINGS Behavioral Health s Poorest Performing Indicators and Rankings Madison County ranks in the worst quartile in the US and Indiana for Depression in the Medicare Population with one in five Medicare enrollees being treated for depression. According to the National Comorbidity Survey of mental health disorders, people over the age of 60 have lower rates of depression than the general population 10.7 percent in people over the age of 60 compared to 16.9 percent overall. The Center for Medicare Services estimates that depression in older adults occurs in 25 percent of those with other illnesses, including: arthritis, cancer, cardiovascular disease, chronic lung disease, and stroke. Madison County also ranks in the worst quartile in the US for Adults who Smoke and Mothers who Smoke During Pregnancy at 27.9% and 24.6% respectively. Smoking during pregnancy poses risks for both mother and fetus. A baby born to a mother who has smoked during her pregnancy is more likely to have less developed lungs and a lower birth weight, and is more likely to be born prematurely. Disparities in Behavioral Health Males have a higher Age-Adjusted ER Rate and Hospitalization Rate due to Alcohol Abuse. Tables 7 and 8 below show all health indicators for both Mental Health and Mental Disorders and Substance Abuse respectively. As highlighted in the Prioritization Process section, the health topic of Behavioral Health was created to focus on the root causes of mental health and substance abuse. The gauges illustrate how Madison County is faring compared to the following six comparisons: the Indiana State Value, Indiana County Value, US Value, US Counties Value, Healthy People 2020 if a target is available, and the Time Trend score. A gauge in the green received a score of 0-1 (good), yellow a score of 1-2 (fair), and red a score of 3 (poor). Table 7. Comparison 7. Comparison Scores Scores for Mental for Mental Health Health & Mental & Mental Disorders Disorders Indicators Mental Health & Mental Disorders Topic Score 2.55 Indicator: Madison County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Depression: Medicare Population Age-Adjusted Death Rate due to Alzheimer s Disease a Age-Adjusted Death Rate due to Suicide a

31 COMMUNITY HEALTH NEEDS ASSESSMENT - 31 Indicator: Madison County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Alzheimer s Disease or Dementia: Medicare Population Poor Mental Health Days a Value represents the number of deaths per 100,000 population Table 8. Comparison Scores for Substance Abuse Substance Abuse Topic Score 1.93 Indicator: Madison County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Adults who Smoke 27.9% 22.8% 2.38 Death Rate due to Drug Poisoning b Mothers who Smoked During Pregnancy Liquor Store Density c Age-Adjusted ER Rate due to Alcohol Abuse e Age-Adjusted Hospitalization Rate due to Alcohol Abuse d Health Behaviors Ranking a

32 COMMUNITY HEALTH NEEDS ASSESSMENT - 32 Indicator: Madison County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Adults who Drink Excessively Alcohol- Impaired Driving Deaths a Value represents Madison County s rank out of 92 Indiana Counties b Value represents the number of deaths per 100,000 population c Value represents the number of stores per 100,000 population d Value represents the number of hospitalizations per 10,000 population ages 18+ e Value represents the number of ER visits per 10,000 population ages 18+ COMMUNITY INPUT Three out of six key informants and five out of six key informants IS IT THREE OUT OF SIX OR FIVE OUT OF SIX? cited mental health and substance abuse as needs for Madison County respectively. The most pressing issues in regard to behavioral health, as cited by key informants were a rise in the use of prescription pain killers, substance abuse in youth, and the need for mental health providers. The figure to the right includes some direct quotes from key informants regarding the topic area of behavioral health in their community and the populations most affected. Quotes from Key Informants There is a high rate of pregnant women who use prescription drug pain killers, and smoke maternal care is critical. Youth drug use is increasing Rise in heroin use, often laced with other things especially among youth with e-cigarettes the youth manage to use e-cigarettes to vaporize alcohol, marijuana and heroin. There is a great need for mental health services and we struggle with the sheer number of referrals.

33 COMMUNITY HEALTH NEEDS ASSESSMENT - 33 RESPIRATORY DISEASES SECONDARY DATA FINDINGS Respiratory Disease s Poorest Performing Indicators and Rankings Madison County ranks in the worst quartile in the US and Indiana counties for Asthma in the Medicare Population, with 7.5% of that population suffering from asthma. Madison County also sees high hospitalization and ER rates for pediatric and adult asthma in the general population. Asthma symptoms are often brought on by exposure to inhaled allergens (like dust, pollen, cigarette smoke, and animal dander) or by exertion and stress. Madison County also has a high incidence and death rate due to Lung and Bronchus Cancer and Chronic Obstructive Pulmonary Disease (COPD). The greatest risk factor for lung cancer is duration and quantity of smoking. Disparities in Respiratory Diseases Females and African American children have higher hospitalization rates due to asthma. The topic of respiratory diseases has strong evidentiary support from the secondary data as being a key issue in Madison County. Table 9 below shows the all of the indicators that contributed to respiratory diseases receiving an overall topic score of The gauges illustrate how Madison County is faring compared to the following six comparisons: the Indiana State Value, Indiana County Value, US Value, US Counties Value, Healthy People 2020 if a target is available, and the Time Trend score. A gauge in the green received a score of 0-1 (good), yellow a score of 1-2 (fair), and red a score of 3 (poor). Table 9. Comparison Scores for Respiratory Diseases Respiratory Diseases Topic Score 2.05 Indicator: Madison County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Asthma: Medicare Population 7.5% Age-Adjusted Death Rate due to Lung Cancer a Lung & Bronchus Cancer Incidence Rate b Age-Adjusted Death Rate due to Chronic Lower Respiratory Diseases a

34 COMMUNITY HEALTH NEEDS ASSESSMENT - 34 Indicator: Madison County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Age-Adjusted ER Rate due to Influenza and Pneumonia c Age-Adjusted ER Rate due to Pediatric Asthma c Age-Adjusted Hospitalization Rate due to Bacterial Pneumonia c Age-Adjusted ER Rate due to Adult Asthma c Age-Adjusted Hospitalization Rate due to Asthma c Age-Adjusted ER Rate due to Asthma c Age-Adjusted ER c Rate due to COPD Age-Adjusted Hospitalization Rate due to Adult Asthma c Age-Adjusted ER Rate due to Immunization Preventable Pneumonia and Influenza c Age-Adjusted Hospitalization Rate due to Pediatric Asthma c Indicator: Madison County Indiana State Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Total Indicator

35 COMMUNITY HEALTH NEEDS ASSESSMENT - 35 Value Value Score Score COPD: Medicare Population Age-Adjusted ER Rate due to Bacterial Pneumonia c Age-Adjusted Hospitalization Rate due to COPD c Age-Adjusted Hospitalization Rate due to Immunization Preventable Pneumonia and Influenza c a Value represents the number of deaths per 100,000 population b Value represents number of cases per 100,000 population c Value represents number of admissions per 10,000 population COMMUNITY INPUT One out of six Key Informants cited Respiratory Diseases as a need for Madison County, though many cited a root cause, smoking tobacco, as a persistent problem in the community. Additionally, participants in the prioritization sessions felt that the many negative indicators comprising the health topic of respiratory diseases were solid grounds for prioritizing this topic. Participants hoped that by tackling the root cause smoking, then positive effects would be seen in respiratory disease indicators as well.

36 COMMUNITY HEALTH NEEDS ASSESSMENT - 36 DIABETES SECONDARY DATA FINDINGS Diabetes Poorest Performing Indicators and Rankings Madison County ranks in the worst quartile of US and Indiana counties for Diabetes in the Medicare Population and Age-Adjusted Death Rate due to Diabetes with a death rate of 29.4 per 100,000 population, compared 24.7 per 100,000 population in Indiana overall. Diabetes can have a harmful effect on most of the organ systems in the human body; it is a frequent cause of end-stage renal disease, non-traumatic lowerextremity amputation, and a leading cause of blindness among working-age adults. Persons with diabetes are also at increased risk for ischemic heart disease, neuropathy and stroke. In keeping with the root cause approach that was cited above in the behavioral health and respiratory disease sections, diabetes was chosen as a priority in tandem with exercise, nutrition and weight (following section). Table 10 below shows the indicators that contributed to the topic of diabetes receiving an overall score of The gauges illustrate how Madison County is faring compared to the following six comparisons: the Indiana State Value, Indiana County Value, US Value, US Counties Value, Healthy People 2020 if a target is available, and the Time Trend score. A gauge in the green received a score of 0-1 (good), yellow a score of 1-2 (fair), and red a score of 3 (poor). Table 10. Comparison Scores for Diabetes Indicators Diabetes Topic Score 1.80 Indicator: Madison County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Diabetes: Medicare Population Age-Adjusted Death Rate due to 29.4% 24.7% 2.05 Diabetes a Age-Adjusted Hospitalization Rate due to Long-Term Complications of Diabetes c Age-Adjusted ER Rate due to Diabetes b Age-Adjusted ER Rate due to Long- Term Complications of Diabetes b

37 COMMUNITY HEALTH NEEDS ASSESSMENT - 37 Indicator: Madison County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Age-Adjusted Hospitalization Rate due to Diabetes c Age-Adjusted Hospitalization Rate due to Uncontrolled Diabetes c Age-Adjusted ER Rate due to Short- Term Complications of Diabetes b Age-Adjusted ER Rate due to Uncontrolled Diabetes b Diabetic Screening: Medicare Population 87.6% 84.0% 0.93 a Value represents the number of deaths per 100,000 population b Value represents the number of ER visits per 10,000 population 18+ years c Value represents the number of hospitalizations per 10,000 population 18+ years COMMUNITY INPUT Two out of six key informants cited diabetes as a need for Madison County. Key themes from the informants indicate that diabetes along with the behaviors that exacerbate the disease, such as nutritional habits, can sometimes affect low income populations more heavily. The figure to the right includes some direct quotes from key informants regarding diabetes in relation to health of the community and the populations most affected. Quotes from Key Informants Diabetes, obesity and smoking are big cost drivers for my company, and issues that community struggles with too especially the low income population. We have big problems with asthma, cancer, diabetes - people will wait until a crisis situation and go to ER.

38 COMMUNITY HEALTH NEEDS ASSESSMENT - 38 EXERCISE, NUTRITION, & WEIGHT SECONDARY DATA FINDINGS Exercise, Nutrition, & Weight s Poorest Performing Indicators and Rankings Madison County ranks in the worst quartile in the US and in Indiana counties for Child Food Insecurity Rate of 24%. Children exposed to food insecurity are of particular concern given the implications scarce food resources pose to a child s health and development. Children who are food insecure are more likely to be hospitalized and may be at higher risk for developing obesity and asthma. Children who experience food insecurity may also be at higher risk for behavioral and social issues including fighting, hyperactivity, anxiety and bullying. Madison County also ranks in the worst quartile in the US and in Indiana counties for Adults who are Obese and Adults who are Sedentary at 37.3% and 34.1% respectively. The percentage of obese adults is an indicator of the overall health and lifestyle of a community. Obesity increases the risk of many diseases and health conditions including heart disease, Type 2 diabetes, cancer, hypertension, stroke, liver and gallbladder disease, respiratory problems, and osteoarthritis. The Healthy People 2020 national health target is to reduce the proportion of adults aged 20 and older who are obese to 30.5%. The secondary data analysis may have generally illustrated a fairly well performing county in regard to exercise, nutrition, and weight issues; however, key populations and specific problems were highlighted in both the secondary and primary data analysis. Table 11 below shows the indicators that contributed to exercise, nutrition, and weight receiving an overall topic score of The gauges illustrate how Madison County is faring compared to the following six comparisons: the Indiana State Value, Indiana County Value, US Value, US Counties Value, Healthy People 2020 if a target is available, and the Time Trend score. A gauge in the green received a score of 0-1 (good), yellow a score of 1-2 (fair), and red a score of 3 (poor). Table 11. Comparison Scores for Exercise, Nutrition, & Weight Exercise, Nutrition, & Weight Topic Score 1.72 Indicator: Madison County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Child Food Insecurity Rate 24% 21.8% 2.35 Adults who are Obese 37.3% 31.4% 2.18 Adults who are Sedentary 34.1% 27.9% 2.08 Food Insecurity Rate 16% 15.7% 2.05 Food Environment Index c

39 COMMUNITY HEALTH NEEDS ASSESSMENT - 39 Indicator: Madison County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score People 65+ with Low Access to a Grocery Store 4% 1.90 Health Behaviors b Ranking Children with Low Access to a Grocery Store 5% 1.70 Grocery Store a Density Low-Income and Low Access to a Grocery Store 6.3% 1.70 Low-Income Preschool Obesity 14.6% 1.60 Farmers Market Density a SNAP Certified a Stores Households with No Car and Low Access to a Grocery Store 2.2% 1.50 Recreation and a Fitness Facilities Fast Food Restaurant Density a Access to Exercise Opportunities 66.5% 63.9% 1.03 a Value expressed as the number per 1,000 population b Rankings equate to the value out of 92 Indiana counties c Index ranges from 0 (worst) to 10 (best)

40 COMMUNITY HEALTH NEEDS ASSESSMENT - 40 COMMUNITY INPUT Four out of six key informants cited Exercise, Nutrition, and Weight as a need for Madison County. Key themes from the informants centered around personal accountability and sticking to healthier habits, a recent spike in obesity rates, and difficulty in finding accessible healthy foods with Supplemental Nutrition Assistance Program (SNAP) benefits. The figure to the right includes some direct quotes from key informants regarding exercise, nutrition, and weight in their community and the populations most affected. Quotes from Key Informants We need more personal accountability, especially with diet/nutrition many give up on trying to make healthy changes. Obesity rates have been increasing slowly up until the early 2000 s, then increased dramatically after that. Both children and adults are affected, but we are seeing a lot of childhood obesity. It is harder than you would think to find healthy food with your OTHER SIGNIFICANT COMMUNITY HEALTH NEEDS As part of the community health needs assessment process, the primary and secondary data analysis identified additional significant community health needs (Table 12). While these health needs have not been prioritized for this CHNA cycle, St. Vincent Anderson Regional and Mercy, and other community partners will still continue to work hard to address the following issues: Economy Social Environment Wellness & Lifestyle Prevention & Safety Kidney & Urinary Tract Diseases

41 COMMUNITY HEALTH NEEDS ASSESSMENT - 41 Table 12. Other Significant Community Health Needs for Madison County Health or Quality of Life Topic Topic Score Insights from Secondary Data Warning Indicators Contributing to Topic Score Score range: Good Bad Insights from Primary Data/ Community Input Number of Community Members Citing Topic as Pressing Health Concern (Total # interviewed=6) =issue cited =issue not cited Key Themes from Community Input Economy 2.15 Households w/cash Public Assistance Income Homeowner Vacancy Rate People Living Below Poverty Level High number of unemployed and working poor after loss of GM factory jobs; capacity and funding barriers as a result of economic issues Social Environment 2.19 Single Parent Households Children Living Below Poverty Level Young Children Living Below Poverty Level High rates of child abuse and neglect in the community; poverty and working poor households 2.35 affecting younger population Wellness & Lifestyle 2.04 Life Expectancy for Females Life Expectancy for Males Poor Physical Health Days Issues with lifestyle choice problems; lack of interest among residents in managing their own health 2.03 Prevention & Safety 2.30 Age-Adjusted Death Rate due to Unintentional Injuries Death Rate due to Drug Poisoning N/a, not mentioned as a top health need/concern during community input process

42 COMMUNITY HEALTH NEEDS ASSESSMENT - 42 Severe Housing Problems 1.98 Kidney & Urinary Tract Infections 2.09 Chronic Kidney Disease: Medicare Population Age-Adjusted Hospitalization Rate due to Urinary Tract Infection Age-Adjusted ER Rate due to Urinary Tract Infections N/a, not mentioned as a top health need/concern during community input process 2.03 Conclusion This community health needs assessment utilized a comprehensive set of secondary data indicators measuring the health and quality of life needs of Madison County, Indiana, residents and was further informed with community input from knowledgeable persons representing the broad interests of the community. The prioritization of the identified health needs will guide the community health improvement efforts of St. Vincent Anderson Regional and Mercy hospitals. From this process, each hospital will outline how they plan to address their prioritized health needs of Access to Health Services, Behavioral Health (with special attention to Substance Abuse and Mental Health & Mental Disorders), Respiratory Diseases, Diabetes, and Exercise, Nutrition, & Weight into their Implementation Strategy. In addition, we hope to incorporate any feedback on this report into our next Community Health Needs Assessment process. Please send your feedback and/or comments to CommunityDevelopment@stvincent.org.

43 COMMUNITY HEALTH NEEDS ASSESSMENT - 43 Appendix A: Evaluation of Preceding CHNA Priorities FY14-FY15 St. Vincent Anderson Regional Hospital Note: The report below is St.Vincent Anderson s contribution to the St.Vincent Northeast Regional Plan, which includes St. Vincent Anderson Regional Hospital, St. Vincent Mercy and St. Vincent Randolph Significant health need identified in previous CHNA Obesity Strategy/Action Step Work with area Food Pantries/Food Banks to ensure they have healthy food to distribute to their clients 1) Develop public education materials for the public on healthy food donation options 2) Conduct quarterly food drives at the hospitals specifically soliciting healthy foods 3) Work with pantries and food banks to assemble healthy food packages and recipes for the clients 4) Work with area faith based organizations to educate their congregations on healthy food donation options 5) Partner with faith based organizations to conduct food drives specifically soliciting healthy foods 6) Work with farmers (through the Farmers Initiative) to provide fresh produce to the pantries/food banks Promote Community Gardens 1) Engage the farming community in dedicating garden space for community use 2) Partner with Aspire to share their experience and knowledge with others who want to initiate a community gardening program 3) Partner with Madison Health Partners community gardening program Indicators of Success An Associate is a representative on the Community Transformation Committee. CT committee has compiled a list of food pantries in the area as well as farmers markets. An Associate is a member of the Second Harvest Board. January 24, 2014 was the opening of a Food Pantry, in partnership with Second Harvest Food Bank, for patients in need who are referred by Social Workers. The hospital plans to conduct a food drive and health screening at Impact Center in conjunction with Open Door Health Services on Associates are working to obtain list of Farmer s Markets and community gardens that will be targeted in the spring on The Community Transformation Committee is putting together a list of food pantries, free meal sites, and farmers markets, etc. SVAR donates funds to Madison Health Partners which in turn provides funds to support

44 COMMUNITY HEALTH NEEDS ASSESSMENT - 44 Significant health need identified in previous CHNA Strategy/Action Step 4) Partner with targeted area schools to develop community gardens Work with community provided meal sites to ensure that meals contain healthy food choices 1) Partner with faith-based organizations to develop healthy menus for their soup kitchens/meal programs 2) Investigate a food rescue partnership where leftover prepared foods from SVH regional locations can be donated to the meal sites Partner with area employers to educate their employees about healthy food choices 1) Provide information about healthy food choices for inclusion in cafeteria, in the employee newsletters, and through other social media outreach opportunities 2) Expand the Spirit of Wellness program throughout the ministries and demonstrate the impact Explore the potential to expand the Spirit of Wellness program to other employers in the community; promote healthy eating and exercise to the general population 1) Expand Walk with a Doc program to all SV hospitals in the region 2) Promote Choose to Lose program to patients and families in the St. Vincent system 3) Support the development of safe places to walk/walking trails Partner with area agencies to expand programs focused on youth: 1) In Randolph County expand and support the Y s Girls on the Run Indicators of Success community gardens in Madison County. The hospital wrote 3 articles for the Anderson Herald-Bulletin; 3 articles for employee newsletters. Spirit of Wellness had been a several month program but was expanded and is now a year-long program for associates, with 250 participants from Northeast Region in January, 2014 and 200 participants in January, The hospital provided health risk assessments, education and screenings to the Edgewood Fire Dept. and Tractor Supply Distribution Center employees. Employee wellness proposals to an Elwood manufacturing company. Others in preparation: ELSA (Elwood); Nestle (Anderson); Ontario Systems (Muncie) Choose to Lose for Kids and Families program (based on Project #18) began in 2014, with 2 sessions (average 1-2 families) completed. Three SV Northeast Region

45 COMMUNITY HEALTH NEEDS ASSESSMENT - 45 Significant health need identified in previous CHNA Strategy/Action Step program 2) In Madison County expand and support the Y s Kids Marathon 3) In Randolph County expand health and wellness activities highlighted in the Achieve grant 4) Target area schools to expand Project 18, a partnership with Peyton Manning, to engage school aged kids in healthy eating and exercise 5) Continue St. Vincent Mercy partnership with the town and YMCA for the summertime outdoor pool project Explore partnerships with school systems to identify children at high risk for obesity and provide services. Services could include: 1) Provide exercise and nutrition classes 2) Ensure there are healthy food options in the cafeteria 3) Prepare a pilot project with the three hospitals to target 5 youth/families each to break the cycle of obesity in their families Indicators of Success associates are representatives on local YMCA board of directors. The hospital provided financial support of the Kids Marathon in Madison County, which took place May 17, 2014 and May 16, The hospital providing health educational materials regarding nutrition at the Kids Marathon. Substance Abuse Promote the availability of smoking cessation programs 1) Conduct an inventory of existing programs and qualifications to participate 2) Assess effectiveness of existing programs 3) Partner with community programs to cross-promote and enroll participants Target smoking cessation programs to community employers 1) Continue health insurance benefit for SVH associates who participate in smoking cessation classes An inventory of existing programs was completed. The Director of Respiratory Services facilitates smoking Cessation services provided to the public. Smoking cessation classes offered to employers as part of wellness proposals. SVARH associate serves on Board of Intersect Sponsorship of Education / Awareness / Stop Smoking Campaigns with Intersect ($4,500

46 COMMUNITY HEALTH NEEDS ASSESSMENT - 46 Significant health need identified in previous CHNA Access to Primary Care Strategy/Action Step 2) Reach out to employers in the community to include health insurance benefit for their employees who participate in smoking cessation classes Continue primary care provider recruitment efforts in Madison County Elwood/Alexandria: 1) New providers 2) Replacement providers 3) Explore funding opportunities (Federal & other) for rural providers to assist in the recruitment of providers Develop methods for connecting people to patient centered medical homes: 1) Continue use of Physician Extenders 2) Continue use of Health Access Workers/Medical Access Workers to connect people to health care 3) Investigate implementation of Patient Navigators and/or Certified Enrollment Specialists Indicators of Success donation) to serve 500 people. The hospital has recruited 1 Nurse Midwife, 3 GI Specialists, and 1 Ortho. Surgeon. Madison and Randolph Counties recruitment successes include 6 Primary Care Providers and 2 OB/GYN. The Open Door Clinic, which is a FQHC, opened in September, 2014 and is located on SVARH campus. More than 21 mid-level providers utilized at various practices throughout NE Region. See recruitment activities above. The hospital employs 1.5 Health Access Workers (HAW) who assists individuals with finding a medical home; applying for public programs such as Medicaid, food stamps, and the Healthy Indiana Plan; and in assessing needs so referrals can be made for other forms of community-based assistance. The HAW also advocates for clients with service providers and serves as a system navigator. RUAH outcomes are measured using the Pathways Model with five defined pathways/protocols (enrollment, medical home, pregnancy, medical referral and social services) as a means of tracking interventions and improving accountability for

47 COMMUNITY HEALTH NEEDS ASSESSMENT - 47 Significant health need identified in previous CHNA Strategy/Action Step Indicators of Success contributing to positive, measurable changes in patients lives. During fiscal year 2014, the HAWs completed 528 pathways. During fiscal year 2015, the HAWs completed 962 pathways. In addition to care coordination, RUAH assists patients who meet income guidelines in obtaining free or reduced-cost prescription drugs. SVARH employs one Medication Access Coordinator (MAC) who works with a sophisticated and continuallyupdated database to track eligibility and requirements that vary by pharmaceutical company and medication. In fiscal year 2014, the MAC helped patients obtain a total of 1,232 medications for which the average wholesale price totaled $1,579,593. In fiscal year 2015, the MAC helped patients obtain 635 medications for which the average wholesale price totaled $1,091,749. Mental Health Work with The Anderson Center to expand the Day School 1) Connect with the Indiana State Department of Education to confirm funding mechanism 2) Develop a business plan to support the expansion 3) Promote Day School option to school districts in Madison County 4) Recruit personnel to support expansion SVARH recruited a physician and behavioral nurse practitioner to increase access to behavioral services. Currently a referral form is in place though AC assessment office when a patient presents in either Mercy or Randolph for mental health and addiction issues. The AC accepts patients from Randolph and Mercy unless we are full.

48 COMMUNITY HEALTH NEEDS ASSESSMENT - 48 Significant health need identified in previous CHNA Strategy/Action Step Indicators of Success Expand access to mental health services 1) Develop a cost sharing mechanism for The Anderson Center across the three hospitals in the St. Vincent Anderson Region to support the expansion of services 2) Demonstrate the impact of access to mental health services on Emergency Department usage Partner with Aspire community mental health to develop plan for expansion into Randolph County Work with area nursing homes to develop and implement support groups for families of dementia patients 1) Identify facilities that have memory/alzheimer s units 2) Research model programs across the country 3) Pilot programs at St. Vincent Anderson and St. Vincent Randolph (already in place at St. Vincent Mercy) 4) Recruit additional nursing home partners Tele-mental health initiative for northeast region being explored for deployment in FY SVARH associate has provided education to Randolph regarding referring to the Anderson Center and has joined the Community Coalition to assist with coordinating services in Randolph. SVAR is assessing options for expanding the Day School program. Anderson Community School (ACS) is the current partner for Madison County. All Madison County Referrals to the Program must go through ACS as the school system is the only source that can refer into the program. *The last year of the FY14- FY16 implementation strategy will be reported and attached to the FY16 Form 990.

49 COMMUNITY HEALTH NEEDS ASSESSMENT - 49 FY14-FY15 St. Vincent Mercy Significant health need identified in previous CHNA Obesity Strategy/Action Step Work with area Food Pantries/Food Banks to ensure they have healthy food to distribute to their clients 1) Develop public education materials for the public on healthy food donation options 2) Conduct quarterly food drives at the hospitals specifically soliciting healthy foods 3) Work with pantries and food banks to assemble healthy food packages and recipes for the clients 4) Work with area faith based organizations to educate their congregations on healthy food donation options 5) Partner with faith based organizations to conduct food drives specifically soliciting healthy foods 6) Work with farmers (through the Farmers Initiative) to provide fresh produce to the pantries/food banks Promote Community Gardens 1) Engage the farming community in dedicating garden space for community use 2) Partner with Aspire to share their experience and knowledge with others who want to initiate a community gardening program 3) Partner with Madison Health Partners community gardening program 4) Partner with targeted area schools to develop community gardens Work with community provided meal sites to ensure that meals contain healthy food Indicators of Success The SVM Mission Team organizes food bank efforts. The team gathers oral hygiene products and toilet paper once a month and targeted food items once every other month. Additionally, the team collected 700 pounds of food for Christmas families. The hospital is a sponsor of the local farmers market which includes fresh produce, which takes place every Saturday morning. The hospital collaborated with Madison Health Partners (via donation of funds) for Madison County Community Gardens.

50 COMMUNITY HEALTH NEEDS ASSESSMENT - 50 Significant health need identified in previous CHNA choices Strategy/Action Step 1) Partner with faith-based organizations to develop healthy menus for their soup kitchens/meal programs 2) Investigate a food rescue partnership where leftover prepared foods from SVH regional locations can be donated to the meal sites Partner with area employers to educate their employees about healthy food choices 1) Provide information about healthy food choices for inclusion in cafeteria, in the employee newsletters, and through other social media outreach opportunities 2) Expand the Spirit of Wellness program throughout the ministries and demonstrate the impact 3) Explore the potential to expand the Spirit of Wellness program to other employers in the community Promote healthy eating and exercise to the general population 1) Expand Walk with a Doc program To all SV hospitals in the region 2) Promote Choose to Lose program to patients and families in the St. Vincent system 3) Support the development of safe places to walk/walking trails Partner with area agencies to expand programs focused on youth: 1) In Randolph County expand and support the Y s Girls on the Run program 2) In Madison County expand and support the Y s Kids Marathon 3) In Randolph County expand health Indicators of Success SVM works with the 4 larger churches in Elwood that provide community meals 1 day per week. SVM associates assist with serving meals to approximately 150 people at each meal. SVM offers an employee wellness initiative to Red Gold and is in the process of promotion to other manufacturers. SVM currently provides education regarding diabetes. The hospital would like to expand to include pre-diabetic population. A wellness program for Elwood school teachers was recently completed. Screening offered twice for Hgb A1C in partnership with Madison Health Partners where 18 individuals were screened with two individuals being referred to PCP for early intervention. The hospital collaborated with the local school system to mark out

51 COMMUNITY HEALTH NEEDS ASSESSMENT - 51 Significant health need identified in previous CHNA Strategy/Action Step and wellness activities highlighted in the Achieve grant 4) Target area schools to expand Project 18, a partnership with Peyton Manning, to engage school aged kids in healthy eating and exercise 5) Continue St. Vincent Mercy partnership with the town and YMCA for the summertime outdoor pool project Explore partnerships with school systems to identify children at high risk for obesity and provide services. Services could include: 1) Provide exercise and nutrition classes 2) Ensure there are healthy food options in the cafeteria 3) Prepare a pilot project with the Three hospitals to target 5 youth/families each to break the cycle of obesity in their families Indicators of Success walking route both outside the school perimeter and inside the school complex to be used during poor weather. The hospital fulfilled its commitment of funding for the community swimming pool to encourage physical activity for youth. Substance Abuse Promote the availability of smoking cessation programs 1) Conduct an inventory of existing programs and qualifications to participate 2) Assess effectiveness of existing programs 3) Partner with community programs to cross-promote and enroll participants Target smoking cessation programs to community employers 1) Continue health insurance benefit for SV associates who participate in smoking cessation classes 2) Reach out to employers in the community to include health An inventory of existing programs was completed. The benefit is available for associates who are tobacco free or willing to participate in tobacco cessation. The hospital collaborated with INSPECT (Quit Line) for tobacco cessation support.

52 COMMUNITY HEALTH NEEDS ASSESSMENT - 52 Significant health need identified in previous CHNA Access to Primary Care Strategy/Action Step insurance benefit for their employees who participate in smoking cessation classes Continue primary care provider recruitment efforts in Madison County Elwood/Alexandria: 1) New providers 2) Replacement providers 3) Explore funding opportunities (Federal & other) for rural providers to assist in the recruitment of providers Develop methods for connecting people to patient centered medical homes: 1) Continue use of Physician Extenders 2) Continue use of Health Access Workers/Medical Access Workers to connect people to health care 3) Investigate implementation of Patient Navigators and/or Certified Enrollment Specialists Indicators of Success The hospital is working towards automatic referrals for tobacco cessation resources within the EMR, which is scheduled to be activated in early The recruited a Nurse Practitioner began, who started work in January, The process continues to fill open positions in IM, FP in Elwood with two MDs. Physician extenders (~21 mid-level providers) utilized at a number of practice sites throughout the region by SVMG and ministries and included in recruitment activities identified in the previously mentioned recruitment and retention strategies. Athena portal allowing patients to access to their info implemented 4-14 (SVMG sites). Also portal coming to hospital system with next QUEST update. The hospital employs a full time Health Access Worker (HAW), who assists individuals with finding a medical home; applying for public programs such as Medicaid, food stamps, and the Healthy Indiana Plan; and in assessing needs so referrals can be made for other forms of community-based assistance. The HAW also advocates for clients with service providers and serves as a system navigator. RUAH outcomes are

53 COMMUNITY HEALTH NEEDS ASSESSMENT - 53 Significant health need identified in previous CHNA Strategy/Action Step Indicators of Success measured using the Pathways Model with five defined pathways/protocols (enrollment, medical home, pregnancy, medical referral and social services) as a means of tracking interventions and improving accountability for contributing to positive, measurable changes in patients lives. During fiscal year 2014, the HAW completed 209 pathways. During fiscal year 2015, the health access worker completed 234 pathways. In addition to care coordination, RUAH assists patients who meet income guidelines in obtaining free or reduced-cost prescription drugs. St.Vincent Mercy employs a Medication Access Coordinator (MAC) who works with a sophisticated and continuallyupdated database to track eligibility and requirements that vary by pharmaceutical company and medication. In fiscal year 2014, the MAC helped patients obtain a total of 46 medications for which the average wholesale price totaled $28,776. In fiscal year 2015, the MAC helped patients obtain 227 medications for which the average wholesale price totaled $185,550. Mental Health Work with The Anderson Center to expand the Day School 1) Connect with the Indiana State Department of Education to confirm funding mechanism The local Stress Center provides access to outpatient behavioral services and there is an Aspire site in Elwood.

54 COMMUNITY HEALTH NEEDS ASSESSMENT - 54 Significant health need identified in previous CHNA Strategy/Action Step 2) Develop a business plan to support the expansion 3) Promote Day School option to school districts in Madison County 4) Recruit personnel to support expansion Expand access to mental health services 1) Develop a cost sharing mechanism for The Anderson Center across the three hospitals in the St. Vincent Anderson Region to support the expansion of services 2) Demonstrate the impact of access to mental health services on Emergency Department usage 3) Partner with Aspire community mental health to develop plan for expansion into Randolph County Work with area nursing homes to develop and implement support groups for families of dementia patients 1) Identify facilities that have memory/alzheimer s units 2) Research model programs across the country 3) Pilot programs at St. Vincent Anderson and St. Vincent Randolph (already in place at St. Vincent Mercy) 4) Recruit additional nursing home partners Indicators of Success An Alzheimer s Support Group, open to the community, meets regularly at the hospital. *The last year of the FY14- FY16 implementation strategy will be reported and attached to the FY16 Form 990.

55 Appendix B: Secondary Data Analysis COMMUNITY HEALTH NEEDS ASSESSMENT - 55 SCORING METHOD For each indicator, the county was assigned a score based on its comparison to other communities, whether health targets have been met, and the trend of the indicator value over time. These comparison scores range from 0-3, where 0 indicates the best outcome and 3 the worst. Availability of each type of comparison varies by indicator and is dependent upon the data source, comparability with data collected for other communities, and changes in methodology over time. Indicators were categorized into 29 topic areas and each topic area receives a score. Indicators may be categorized in more than one topic area. Topic scores are determined by the comparisons of all indicators within the topic. COMPARISON TO A DISTRIBUTION OF COUNTY VALUES: WITHIN STATE AND NATION For ease of interpretation and analysis, indicator data on the St. Vincent Health Community Dashboard is visually represented as a green-yellow-red gauge showing how the community is faring against a distribution of counties in Indiana or the United States. A distribution is created by taking all county values within the state or nation, ordering them from low to high, and dividing them into three groups (green, yellow, red) based on their order. Indicators with the poorest comparisons ( in the red ) scored high, whereas indicators with good comparisons ( in the green ) scored low. HCI Platform County Distribution Gauge COMPARISON TO VALUES: STATE, NATIONAL, AND TARGETS The county value is compared to the state value, the national value, and Healthy People 2020 (HP2020) target values. Healthy People 2020 goals are national objectives for improving the health of the nation set by the Department of Health and Human Services (DHHS) Healthy People Initiative. For all value comparisons, the scoring depends on whether the county value is better or worse than the comparison value, as well as how close the county value is to the target value. TREND OVER TIME The Mann-Kendall statistical test for trend was used to assess whether the county value is increasing over time or decreasing over time, and whether the trend is statistically significant. The trend comparison uses the four most recent comparable values for the county, and statistical significance is determined at the 90% confidence level. For each indicator with values available for four time periods, scoring was determined by direction of the trend and statistical significance. MISSING VALUES Indicator scores are calculated using the comparison scores, availability of which depends on the data source. If the comparison type is possible for an adequate proportion of indicators on the community dashboard, it will be included in the indicator score. After exclusion of comparison types with inadequate availability, all missing comparisons are substituted with a neutral score for the purposes of calculating the indicator s weighted average.

56 COMMUNITY HEALTH NEEDS ASSESSMENT - 56 When information is unknown due to lack of comparable data, the neutral value assumes that the missing comparison score is neither good nor bad. INDICATOR SCORING Indicator scores are calculated as a weighted average of all included comparison scores. More weight was given to comparison to US counties, comparison to Indiana counties, and trend over time. If neither of the included comparison types are possible for an indicator, then a score is not calculated and the indicator is excluded from the data scoring results. TOPIC SCORING Indicator scores are averaged by topic area to calculate topic scores. Each indicator may be included in up to three topic areas if appropriate. Resulting scores range from 0-3, where a higher score indicates a greater level of need as evidenced by the data. A topic score is only calculated if it includes at least three indicators. These scores were used to categorize the topics as red (score 1.5), yellow (1.25 score <0.1.5), or green (score <1.25). DISPARITIES To identify indicators with the largest disparities by gender or race/ethnicity, the Index of Disparity 1 measure was used to calculate the average of the absolute differences between rates for each subgroup within a sub-population category and the overall county rate, divided by the county rate. The index of disparity summarizes disparities across groups within a population that can be applied across indicators. The measure is expressed as a percentage. Across all indicators, an Index of Disparity score that ranked in the top 25% of all disparities scores in either gender or race/ethnicity category was identified as having a high disparity. The availability of sub-population data varies by source and indicator. In this example to the right, Age-Adjusted Death Rate due to Diabetes by Gender has county values for the female and male subgroups that are closer to each other and close to the overall county value when compared to the subgroup values for Age- Adjusted Death Rate due to Diabetes by Race/Ethnicity. The ±3.3 ±11.4 ±4.8 ±2.8 1 Pearcy, J. & Keppel, K. (2002). A Summary Measure of Health Disparity. Public Health Reports, 117,

57 COMMUNITY HEALTH NEEDS ASSESSMENT - 57 absolute difference between the Black or African American value and the overall value is much larger than the difference between the White value and overall value, resulting in a higher Index of Disparity score than the score calculated for the gender subgroups. SCORING RESULTS The following table lists all indicators by topic area, with the most recent value for Madison County and comparison scores (0-3 or good to bad). The county value is compared to a distribution of Indiana and US counties, state and national values, and the Healthy People 2020 target. Indicators are also compared across four time periods and are scored under the trend column. If data was not available for a comparison or disparity score, then the cell is left blank. Source: as of January 20, Topic Indicator Period Score Access to Health Services Non-Physician Primary Care Provider Rate Topic Score: 1.54 Preventable Hospital Stays Adults with Health Insurance Primary Care Provider Rate Children with Health Insurance Clinical Care Ranking Dentist Rate Cancer Age-Adjusted Death Rate due to Lung Cancer Topic Score: 1.47 Lung and Bronchus Cancer Incidence Rate Prostate Cancer Incidence Rate Age-Adjusted Death Rate due to Colorectal Cancer Colorectal Cancer Incidence Rate Oral Cavity and Pharynx Cancer Incidence Rate Cancer: Medicare Population Breast Cancer Incidence Rate Age-Adjusted Death Rate due to Breast Cancer Mammography Screening: Medicare Population Age-Adjusted Death Rate due to Prostate Cancer Children's Health Child Food Insecurity Rate Topic Score: 1.87 Age-Adjusted ER Rate due to Pediatric Asthma Child Abuse Rate Age-Adjusted Hospitalization Rate due to Pediatric Asthma Children with Low Access to a Grocery Store Low-Income Preschool Obesity Children with Health Insurance

58 COMMUNITY HEALTH NEEDS ASSESSMENT - 58 Topic Indicator Period Score Diabetes Diabetes: Medicare Population Topic Score: 1.8 Age-Adjusted Death Rate due to Diabetes Age-Adjusted Hospitalization Rate due to Long- Term Complications of Diabetes Age-Adjusted ER Rate due to Diabetes Age-Adjusted ER Rate due to Long-Term Complications of Diabetes Age-Adjusted Hospitalization Rate due to Diabetes Age-Adjusted Hospitalization Rate due to Uncontrolled Diabetes Age-Adjusted Hospitalization Rate due to Short- Term Complications of Diabetes Age-Adjusted ER Rate due to Short-Term Complications of Diabetes Age-Adjusted ER Rate due to Uncontrolled Diabetes Diabetic Screening: Medicare Population Economy Households with Cash Public Assistance Income Topic Score: 2.15 Homeowner Vacancy Rate People Living Below Poverty Level Children Living Below Poverty Level Families Living Below Poverty Level Persons with Disability Living in Poverty Child Food Insecurity Rate Young Children Living Below Poverty Level Renters Spending 30% or More of Household Income on Rent Per Capita Income Students Eligible for the Free Lunch Program Homeownership Median Household Income Unemployed Workers in Civilian Labor Force Oct Food Insecurity Rate Severe Housing Problems People Living 200% Above Poverty Level Social and Economic Factors Ranking Low-Income and Low Access to a Grocery Store Low-Income Preschool Obesity SNAP Certified Stores People 65+ Living Below Poverty Level Topic Indicator Period Score

59 COMMUNITY HEALTH NEEDS ASSESSMENT - 59 Education Student-to-Teacher Ratio Topic Score: 1.67 People 25+ with a Bachelor's Degree or Higher th Grade Students Proficient in English/Language Arts th Grade Students Proficient in Math th Grade Students Proficient in English/Language Arts High School Graduation th Grade Students Proficient in Math People 25+ with a High School Degree or Higher Environment Houses Built Prior to Topic Score: 1.58 Liquor Store Density Food Environment Index Severe Housing Problems People 65+ with Low Access to a Grocery Store Children with Low Access to a Grocery Store Grocery Store Density Low-Income and Low Access to a Grocery Store Physical Environment Ranking Farmers Market Density SNAP Certified Stores Annual Particle Pollution Households with No Car and Low Access to a Grocery Store PBT Released Recreation and Fitness Facilities Annual Ozone Air Quality Fast Food Restaurant Density Drinking Water Violations FY Recognized Carcinogens Released into Air Access to Exercise Opportunities Exercise, Nutrition, & Weight Child Food Insecurity Rate Topic Score: 1.72 Adults who are Obese Adults who are Sedentary Food Insecurity Rate Food Environment Index People 65+ with Low Access to a Grocery Store Health Behaviors Ranking Children with Low Access to a Grocery Store Grocery Store Density Low-Income and Low Access to a Grocery Store Low-Income Preschool Obesity Farmers Market Density SNAP Certified Stores Households with No Car and Low Access to a Grocery Store Recreation and Fitness Facilities Fast Food Restaurant Density

60 COMMUNITY HEALTH NEEDS ASSESSMENT - 60 Access to Exercise Opportunities Heart Disease & Stroke Hypertension: Medicare Population Topic Score: 1.55 Hyperlipidemia: Medicare Population Age-Adjusted Death Rate due to Coronary Heart Disease Age-Adjusted ER Rate due to Heart Failure Ischemic Heart Disease: Medicare Population Age-Adjusted Hospitalization Rate due to Heart Failure Stroke: Medicare Population Heart Failure: Medicare Population Age-Adjusted Death Rate due to Cerebrovascular Disease (Stroke) Atrial Fibrillation: Medicare Population Immunizations & Infectious Diseases Gonorrhea Incidence Rate Topic Score: 1.63 Age-Adjusted Death Rate due to Influenza and Pneumonia Age-Adjusted Hospitalization Rate due to Bacterial Pneumonia Age-Adjusted ER Rate due to Immunization- Preventable Pneumonia and Influenza Age-Adjusted ER Rate due to Bacterial Pneumonia Age-Adjusted ER Rate due to Hepatitis Chlamydia Incidence Rate Age-Adjusted Hospitalization Rate due to Hepatitis Age-Adjusted Hospitalization Rate due to Immunization-Preventable Pneumonia and Influenza Salmonella Infection Incidence Rate Kidney & Urinary Tract Diseases Chronic Kidney Disease: Medicare Population Topic Score: 2.09 Age-Adjusted Hospitalization Rate due to Urinary Tract Infections Age-Adjusted ER Rate due to Urinary Tract Infections Age-Adjusted Death Rate due to Kidney Disease Maternal, Fetal & Infant Health Mothers who Smoked During Pregnancy Topic Score: 1.81 Babies with Very Low Birth Weight Babies with Low Birth Weight Infant Mortality Rate Teen Birth Rate Mothers who Received Early Prenatal Care Preterm Births Topic Indicator Period Score Men's Health Life Expectancy for Males

61 COMMUNITY HEALTH NEEDS ASSESSMENT - 61 Topic Score: 1.62 Prostate Cancer Incidence Rate Age-Adjusted Death Rate due to Prostate Cancer Mental Health & Mental Disorders Depression: Medicare Population Topic Score: 2.55 Age-Adjusted Death Rate due to Alzheimer's Disease Age-Adjusted Death Rate due to Suicide Alzheimer's Disease or Dementia: Medicare Population Poor Mental Health Days Older Adults & Aging Depression: Medicare Population Topic Score: 1.92 Rheumatoid Arthritis or Osteoarthritis: Medicare Population Osteoporosis: Medicare Population Age-Adjusted Death Rate due to Alzheimer's Disease Asthma: Medicare Population Chronic Kidney Disease: Medicare Population Alzheimer's Disease or Dementia: Medicare Population People 65+ Living Alone Hypertension: Medicare Population Diabetes: Medicare Population Hyperlipidemia: Medicare Population COPD: Medicare Population People 65+ with Low Access to a Grocery Store Ischemic Heart Disease: Medicare Population Stroke: Medicare Population Cancer: Medicare Population Heart Failure: Medicare Population People 65+ Living Below Poverty Level Diabetic Screening: Medicare Population Atrial Fibrillation: Medicare Population Mammography Screening: Medicare Population Age-Adjusted Death Rate due to Unintentional Prevention & Safety Injuries Topic Score: 2.30 Death Rate due to Drug Poisoning Severe Housing Problems Public Safety Child Abuse Rate Topic Score: 1.44 Age-Adjusted Death Rate due to Motor Vehicle Traffic Collisions Alcohol-Impaired Driving Deaths Topic Indicator Period Score Respiratory Diseases Asthma: Medicare Population

62 COMMUNITY HEALTH NEEDS ASSESSMENT - 62 Topic Score: 2.05 Age-Adjusted Death Rate due to Lung Cancer Lung and Bronchus Cancer Incidence Rate Age-Adjusted Death Rate due to Chronic Lower Respiratory Diseases Age-Adjusted Death Rate due to Influenza and Pneumonia Age-Adjusted ER Rate due to Pediatric Asthma Age-Adjusted Hospitalization Rate due to Bacterial Pneumonia Age-Adjusted ER Rate due to Adult Asthma Age-Adjusted Hospitalization Rate due to Asthma Age-Adjusted ER Rate due to Asthma Age-Adjusted ER Rate due to COPD Age-Adjusted Hospitalization Rate due to Adult Asthma Age-Adjusted ER Rate due to Immunization- Preventable Pneumonia and Influenza Age-Adjusted Hospitalization Rate due to Pediatric Asthma COPD: Medicare Population Age-Adjusted ER Rate due to Bacterial Pneumonia Age-Adjusted Hospitalization Rate due to COPD Age-Adjusted Hospitalization Rate due to Immunization-Preventable Pneumonia and Influenza Social Environment Single-Parent Households Topic Score: 2.19 Children Living Below Poverty Level Young Children Living Below Poverty Level People 65+ Living Alone Child Abuse Rate Voter Turnout Social and Economic Factors Ranking Substance Abuse Adults who Smoke Topic Score: 1.93 Death Rate due to Drug Poisoning Mothers who Smoked During Pregnancy Liquor Store Density Age-Adjusted ER Rate due to Alcohol Abuse Age-Adjusted Hospitalization Rate due to Alcohol Abuse Health Behaviors Ranking Adults who Drink Excessively Alcohol-Impaired Driving Deaths Topic Indicator Period Score Transportation Households without a Vehicle

63 COMMUNITY HEALTH NEEDS ASSESSMENT - 63 Topic Score: 1.95 Mean Travel Time to Work Workers Commuting by Public Transportation Workers who Drive Alone to Work Solo Drivers with a Long Commute Age-Adjusted Death Rate due to Motor Vehicle Traffic Collisions Households with No Car and Low Access to a Grocery Store Wellness & Lifestyle Life Expectancy for Females Topic Score: 2.04 Life Expectancy for Males Poor Physical Health Days Morbidity Ranking Self-Reported General Health Assessment: Poor or Fair Women's Health Life Expectancy for Females Topic Score: 1.18 Breast Cancer Incidence Rate Age-Adjusted Death Rate due to Breast Cancer Mammography Screening: Medicare Population DATA SOURCES The St. Vincent Data Platform utilizes indicator data from the following data sources: American Community Survey American Lung Association Annie E. Casey Foundation Centers for Disease Control and Prevention Centers for Medicare and Medicaid Services County Health Rankings Feeding America Indiana Hospital Association Indiana Secretary of State Indiana State Department of Health Indiana University Center for Health Policy Institute for Health Metrics and Evaluation National Cancer Institute National Center for Education Statistics National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Nielsen Claritas Small Area Health Insurance Estimates US Bureau of Labor Statistics US Census County Business Patterns US Department of Agriculture: Food Environment Atlas US Environmental Protection Agency

64 COMMUNITY HEALTH NEEDS ASSESSMENT - 64 Appendix C: Community Input Key Informant Interview Questions Questions that were asked during the Key Informant Interviews are presented below: Q1. Could you tell me a little bit about yourself, your background, and your organization? Q2. What are the major health needs/issues you see in the community? Q3. Who in your community appears to struggle most with these issues you ve identified and how does it impact their lives? Q4. Are there any barriers to receiving care in the community? Q5. Could you tell me about some of the strengths and resources in your community that address these issues, such as groups, initiatives, services, or programs? Q6. What advice do you have for a group developing a plan to address these needs? Q7. Is there anything else you d like us to note?

65 Appendix D: Prioritization Tools COMMUNITY HEALTH NEEDS ASSESSMENT - 65 Prioritization Matrix Tools Madison County This packet will help you assess each of the 10 pressing health needs identified by HCI s data analysis, and how each of those health needs relate to the criteria set forth by St. Vincent for prioritizing health topics in your service area. Please have a quick look through the packet, and then follow the directions below to score how well each of the health topics meets the prioritization criteria. After you have completed the ranking below, please submit your results on the Poll Everywhere software. The software will collate your results with those of other participants, and will instantaneously show the group s collective ranking of the most pressing health needs in your service area. Directions 1. On the following pages, score each health need for how well it meets each criteria: 1=does not meet criteria 2=could meet criteria 3=meets criteria 2. Add total scores for each health need and write total in Total Health Topic Score column. 3. Write the total scores for each topic in the table below. 4. Assign ranking to health needs based on total score, with highest score receiving a ranking of 1. If you have tying scores for health topics, assign rank as you see best fit. Please feel free to work in groups and ask questions of HCI staff and your colleagues! Health Topics Total Score Rank Social Environment Mental Health & Mental Disorders Prevention & Safety Kidney & Urinary Tract Diseases Respiratory Diseases Wellness & Lifestyle Economy Substance Abuse Exercise, Nutrition, & Weight Access to Health Services If you feel a health topic is missing from this list, please write it here:

66 COMMUNITY HEALTH NEEDS ASSESSMENT - 66 Social Environment Topic Score Health Topic Community Input (Total N=6) Key Themes from Community Warning Indicators from Secondary Data 2.19 Social Environment High rates of child abuse and neglect in the community; poverty and working poor households impacting younger population Single-Parent Households Children Living Below Poverty Level People 65+ Living Alone Prioritization Criteria Alignment w/ascension Health Strategies Healthcare that leaves no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Amongst Sub-Groups? Community Input Key Data Insights Key Themes from Community Input & Secondary Data Indicators indicate this issue affects poor & vulnerable populations No community organizations in Resource List who directly address this health topic. (Refer to Resource Handout) Are there community resources who could be potential partners? Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 200 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) No race or gender disparity data Cited by 1 out of 6 Key Informants How Well Does Health Topic Relate to Criteria 1=does not meet criteria 2=could meet criteria 3=meets criteria Total Health Topic Score

67 COMMUNITY HEALTH NEEDS ASSESSMENT - 67 Mental Health & Mental Disorders Topic Score Health Topic Community Input (Total N=6) Key Themes from Community Warning Indicators from Secondary Data 2.55 Mental Health & Mental Disorders Great need for mental health services in community; hard to keep up with volume of mental health referrals Depression: Medicare Population Age-Adjusted Death Rate due to Alzheimer s Age-Adjusted Death Rate due to Suicide Prioritization Criteria Alignment w/ascension Health Strategies Healthcare that leaves no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Amongst Sub-Groups? Community Input Key Data Insights Key Themes from Community Input & Secondary Data Indicators indicate this issue affects poor & vulnerable populations 2 community organizations in Resource List who address this health topic. (Refer to Resource Handout) Are there community resources who could be potential partners? Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 100 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) No race or gender disparity data in HCI data analysis Cited by 3 out of 6 Key Informants How Well Does Health Topic Relate to Criteria 1=does not meet criteria 2=could meet criteria 3=meets criteria Total Health Topic Score

68 COMMUNITY HEALTH NEEDS ASSESSMENT - 68 Prevention & Safety Topic Score Health Topic Community Input (Total N=6) Key Themes from Community Warning Indicators from Secondary Data 2.30 Prevention & Safety N/a, not mentioned as a top health need/concern during community input process Age-Adjusted Death Rate due to Unintentional Injuries Death Rate due to Drug Poisoning Severe Housings Problems Prioritization Criteria Alignment w/ascension Health Strategies Healthcare that leaves no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Amongst Sub-Groups? Community Input Key Data Insights Not enough data to determine in HCI data synthesis No community organizations in Resource List who address this health topic. (Refer to Resource Handout) Are there community resources who could be potential partners? Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 135 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) No race or gender disparity data in HCI data analysis Cited by 0 out of 6 Key Informants How Well Does Health Topic Relate to Criteria 1=does not meet criteria 2=could meet criteria 3=meets criteria Total Health Topic Score

69 COMMUNITY HEALTH NEEDS ASSESSMENT - 69 Kidney & Urinary Tract Diseases Topic Score 2.09 Health Topic Kidney & Urinary Tract Diseases Community Input (Total N=6) Key Themes from Community N/a, not mentioned as a top health need/concern during community input process Warning Indicators from Secondary Data Chronic Kidney Disease: Medicare Population Age-Adjusted Hosp. Rate due to UTIs Age-Adjusted ER Rate due to UTIs Prioritization Criteria Alignment w/ascension Health Strategies Healthcare that leaves no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Amongst Sub-Groups? Community Input Key Data Insights Not enough data to determine in HCI data synthesis No community organizations in Resource List who address this health topic. (Refer to Resource Handout) Are there community resources who could be potential partners? Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? No Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) Females more likely to visit ER or be hospitalized due to urinary tract infections Cited by 0 out of 6 Key Informants How Well Does Health Topic Relate to Criteria 1=does not meet criteria 2=could meet criteria 3=meets criteria Total Health Topic Score

70 COMMUNITY HEALTH NEEDS ASSESSMENT - 70 Respiratory Diseases Topic Score Health Topic 2.05 Respiratory Diseases Community Input (Total N=6) Key Themes from Community Asthma is a big health concern, stemming from high rates of smoking Warning Indicators from Secondary Data Asthma: Medicare Population Age-Adjusted Death Rate due to Lung Cancer Lung Cancer Incidence Rate Prioritization Criteria Alignment w/ascension Health Strategies Healthcare that leaves no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Amongst Sub-Groups? Community Input Key Data Insights Not enough data to determine in HCI data synthesis No community organizations in Resource List who address this health topic. (Refer to Resource Handout) Are there community resources who could be potential partners? Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 40 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) Females & African American children have higher hospitalization rates due to asthma Cited by 1 out of 6 Key Informants How Well Does Health Topic Relate to Criteria 1=does not meet criteria 2=could meet criteria 3=meets criteria Total Health Topic Score

71 COMMUNITY HEALTH NEEDS ASSESSMENT - 71 Wellness & Lifestyle Topic Score Health Topic 2.04 Wellness & Lifestyle Community Input (Total N=6) Key Themes from Community Issues with lifestyle choice problems; lack of interest among residents in managing their own health Warning Indicators from Secondary Data Life Expectancy for Females Life Expectancy for Males Poor Physical Health Days Prioritization Criteria Alignment w/ascension Health Strategies Healthcare that leaves no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Amongst Sub-Groups? Community Input Key Data Insights Not enough data to determine in HCI data synthesis No community organizations in Resource List who address this health topic. (Refer to Resource Handout) Are there community resources who could be potential partners? Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 60 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) No race or gender disparity data in HCI data analysis Cited by 2 out of 6 Key Informants How Well Does Health Topic Relate to Criteria 1=does not meet criteria 2=could meet criteria 3=meets criteria Total Health Topic Score

72 COMMUNITY HEALTH NEEDS ASSESSMENT - 72 Economy Topic Score Health Topic Community Input (Total N=6) Key Themes from Community 2.15 Economy High number of unemployed and working poor after loss of GM factory jobs; capacity and funding barriers as a result of economic issues Warning Indicators from Secondary Data Households with Cash Public Assistance Income Homeowner Vacancy Rate People Living Below Poverty Level Children Living Below Poverty Level Prioritization Criteria Alignment w/ascension Health Strategies Healthcare that leaves no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence Based Practices Are There Disparities Amongst Sub-Groups? Community Input Key Data Insights Key Themes from Community Input & Secondary Data Indicators indicate this issue affects poor & vulnerable populations 1 community organization in Resource List who address this health topic. (Refer to Resource Handout) Are there community resources who could be potential partners? Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 160 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) No race or gender disparity data in HCI data analysis Cited by 4 out of 6 Key Informants How Well Does Health Topic Relate to Criteria 1=does not meet criteria 2=could meet criteria 3=meets criteria Total Health Topic Score

73 COMMUNITY HEALTH NEEDS ASSESSMENT - 73 Substance Abuse Topic Score Health Topic 1.93 Substance Abuse Community Input (Total N=6) Key Themes from Community Issues of substance and e- cigarette abuse, especially among youth; high rates of prescription drug use and smoking among pregnant women Warning Indicators from Secondary Data Adults who Smoke Death Rate due to Drug Poisoning Mothers who Smoked During Pregnancy Liquor Store Density Prioritization Criteria Alignment w/ascension Health Strategies Healthcare that leaves no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Amongst Sub-Groups? Community Input Key Data Insights Not enough data to determine in HCI data synthesis 2 community organizations in Resource List who address this health topic. (Refer to Resource Handout) Are there community resources who could be potential partners? Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 175 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) Males have higher Age-Adjusted ER Rate and Hospitalization Rate due to Alcohol Abuse Cited by 6 out of 6 Key Informants How Well Does Health Topic Relate to Criteria 1=does not meet criteria 2=could meet criteria 3=meets criteria Total Health Topic Score

74 COMMUNITY HEALTH NEEDS ASSESSMENT - 74 Exercise, Nutrition & Weight Topic Score Health Topic 1.72 Exercise, Nutrition, & Weight Community Input (Total N=6) Key Themes from Community Childhood and adult obesity; lack of nutrition and personal accountability with diet; food insecurity Warning Indicators from Secondary Data Child Food Insecurity Rate Adults who are Obese Adults who are Sedentary Food Insecurity Rate Prioritization Criteria Alignment w/ascension Health Strategies Healthcare that leaves no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Amongst Sub-Groups? Community Input Key Data Insights Key Themes from Community Input & Secondary Data Indicators indicate this issue affects poor & vulnerable populations 1 community organization in Resource List who address this health topic. (Refer to Resource Handout) Are there community resources who could be potential partners? Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 190 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) No race or gender disparity data in HCI data analysis Cited by 4 out of 6 Key Informants How Well Does Health Topic Relate to Criteria 1=does not meet criteria 2=could meet criteria 3=meets criteria Total Health Topic Score

75 COMMUNITY HEALTH NEEDS ASSESSMENT - 75 Access to Health Services Topic Score Health Topic 1.54 Access to Health Services Community Input (Total N=6) Key Themes from Community Many residents are uninsured, can t afford health care, or don't know what services are available; trust and language barriers among Hispanic population and others in community Warning Indicators from Secondary Data Non-Physician Primary Care Provider Rate Preventable Hospital Stays Adults with Health Insurance Prioritization Criteria Alignment w/ascension Health Strategies Healthcare that leaves no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Amongst Sub-Groups? Community Input Key Data Insights Some key themes from Community Input indicate this issue affects poor & vulnerable populations 7 community organizations in Resource List who address this health topic. (Refer to Resource Handout) Are there community resources who could be potential partners? Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 100 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) No race or gender disparity data in HCI data analysis Cited by 6 out of 6 Key Informants How Well Does Health Topic Relate to Criteria 1=does not meet criteria 2=could meet criteria 3=meets criteria Total Health Topic Score

76 COMMUNITY HEALTH NEEDS ASSESSMENT - 76 Appendix E: Authors Heather Cobb, MPH HCI Public Health Consultant Project Lead Norwin Espiritu, MPH HCI Senior Researcher Lead Project Researcher Mari Rasmussen, MPH HCI Public Health Consultant Primary Data Specialist Nicolia Eldred-Skemp, MPH HCI Research Associate Project Support Claire Lindsay, MPH HCI Research Associate Project Support Yelena Meisel, MPH HCI Director of Consulting Services Project Advisor

77 COMMUNITY HEALTH NEEDS ASSESSMENT - 77 Appendix F: Community Input Report for Madison County The purpose of this work is to provide a report of the input from community members about the health needs of Madison County. It is designed to be either a stand-alone report or appendix to the Community Health Needs Assessment (CHNA) report prepared by the Healthy Communities Institute (HCI). Using results from the CHNA report, the top three system-wide health priorities were identified as: Behavioral Health Access to Health Services Exercise, Nutrition, and Weight For this reason, this report will focus on the interpretation of the sample results for these priorities. NOTE: Behavioral health consists of the health needs: mental health/mental disorders, substance abuse, and smoking/tobacco use. The decision to fold these health needs into one health priority was obtained through group consensus during sessions. Details about the methods and analysis, results, interpretation, and a conclusion comprise the report. METHODS Take the Survey Your Input Counts! survey is an online, opinion tool designed by a collaborative of four hospital systems to gather community input about the health needs in Indiana (n=92 counties) [1]. The survey contains 20 closed questions (with optional Comment box) and collects information at the county level from October 1, 2014 to August 31, 2015 (see Supplement - Survey). Questions for this survey and those used by HCI in the CHNA prioritization session and key informant interviews were developed independently of each other. This sample s respondents were not administered the same survey given in the session and interview however, questions assessing similar health needs were identified. Areas of apparent differences and congruency are highlighted in this report. A total of 7,102 responses were received from Indiana residents. For this report, county (county=madison) and zip code within the county were used as inclusion criteria for this report (see Supplement Zip Codes) [2]. The initial sample included 126 respondents. Exclusion criteria applied to the initial sample were records outside data collection period, zip codes outside of the county, or incomplete/incorrect zip codes (n=11). After applying the exclusion criteria, 115 respondents (1.62%) self-identified as Madison County residents. Descriptive statistics were performed using Microsoft Excel and analytic tools within Survey Monkey. RESULTS Table 1 provides demographic results for the sample s respondents. Race and ethnicity were reflective of HCI findings [3]. Most of the respondents self-identified as Caucasian (n=105, 91.30%). Ethnicity was 1.74% (n=2). The majority of respondents were between and years old (n=29, 25.55%, respectively). The most frequently reported household income range was $50,000-74,999 (n=26, 23.42%).

78 COMMUNITY HEALTH NEEDS ASSESSMENT - 78 Table 1. Respondent Demographics Characteristics n (%) Race/Ethnicity Age Range (years) Household Income Range Education American Indian/Alaskan Native Asian/Pacific Islander Black/African American White/Caucasian Burmese Hispanic $0-24,999 $25,000-49,999 $50,000-74,999 $75,000-99,000 $100, ,999 $125, ,999 $150, ,999 $175, ,999 $200,000 and up Did not finish high school/no GED High school diploma/ged Some college Technical/trade school Associate s degree Bachelor s degree *The survey allowed multiple selections for race/ethnicity. 34 (3.01%) 23 (2.04%) 266 (23.54%) 805 (71.24%) 3 (0.27%) 57 (5.04%) *Respondents=1,130 (100%) 75 (6.64%) 210 (18.58%) 191 (16.90) 233 (20.62%) 262 (23.19%) 159 (14.07%) Respondents=1,130 (100%) 196 (17.98%) 276 (25.32%) 221 (20.28%) 141 (12.94%) 121 (11.10%) 42 (3.85%) 38 (3.49%) 20 (1.83%) 35 (3.21%) Respondents=969 (85.75%) 32 (3.42%) 74 (7.90%) 141 (15.05%) 39 (4.16%) 47 (5.02%) 319 (34.04%) 285 (30.42%) Respondents=937 (84.18%) Respondents were asked in Question 3 to, Select the top five health needs in your community (city/town/neighborhood/zip code) [1]. Predetermined needs were presented and ranked by respondents from 1 to 5 (top health need=1, descending scale to 5). The majority (n=105, 91.30%) ranked substance abuse as the top health need in Madison County. The four other identified health needs were obesity (n=80%), mental health (n=78, 67.83%), smoking and tobacco use (n=69, 60.00%), and access to healthcare (n=57, 49.57%). Aggregate rankings for the remaining health needs are provided in Figure 1.

79 COMMUNITY HEALTH NEEDS ASSESSMENT Figure 1. Frequencies of Reported Health Needs Frequency Substance abuse (alcohol, other drugs)=105 Obesity=80 Mental health (depression, anxiety, sadness)=78 Smoking and tobacco use=69 Access to healthcare=57 Question 5 of the survey asked respondents to Select the top 3 ways to improve mental health in your community [1]. Response scheme was similar to Question 3. Ways to improve mental health were presented in a list format and respondents ranked each way in order from 1 to 3 (top way=1, descending scale to 3). Most respondents indicated that an increase substance abuse programs and resources was the top way to improve mental health in Madison County (n=65, 56.52%). The two other ways that rose to the top were increased awareness of mental health services (n=59, 51.30%) and increased substance abuse programs/resources and prevention programs (n=54, 46.96%, respectively). Findings for the remaining ways to improve mental health are provided in Figure Figure 2. Frequencies of Reported Ways to Improve Mental Health Frequency Increase substance abuse program and resources=65 Increase awareness of mental health services=59 Increase prevention programs=54 Increase programs for mental health problems (depression, anxiety, and suicide)=52 Increase number of treatment facilities=43 Increase mental health screenings from doctor=39 Increase mental health treatment from doctor=21 Not a problem= Access to healthcare services was assessed in Question 12 (see Figure 3). Respondents chose the top three challenges to their household when receiving healthcare and ranked them in order from 1 to 3 (top challenge=1, descending scale to 3). No problems receiving health services (n=61, 53.04%) was the most frequent response.

80 COMMUNITY HEALTH NEEDS ASSESSMENT - 80 Cost of co-pay (n=43, 37.39%) and limited hours at doctor s office (n=30, 26.08%) were the most common challenges to health services indicated by respondents. Figure 3. Perceived Challenges to Receiving Health Services Question 4 collected respondents opinions about reasons why obesity was a health problem in their community. Respondents ranked perceived reasons in order from 1 to 3 (top challenge=1, descending scale to 3). Most respondents indicated that an unhealthy diet and exercise habits was the main reason for obesity in Madison County (n=90, 78.26%). The two other reasons that rose to the top were access to healthy and affordable foods (n=88, 76.52%) and not promoting healthy habits in the community, schools, and churches (n=61, 53.04%). Findings for the remaining opinions about reasons for obesity are provided in Figure 4.

81 COMMUNITY HEALTH NEEDS ASSESSMENT Figure 4. Perceived Reasons for Obesity Frequency Unhealthy diet and exercise habits=90 Access to healthy and affordable foods (fruits & vegetables)=88 Not promoting healthy habits in our community, schools, and churches=61 Lack of recreation, physical activity programs=36 Lack of sidewalks, bike trails=24 Safety reasons (personal, traffic, neighborhood)=13 Access to parks and places to exercise=11 Not a problem=4 4 Question 10 assesses the conversation topics that respondents are having with their doctor. A select all that apply response scheme was used to collect the data [1]. Exercise (n=55, 47.82%) and diet or nutrition (n=44, 38.26%) were the most frequently reported conversation topics. Use/misuse of prescribed medication (n=5, 4.34%) and domestic violence or abuse (n=2, 1.73%) were the least reported topics (see Figure 5). Figure 3. Conversation Topics with Doctors