Community Health Needs Assessment (CHNA) & Action Plan Update 2015

Transcription

1 Community Health Needs Assessment (CHNA) & Action Plan Update 2015 Prepared pursuant to section 501(r) of the Internal Revenue Code and posted for public review December 2015.

2 Table of Contents Introduction... 1 Page Summary... 1 Description of the Olmsted Medical Center... 6 Table 1: OMC Medical and Surgical Services... 6 Description of the Community... 7 Figure 1: Map of Olmsted Medical Center s Primary Service Area... 7 Table 2: Ethnicity of Olmsted County Residents... 7 Table 3: Age Distribution of Olmsted County Residents... 7 Internal CHNA Work Group... 9 Acknowledgements Appendix 1: Membership of the CHNA Core Group, Data Subgroup, and HAPP group Exhibit 1: Summary of the Olmsted County Community Health Improvement Plan

3 Introduction Under the provisions of the Affordable Care Act of 2010, the Olmsted Medical Center is required to conduct a formal community health needs assessment every three years. The assessment is to include identification of the most pressing healthcare issues in the community, implementation of programs to address these issues, and documentation of progress towards meeting the needs on the annual Form 990 report. The Olmsted Medical Center completed its assessment and implementation strategy in 2013, filed a summary report in 2014, and documents the details of the plan progress during 2015 in this summary report. Summary To arrive at a true community-based health needs assessment, Olmsted Medical Center (OMC) collaborated with Olmsted County Public Health Services (OCPHS) and Mayo Clinic. These organizations have a long history of cooperation and collaboration with each other, as well as with other community partners, in addressing local health issues. The three organizations agreed that a joint health needs assessment survey was the best strategy for the community and began discussions in early 2012 regarding the opportunity to work together on a community health needs assessment (CHNA). The collaborative is referred to as the Olmsted County CHNA Core Group. The CHNA survey was completed in 2013, and the top five community health priorities were identified as mental health, obesity, diabetes, vaccine preventable diseases, and homelessness/financial stress. OMC determined that the homelessness/financial stress priority was beyond the scope of OMC s mission and resources; however, OMC does provide financial assistance for medical care for eligible patients and also participates in the community-wide efforts to address this most difficult issue. OMC has been involved with the monthly Olmsted County CHNA and Community Health Improvement Plan (CHIP) Core Group meetings, the monthly CHNA Data Subgroup meetings, and the quarterly Health Assessment and Planning Partnership (HAPP) meetings (see Appendix 1: Olmsted County CHNA and CHIP Core Group members, CHNA Data Subgroup members, and HAPP community partners). The above work groups are working collaboratively on a community-wide health improvement plan (CHIP) involving the top five designated community health priorities. OMC currently is an active partner with the individual work groups associated with mental health, diabetes, obesity, vaccine preventable diseases, and poverty/financial stress and homelessness. These work groups either meet monthly or quarterly. Each work group is responsible for reviewing and evaluating the CHIP summary, making recommendations to the goals and strategies, and developing appropriate measurements for community health improvement or change (see Appendix 2: Olmsted County CHIP summary). OMC developed its own internal work plan to address four of the priority health issues. The summary of that plan and its implementation during this reporting period are as follows: Mental health: OMC believes that access to mental health services, particularly early diagnosis and treatment, is a critical step in addressing mental health issues in the community. Because of the great demand for mental health services and the limited number of psychiatry and psychology clinicians, primary care clinicians are often the first clinicians to evaluate patients with mental health diagnoses. There is a growing need for primary care clinicians to be prepared to diagnose and treat those patients that can be managed in the primary care setting. OMC has been educating primary care clinicians through educational programs to improve their abilities to care for the mental health concerns of their patients. In 2015, OMC psychiatry and psychology clinicians provided educational presentations on evaluating mental health concerns for other clinicians at monthly department meetings at Olmsted Medical Center, at Clinical Case Reviews within the Department of Psychiatry/Psychology, and at Clinical Staff Meetings. Since 2013, OMC held six CME offerings related to mental health issues that included areas of chronic disease management, addiction medicine, pain management, and new developments regarding the use of medical cannabis. These areas are all closely linked to the mental health of OMC patients: Addictions in Pregnancy by Dr. Charles Schauberger (external consultant), December 2013 Child Abuse in Primary Care by Dr. Arne Graff (external consultant), August 2014 Smoking Cessation by Dr. Jeffrey Poterucha (external consultant), November rev1215 [1]

4 Diabetes and Psychology led by Dr. Erin Sterenson (internal consultant), February 2015 Minnesota s Medical Cannibus Update by Dr. Tom Arneson (external consultant), May 2015 Topical Treatments for Pain Management by Dr. Bernard Quebral (external consultant), July 2015 The OMC Psychiatry/Psychology department is located in the OMC Rochester Southeast Clinic, while outreach clinicians see patients in the OMC Rochester Southeast Family Medicine department, OMC Byron Clinic, OMC Rochester Northwest Clinic, and the OMC Women's Health Pavilion. OMC has also initiated a palliative care program that includes the services of a psychologist as part of the multispecialty consult team. Psychology consultations are also used in conjunction with bariatric surgery evaluations. Further, OMC is providing treatment for opioid and heroin addiction with Suboxone therapy. OMC has also partnered with the University of Minnesota Rochester (UMR) to offer student psychology services at the OMC Skyway Clinic. Clinicians are also available for phone support to UMR staff. Psychiatry and psychology services have also reached OMC s branch clinics and community nursing homes through telemedicine. Telemedicine visits for 2014 totaled 144 and reached patients in 20 different zip codes. Year-to-date telemedicine visits, as of November 2015, totaled 80 and reached patients in 12 different zip codes. In 2015, a new flow chart for assessing level of risk and steps to address imminent risk of a suicidal patient were developed and have been available to clinicians, nursing staff, and triage services. OMC has been actively recruiting more psychology and psychiatry clinicians to fill the gaps in the care for those in our community. During 2016, OMC plans to reinitiate meetings with other community mental health providers to discuss the community's most current mental health needs. OMC continues to assist in producing a comprehensive resource booklet on available mental health services and sources of care in Olmsted County. This resource is also available to OMC staff on the OMC intranet. OMC supported the Southeastern Minnesota chapter of the National Alliance on Mental Illness ( and the Homeless Community Network in this effort. This continues to be a resource for staff to make appropriate patient referrals to community organizations. Adult obesity: OMC believes that exercise is an important component of weight control and good health, and participates in several approaches to promote regular exercise within the community. In 2012, OMC opened its Sports Medicine and Athletic Performance (SMAP) building in Northwest Rochester and offers easily accessible exercise classes. OMC Sports Medicine and Athletic Performance department has offered group fitness classes and exercise programs at no cost to all OMC employees and their dependents through March 31, In 2014, there were 11,467 visits to SMAP (3,392 OMC employee visits and 8,075 community member visits). As of November 2015, reports show 10,306 visits (3,817 OMC employee visits and 6,489 community member visits). At community outreach events, OMC provides information regarding basic exercise facts and the relationship of regular exercise and obesity prevention to longevity and good health. OMC is working with its Health Care Home Patient Advisory committee to discuss ideas with these patient advisors. This year to date, OMC has participated in 53 community outreach events including health fairs, UMR student orientation, Healthy Kids Day at the YMCA, sports tournaments, and other special events to promote weight control and good health. OMC has used its telemedicine capabilities to offer weight management counseling services to patients from surrounding areas who are unable to travel to Rochester because of illness, disability, or financial concerns. Nutrition counseling services delivered via telemedicine totaled 13 in 2014 and 14 as of November In October 2013, OMC began identifying, monitoring, and counseling pediatric patients aged 3-17 that are above the 85 th percentile for their recommended body mass index (BMI). This information is reported to Minnesota Community Measurement as a quality measure. This health management indicator has allowed clinicians to document the counseling, education, and referrals that the patient and family have received to help manage obesity. This indicator may be used in the future for the adult population to help document the management of obesity. After starting the pediatric measurements in October 2013, the number of referrals to Patient Education for nutrition counseling increased from 29 in 2013, to 109 in 2014, and 160 as of November rev1215 [2]

5 Vaccine preventable diseases: Annually, OMC, Olmsted County Public Health Services, and Mayo Clinic collaborate with surrounding schools in the area to bring influenza immunizations directly to the students during their school day. Both OMC and Mayo Clinic supply support personnel to each school and administer influenza immunizations with parental permission to students in grades K-9 in public and private schools. In 2013, 4,305 immunizations in 30 schools were administered. During 2014, the number of schools was expanded to 35, and 6,126 influenza immunizations were given collectively by OMC and Mayo Clinic. In 2015, the school-based clinics were increased to 42, and 5,288 influenza immunizations were given collectively by OMC and Mayo Clinic. The immunization rates were lower in 2015 due to a delay in manufacturer supply of the FluMist immunizations. OMC did trial a Saturday public immunization clinic at its Rochester Northwest clinic in the Fall of The clinic did not have many participants and was not repeated into 2014 or In the coming years, OMC plans to continue with community-wide efforts to expand the school immunization program. OMC has worked to identify its adolescent and adult patients who lack appropriate tetanus, diphtheria, pertussis, or meningococcal immunizations, and notifies the patient and family to visit the clinic of their choice to receive the appropriate vaccine. OMC is currently using pre-visit planning to identify immunization needs of patients before their scheduled visits. Needed immunizations are administered by the nursing staff according to approved standing orders for immunizations of children over the age of 10 years (as well as adults). The Immunization Core Team makes recommendations regarding new immunization (such as PCV-13, HPV-9, Meningitis B vaccines) after verifying insurance coverage. High-risk patients, including those with diabetes, asthma, and congestive heart failure who lack recommended immunizations, are identified through chronic disease and immunization registries, and are encouraged through telephone calls or other reminders (including computer-generated letters that are sent by mail) to receive the needed immunizations. OMC will continue to use its MyOMC secure online patient portal where feasible to promote this communication. OMC clinicians continue to receive regular updates regarding the newest vaccine recommendations. In 2014, recommendations for adults changed regarding the pneumococcal conjugate vaccine (PCV-13). With ongoing education of the clinical staff on immunization recommendations, OMC has been able to work collaboratively to increase the adult immunization rates. Adult PCV-13 immunizations have improved significantly during 2014 and 2015 following the new recommendations: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Over the last year, the immunization numbers have doubled and, in some cases, nearly tripled. Diabetes: During the last decade, OMC has been working on improving the care of patients with diabetes and continues to make improvements in control parameters that are publicly reported through Minnesota Community Measurement ( The OMC Diabetes Core Team is led by an endocrinologist and includes an advanced-practice clinician, diabetes nurse educators, other nurses, dietitians, and quality improvement specialists. OMC maintains a registry of more than 2,500 patients with diabetes which enables management of this population through regular reviews of diabetes care during office visits, identification of gaps in care, follow-up phone calls to schedule overdue appointments and appropriate tests, and pre-visit planning to make the most efficient use of each patient s time with the clinician. Registry information is reviewed at OMC Diabetes Core Team meetings and is shared with the Quality and Patient Safety Committee rev1215 [3]

6 During 2014, OMC Family Medicine department adopted a quality-improvement project to increase the percentage of patients with diabetes that received or maintained optimal care. Optimal care is considered to be an HgA1C < 8, HgA1C in the last 12 months, statin use, no tobacco use, blood pressure less than 140/90, and documentation of ASA/Plavix use. The goal was met for the period October 1, 2013 to October 1, 2014, and the clinical optimal care percentage increased from 31.82% (826/2596) to 37.82% (1078/2856). This improvement was due largely to the united efforts of the Diabetes Core Team, the clinical nursing staff, clinicians, and the participating patients. During 2015, OMC has continued to see overall improvement in the diabetes optimal care percentages, which rose to 42.05% (1203/2861) in In 2016, The OMC Family Medicine department plans to continue its focus on diabetes optimal management. The Internal Medicine and Family Medicine department s 2016 performance goals also will focus on the improved management of hypertension. Improved management of hypertension will also improve our diabetes optimal care percentages, as a large portion of patients with diabetes cannot attain optimal care of diabetes because of their blood pressure readings. The Diabetes Core Team developed patient-specific action plans and standing orders for following the diabetes protocol related to laboratory monitoring. Standardized laboratory orders are in use when ordering pre-visit laboratory studies and at every clinical visit. Visit summaries include a diabetic care plan that can be completed prior to discharge to educate patients on their current lab values, their goals, and the plan to improve to optimal care. An emphasis on diabetes education has continued to be an important aspect of self-management of this chronic disease. Basic diabetes education is begun with nursing staff within the organization. Diabetes educators are available for more in-depth education. All OMC educators use the teach-back method to assess the knowledge gained by patient s receiving formal diabetes education. Telemedicine visits are being utilized at OMC branch clinics for patients that are unable to travel to Rochester clinic locations to provide patients with diabetes education. There were 65 telemedicine diabetes education appointments in 2014 and 59 visits in The patient education department has initiated a program to evaluate patients with diabetes prior to surgery to provide education regarding diabetes management during the pre- and post-surgical periods. Additional Community Collaborative Efforts OMC is currently participating in additional collaborative efforts throughout the community. The Southeast Minnesota Partnership for Community-Based Health Promotion is a collaborative that started in This collaboration of regional stakeholders aims to facilitate and maintain sustainable clinical-community linkages for evidence-based health promotion programs. The current evidence-based program being promoted is the Chronic Disease Self-Management Program (CDSMP), also known as, Living Well with Chronic Conditions. The CDSMP is a group workshop designed to help participants build confidence in managing their chronic conditions and maintaining their health. Participants are adults with one or more chronic conditions such as arthritis, diabetes, asthma, high blood pressure, heart disease, cancer, chronic pain, anxiety, and depression among others. This program is currently offered in the community through Elder Network, a regional non-profit social service organization. The current programs offered in the 12-county region of southeastern Minnesota are underutilized, and many have been cancelled due to low participation. OMC had previously offered this program, but was unable to continue due to low participation and lack of facilitation staff. OMC is actively participating in bi-weekly meetings to improve awareness of this program in the community, has sent three clinical staff to a four-day training program so OMC can facilitate meetings within our organization and in the community, and plans to educate clinicians further about this program. OMC has partnered with Mayo Clinic, Olmsted County Public Health, Intercultural Mutual Assistance Association (IMAA), and Elder Network to develop a Community Care Team (CCT). The CCT is supported through an Accountable Communities for Health-State Innovation Model (ACH-SIM) grant through the Minnesota Department of Health. These partners form an interdisciplinary community-based team that meets with an OMC Health Care Home (HCH) patient to develop a patient-oriented action plan. The CCT helps adults and their families or support persons to manage their chronic health conditions. This is a rev1215 [4]

7 week program that uses a wrap-around model to connect clients to community services and health providers to improve their overall health and independence. A public health nurse and a community health worker meet with the client in their home for an initial evaluation. The team then meets with the client and a support person to develop the patient-oriented action plan. This plan is implemented over the course of the next 12 weeks, and then a second meeting is scheduled to review the outcomes and help with any additional planning. Many of these clients are unable to manage their healthcare well due to unmet basic needs (e.g., housing, food, finances, medical insurance, and social support). This program was originally limited to the HCH-enrolled patients, but in 2016, OMC s plan is to expand this program to all primary or specialty care clinical areas. A Refugee Health Collaborative is meeting quarterly to discuss the needs and deficits seen in our systems related newly arrived refugees in our community. This collaboration includes Mayo Clinic, Olmsted County Public Health Services (OCPH), Olmsted County Community Services, and OMC. Challenges exist through the continuum of care starting with scheduling an appropriate follow-up after an initial refugee evaluation is done at OCPH. Each refugee needs to be treated as an individual and have their needs and care tailored to themselves and their family, yet this collaboration recognizes the need to help streamline primary care, mental health care, resources, and referrals. Navigation in the community and medical systems is difficult due to facility and system complexity, language barriers, barriers to sharing information between providers, and mental healthcare needs within the refugee populations. The Refugee Health Collaboration will continue to meet and collaborate to improve the care of this population in our community rev1215 [5]

8 Description of the Olmsted Medical Center Located in Rochester, Minnesota and surrounding communities, Olmsted Medical Center ( is an integrated community healthcare provider known for convenient, easily accessible, and personalized primary care delivered in small clinic and hospital settings. Olmsted Medical Center offers the services of more than 20 medical and surgical specialists (Table 1). By written policy, OMC accepts all patients regardless of race, religion, age, gender, sexual orientation, source of payment, or ability to pay. As a 501(c)3 tax exempt healthcare organization, OMC cares for patients regardless of their ability to pay, and in 2014 provided community benefits of over $49 million (29.39% of total operating expenses). OMC employs 156 clinicians and nearly 1,200 staff who provide healthcare services at 18 locations including two multi-specialty outpatient clinics in Rochester; physical and occupational therapy and sports medicine facilities; two walk-in FastCare retail clinics; a clinic in downtown Rochester providing care to the general public and University of Minnesota Rochester students; a Level IV trauma hospital licensed for 61 beds with a 24-hour emergency department and BirthCenter; and primary-care branch clinics in 10 southeastern Minnesota municipalities (Figure 1). OMC is the sole healthcare provider in eight of these communities. During 2014, OMC provided over 296,000 clinician visits for 80,452 individual patients, delivered 873 babies, and performed over 3,800 surgical procedures. Our Mission: The delivery of exceptional patient care focusing on caring, quality, safety, and service. Our Vision: To be the healthcare provider of choice in our service area by leading in quality, access, and service. Our Core Values: Our patients come first. Every employee is a caregiver. Our employees are the key to our success. OMC is an active, contributing partner in the communities it serves. We have a duty to position and prepare OMC for the future. Table 1: OMC Medical and Surgical Services Advanced Wound Healing Anesthesiology Anticoagulation Asthma & Allergy Audiology Bariatric Surgery Cardiology Dermatology Ear, Nose and Throat Emergency Medicine Endocrinology Family Medicine General Surgery Internal Medicine Neurology Obstetrics/Gynecology Occupational Health Ophthalmology Optometry Orthopedics & Sports Medicine Pain Management Pediatrics Plastic Surgery Podiatry Psychiatry/Psychology Radiology Rehabilitation Services Respiratory Therapy Sleep Medicine Sports Medicine & Athletic Performance Travel and Immunization Urology rev1215 [6]

9 Description of the Community OMC considers the community it serves to be all of those patients who elect to receive services at its clinics and hospital, and estimates that 92,000 patients in its service area receive most or all of their primary care at OMC, although all patients are not seen annually. The majority of these patients reside in Olmsted County. OMC also believes that it has a duty to serve the community at large by working with the Olmsted County Public Health Service, other county health services, and other local organizations on health issues of general interest. The community health needs assessment described here involves Olmsted County, Minnesota, which includes the cities of Rochester (population 106,769), Byron (population 4,914), Chatfield (population 1,206), Dover (population 735), Eyota (population 1,977), Oronoco (population 1,300), Pine Island (population 703), and Stewartville (population 5,916). The total population of the county was estimated at 147,066 in About 70% of Olmsted County residents live in the city of Rochester. The ethnicity of the county population is shown in Table 2, and the age distribution is shown in Table 3. The demographics and ethnicity of the small communities that OMC serves outside of Olmsted County are similar except for an average age of about 10 years older than the Olmsted County population and less racial and ethnic diversity. For the years , 8.1% of Olmsted County residents lived at or below the national poverty level. Of note is that minorities now make up over 17% of the Olmsted County population; and 12.4% of the people over the age of 5 speak a language other than English in their homes. The Olmsted County School District reports that the most prevalent languages are Somali, Spanish, Cambodian (Khmer), Arabic, Vietnamese, Chinese, Lao, and Bosnian. Figure 1: Map of Olmsted Medical Center s Primary Service Area Table 2: Ethnicity of Olmsted County Residents Caucasian... 87% Asian % Black % Latino % American Indian and Alaska Native % Hawaiian and Pacific Islander % Source: Table 3: Age Distribution of Olmsted County Residents Under age % Under age % Age % Over % Source: graphics/documents/demographicsworkforce2011s tatewide.pdf rev1215 [7]

10 In addition to the Olmsted Medical Center, there are several other healthcare resources and providers in Olmsted County as follows: The Bluestem Center ( provides multidisciplinary evaluation with long-term follow-up for children, adolescents, and adults, with close integration of school and community support services. Bluestem specializes in complex learning and behavior problems, including neurodevelopmental disorders. Examples include adolescent mental health, attachment issues, Attention Deficit/Hyperactivity Disorder, Autism and Asperger s Disorder, habit and tic disorders of childhood, interdisciplinary treatment planning, pervasive developmental disorders, play therapy, Post Traumatic Stress Disorder, and Tourette s Syndrome. The Mayo Clinic ( is a well-known healthcare system with locations in southeast Minnesota, southwestern Wisconsin, and northern Iowa. It operates two hospitals in Rochester and a very busy emergency department and trauma center serving all residents in Olmsted County, including uninsured and under-insured patients. OMC and Mayo Clinic share many patients and have a long-standing collaborative and cooperative relationship. The Migrant Health Clinic ( serves migrant farm workers and their families in the community who are visiting Rochester and Olmsted County as migrant farm workers. OMC provides physician supervision for the physician assistant who staffs the Migrant Health Clinic. The Olmsted County Public Health Department ( provides a broad spectrum of health and social services to residents of Olmsted County. In particular, OCPHS has received grants from the Minnesota Department of Health for work on the State Health Improvement Project, which concentrates efforts to address the problems of tobacco use, nutrition including infant nutrition, obesity, and physical activity. OMC has been a significant partner with OCPHS regarding infant nutrition and breastfeeding. The Salvation Army Good Samaritan Clinic ( offers free medical and dental services to uninsured residents and refers many patients needing additional medical services to the Olmsted Medical Center. The Zumbro Valley Health Center ( provides adult and child psychotherapy, chemical dependency counseling, case management, crisis services, pharmaceutical services, emergency housing services, and a dental clinic to underinsured residents of Olmsted County. OMC shares many patients with the Zumbro Valley Mental Health Center rev1215 [8]

11 2015 OMC Community Health Needs Assessment Work Group Jamie Breuer, Obesity CHIP work group Brenda Brown, MD CHNA/CHIP core group, Diabetes CHIP work group lead, Mental Health CHIP work group Shelli DeGeus Vaccine preventable disease CHIP work group Lisa Dieser Vaccine preventable disease CHIP work group Erica Hansen Poverty, financial stress and homelessness CHIP work group Lynne Hemann Obesity CHIP work group Randy Hemann, MD Kevin Higgins Jeffrey Gursky, MD Mental health CHIP work group Kathryn Lombardo, MD Michelle Maeder-Hickey Chuck Meyer Kalpana Muthusamy, MD Diabetes CHIP work group Kelly Owens Matthew Peterson Gary Ryba Jeremy Salucka CHNA/CHIP core group Wendy Scheckel Tricia Schilling, LICSW Kasey Trageser Stacey Vanden Heuvel CHNA/CHIP core group Elizabeth Vermilya Obesity CHIP work group Tim Weir Linda Williams, MD CHNA data subgroup Barbara Yawn, MD CHNA data subgroup rev1215 [9]

12 Acknowledgements The Olmsted Medical Center wishes to express its thanks to the Olmsted County Public Health Service, Mayo Clinic, and all of the other participating organizations for their valuable contributions in the planning and conduct of this community health needs assessment. This was a genuine community effort that resulted in the strengthening of existing relationships and the formation of new relationships that will serve the community well as the organizations continue to work together to address the most significant health problems facing the people of this county rev1215 [10]

13 Appendix 1: Membership of the Olmsted County CHNA Core Group, Data Subgroup, and the Health Assessment and Planning Partnership CHNA Core Group Membership Organizations Olmsted County Public Health Services Olmsted Medical Center Mayo Clinic United Way of Olmsted County Data Subgroup Membership Organizations Olmsted County Public Health Services Olmsted County Community Services Olmsted Medical Center Mayo Clinic Olmsted County Planning Department United Way of Olmsted County Health Assessment and Planning Partnership (HAPP) Membership Organizations Channel One Regional Food Bank Diversity Council Elder Network Families First of Minnesota (Childcare Resource and Referral/Head Start) Family Service Rochester IMAA Migrant Health Services National Alliance on Mental Illness (NAMI) of SE Minnesota Olmsted County Community Services Olmsted County Public Health Services Olmsted Medical Center Mayo Clinic Migrant Health Rochester Area Family Y Rochester Area Foundation Rochester Center for Autism Rochester Community and Technical College Rochester Public Library Rochester Public Schools Salvation Army Seasons Hospice Southeastern Minnesota Area Agency on Aging United Way University of Minnesota Rochester Zumbro Valley Health Center rev1215 [11]

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15 Community Health Improvement Plan Olmsted County, Minnesota Making the Healthy Choice the Easy Choice Prepared by: Olmsted County Public Health Services Updated September 8, 2015

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17 Table of Contents Executive Summary...4 Introduction...5 Olmsted County Community...6 Demographics...6 Collaborative Nature...7 Community Health Improvement Plan Context...8 Purpose...8 Framework...9 Process...9 Timeline...11 Health Assessment and Planning Partnership...12 Partnership Representation...12 Team Vision and Goals...12 Community Health Priorities and Strategies...13 Prioritization Process...13 Community Priorities...14 Obesity...17 Diabetes...21 Mental Health...25 Vaccine Preventable Diseases...29 Financial Stress/Homelessness...33 Overarching Strategies...36 Alignment with State and National Priorities...37 Our Future Health: From Planning to Action...38 Implementation...39 Monitoring and Evaluation...40 Sustainability...41 Record of Changes and Updates...42 List of Appendices

18 Executive Summary Health and overall well-being are not confined solely within medical offices in fact, the introduction starts in our homes, schools, places of work, and communities. There are many influences to good health: eating well and staying active, refraining from unhealthy behaviors, adhering to the recommended immunizations and screening tests schedules, and managing stress levels. However, overall health is also determined by numerous social and economic factors: the resources and supports available in our homes and communities (i.e., financial, educational, social and health care); the cleanliness of our water, food and air; the perception and true safety of our communities; and the nature of social relationships. Olmsted County residents all deserve an equal opportunity to make the choices that lead to good health and to ultimately: make the healthy choice, the easy choice. To ensure that that opportunity proceeds with success, advances are needed not only in health care and public health, but also across and throughout the entire community, including: education, housing, community services and planning, and infrastructure. The current Community Health Improvement Plan (CHIP) serves as the first step towards true community-centered planning, integration, and implementation of strategies to improve our community s health. CHIP partners and additional community organizations will work together to promote health equity throughout diverse populations and address social determinants of health to improve health outcomes in five priority areas: Obesity, Diabetes, Mental Health, Vaccine Preventable Diseases, and Financial Stress / Homelessness. 4

19 Introduction Public health departments across the nation have a long history of monitoring, reporting on, and improving the health of local communities, and this holds true for Olmsted County Public Health Services. Additionally, local public health departments are held responsible for the prevention, promotion, and protection efforts throughout communities. However, it is widely-known that these efforts cannot be done independently by public health. Public health, healthcare, non-profit organizations, private sector and other community-based sectors need to partner together to: (1) identify community health issues; (2) prioritize issues; and (3) work towards improving community health. The Olmsted County community has partnered together to develop one local assessment and planning process to develop two guiding documents: the Community Health Needs Assessment and the Community Health Improvement Plan. The assessment and planning process has been initially created to encompass two main stages: Phase I and Phase II. Throughout both Phase I and II, significant community involvement remains as the highest priority. Any plan is only practical and useful, or even helpful if it makes it to the implementation stage. Phase II of the assessment and planning process will revolve around future efforts, beginning in 2015, to: identify and implement community initiatives and activities; and monitor and evaluate the impact on improving the community s health. During this phase, all identified community initiatives and activities will be monitored and assessed for progress. Additionally, adjustments will be made as appropriate to ensure the community strategies and overall Community Health Improvement Plan remains relevant. This Community Health Improvement Plan serves as a reflection of the community s readiness, excitement, and eagerness for collective action to improve Olmsted County s health. Phase I of the assessment and planning process is grounded in the efforts that launched the Community Health Needs Assessment and immediate steps that followed. These efforts and activities took place from mid-2012 through mid to late-2014, and included: Identifying and assessing health indicators Prioritizing the health indicators and identifying top community priorities Determining priority workgroups, specifically workgroup leads Developing broad, community-based strategies that define the Community Health Improvement Plan 5

20 Olmsted County Community Demographics Olmsted County is located in the southeastern part of Minnesota, approximately 80 miles southeast of the Minneapolis/St. Paul metropolitan area. Olmsted County has a total area of 655 square miles, of which just over 650 acres are water areas. Olmsted County consists of 18 townships and all are part of 8 cities, including the cities of Byron, Eyota, Dover, Oronoco, Rochester, Stewartville, and parts of Chatfield and Pine Island. Olmsted County is projected to remain one of Minnesota s fastest-growing counties over the next 30 years, while Rochester will be the central city of the fastest-growing metropolitan area in the State. Olmsted County remains the eighth largest county in the State. According to the 2010 Census, the population of Olmsted County was 144,248. Seventy-four percent of the County population lives in the city of Rochester, with a 2010 population of 106,769. Rochester, the County seat, is the largest city in Minnesota outside of the Minneapolis/St. Paul metropolitan area; Rochester grew by nearly 25% over the last decade (20,963 people). The surrounding cities range in size from a low of 741 in Dover to a high of 5,916 in Stewartville. 6 Olmsted County represents 29% of the population of the 11-county southeast Minnesota region. Olmsted County s population has grown by 35.5% since the 1990 Census. Olmsted County has 2.25 times the population of the next largest county in the region and continues to grow at a significantly higher rate than other counties in southeastern Minnesota while Olmsted County grew by 16% per decade for the last twenty years; the balance of the region grew by only 4%. According to census figures, the median age of Olmsted County residents was 36.3 years in Residents under age 18 made up 25.2% of the population, while those aged 65 years and older made up 12.6% of the population. Olmsted County s population is 51.1% female total female population is 73,763; total male population is 70,485. Olmsted County has seen a significant increase in populations of ethnic and racial minorities in recent years. Minorities (all persons other than non-hispanic Whites) now make up almost 17% of Olmsted County s total population. The minority population grew 75% from 2000 to 2010, compared to an 8.8% increase in the non- Hispanic White population. Over the last 20 years, the minority population has increased from 5,290 (1990) to 23,900 (2010) an increase of 4 ½ times. The 2011 American Community Survey (2011 ACS) reports that 13,292 foreign-born persons reside in Olmsted County. According to the 2011 ACS, 12.4% of people over the age of 5 speak a language other than English in the home. According to Olmsted County school district data, Somali, Spanish, Cambodian (Khmer), Arabic, Vietnamese, Chinese, Lao, and Bosnian are the most prevalent languages spoken in the home. Household and per capita incomes in Olmsted County exceed both the State and national averages. According to the ACS estimates, Olmsted County had a median household income of $66,202, compared to $58,476 for Minnesota and $52,762 for US. However, outside the Minneapolis/St. Paul metropolitan area, Olmsted County has the 3rd highest free and reduced lunch enrollment in schools, which is an indicator of low socioeconomic status. Rochester is most notably known as the home of the Mayo Clinic, and thus a medical community. Major employers in Olmsted County include: Mayo Clinic, IBM, Rochester Public Schools, Olmsted County, Olmsted Medical Center, City of Rochester, Charter Communications, Crenlo, Rochester Community and Technical College, Federal Medical Center, Seneca Food, and Hiawatha Homes.

21 Collaborative Nature Olmsted County Community Olmsted County Public Health Services, Olmsted Medical Center, and the Mayo Clinic have a strong, symbiotic relationship and have collaborated with each other, and other community partners for many years to serve the health needs of the residents in Olmsted County, Minnesota. A unique first example of community collaboration in Olmsted County dates back to the late 1800 s. In 1883, the Great Tornado swept through Rochester, killing 26 people and destroying much of the north side of town. In the wake of that terrifying experience, Sister Mary Alfred, a Franciscan Sister teaching in Rochester, approached the country doctor to discuss the need for a hospital. The Sisters of St Francis offered to build and maintain a hospital if the good doctor would provide the medical staff. The humanitarian spirit of a Franciscan Sister combined with the professional dedication of a small town physician named William Worrall Mayo, and his more famous sons Will and Charlie, formed the foundation that continues today. The humble dedication and practice of sharing information and knowledge of past and present leaders had created a culture where prevention, resiliency, and foresight are the fabric of our community s existence. Since these early beginnings, the community has taken positive and proactive actions to lay a foundation for a culture of health with its residents through the development of public health policies and practices dating back to 1866 when the first health ordinance was enacted, and is embedded in many aspects of our community today. Olmsted County is small enough where people know each other, yet large enough to bring resources together to respond to problems. The spirit of community collaboration and group practice stems back to the Mayo brothers and have shaped and formed the way community leaders approach the challenges related to health, safety, and social conditions in our neighborhoods, cities, and county as a whole. While the Great Tornado could be cited as the original catalyst for collaboration in our community, a series of more recent initiatives, events, decisions and partnerships serve as additional motivation and influence. These consist of: Healthcare Collaborations, including: Coalition for Community Health Integration; Community Healthcare Access Collaborative; Health Workers; Good Samaritan Health Clinics; Rochester Epidemiology Project; School-located Vaccination Clinics; Southeast Minnesota Beacon Project; and Zumbro Valley Mental Health Housing Initiatives, including: Affordable Home Ownership; the Housing Summit and Assessment; Permanent, Supportive Housing; and Transitional Housing Improved Nutrition and Physical Activity, including: Active Living Policies and Plans facilitated by Statewide Health Improvement Plan; CardioVision 2020; Improved Nutrition Access; Increasing Physical Activity Opportunities; and School Gardens Tobacco-Free Living, including: Community Cessation Efforts; Smoke-Free Campuses; Smoke-Free Policies; and Smoke Free Rental Housing These well-established relationships and past initiatives and projects provided a natural stepping stone to conduct one joint community assessment and planning process. One joint process has galvanized leadership from key sectors to be part of the solution to address the conditions and factors that impede optimal health. The above synopsis of the community s collaborative nature was summarized from Olmsted County s Robert Wood Johnson Foundation s Culture of Health Prize Phase I application. 7

22 Community Health Improvement Plan Context Purpose In early 2012, discussions began between Olmsted County Public Health Services, Olmsted Medical Center, and Mayo Clinic on the opportunity to work together on a collective assessment and planning process to produce a joint Community Health Needs Assessment and Community Health Improvement Plan. Olmsted County Public Health Services has conducted community health assessments and developed improvement plans since the enactment of the Local Public Health Act in 1976 (Minnesota State Statue 145A). However, new requirements for local public health agencies in Minnesota and non-profit hospitals provided a unique opportunity to conduct one community assessment and planning process for Olmsted County. For the first time, local public health agencies in Minnesota are now required to develop a plan with, and for the community, instead of an internal department plan. This is apparent within the Minnesota Local Public Health Assessment and Planning Process. This state-wide process now integrates and aligns local public health deliverables with the national accreditation (Public Health Accreditation Board - PHAB) standards and measures. PHAB requires local public health agencies to (1) participate in or lead a collaborative process resulting in a comprehensive community health assessment and (2) conduct a comprehensive planning process resulting in a community health improvement plan. Yes, there are new requirements specifying an assessment and planning process must be conducted at the community level; however, Olmsted County has and is looking above and beyond these requirements and focusing efforts more on the value and benefits of community collaboration. Because of the numerous past collaborations and partnerships within Olmsted County and specifically between Olmsted County Public Health Services, Olmsted Medical Center, and the Mayo Clinic one joint community assessment and planning process was identified as the best strategy for all three organizations and ultimately, the entire community. This is the right thing to do! The purpose and true intent of the current Community Health Improvement Plan is to provide guidance to Olmsted County on improving the community s health priorities. Specifically, the Community Health Improvement Plan: Describes the assessment and planning process, including partners involved Outlines the top five community health priorities, along with the prioritization process used Identifies community-level strategies with key/lead organization involvement Provides measureable and time-framed objectives Describes future implementation, monitoring and evaluation activities In addition to the current requirements for local public health agencies, a new requirement in the Patient Protection and Affordable Care Act (PPACA) requires non-profit hospitals to conduct a community health needs assessment every three years in order to maintain their tax exempt status. Within Olmsted County, two organizations fit this PPACA requirement: Olmsted Medical Center and Mayo Clinic. 8 For a complete description of the organizational requirements, please refer to Appendix B.

23 Community Health Improvement Plan Context Framework Several best practice frameworks and models influenced and guided the overall assessment and planning process for the Olmsted County community. One specific framework was not followed in it s entirety; however, the combination of all steered the collaborative nature of the overall community process. Steps and/or phases of the following frameworks were used throughout Olmsted County s assessment and planning process: Collective Impact Core Public Health Functions and Essential Services County Health Rankings and Roadmaps Health Impact Pyramid Minnesota Local Public Health Assessment and Planning Process (Community Health Improvement Plan) Mobilizing for Action through Planning and Partnerships (MAAP) Precede-Proceed Model Social Determinants of Health Framework For a complete description and listing of the guiding frameworks used in the assessment and planning process, please refer to Appendix C. Process The assessment and planning process began in early 2012 with the formation of the Community Health Needs Assessment/Community Health Improvement Plan Core Group Planning Team (Core Group). The Core Group immediately and continues to be the leadership group guiding the full assessment and planning process. Early on, it was determined that since this community process was new and different from previous planning efforts (i.e. community driven versus organization, independently driven), that the process would have to be completed and implemented in stages (refer to Community Health Improvement Plan Introduction, page 5). The first stage referred to as Phase I included community efforts that launched the Community Health Needs Assessment and immediate steps that followed. For a broad timeline of assessment and planning efforts, please see Community Health Improvement Plan Assessment and Planning Timeline, page 11. Assess Health Indicators: With guidance and leadership from the Data Subgroup and Core Group, a comprehensive Community Health Needs Assessment was completed in late The assessment process integrated a variety of steps, including: identifying potential health indicators; collecting and analyzing relevant information including data from the Community Survey and Community Listening Sessions; and the assembly and dissemination of the final document. For a further defined assessment process, please refer to Olmsted County s 2013 Community Health Needs Assessment: Olmsted County Community Health Needs Assessment. Prioritize Indicators: During the assembly of the Community Health Needs Assessment document, a process was developed and implemented to prioritize the health issues of Olmsted County (Spring 2013). Local data on each issue (i.e. objective factors) was presented and shared with community groups which in turn contributed subjective scores/factors to the full prioritization process (refer to Community Health Improvement Plan Prioritization Process, page 13). Identify Workgroups: After dissemination of the Community Health Needs Assessment and community priorities, an Assessment and Planning Community Meeting was held to launch the next steps of the assessment and planning process (i.e. Community Health Improvement Plan Planning Kick-off November, 2013). During this meeting, community partners were given a brief synopsis of the five community health priorities and were tasked to identify one to two organizations that could lead workgroups into the future. For a complete listing of workgroup leads, please refer to Appendix D. (cont.) 9

24 Community Health Improvement Plan Context Process (cont.) Develop Community Strategies: Once workgroup leads were identified, these organizations and partners moved into developing broad community plans of action designed to achieve progress towards each community priority (i.e. Community Strategies). Workgroup leads, along with other pertinent individuals, partners and community organizations, met periodically between January and September 2014, to develop these broad community strategies. Olmsted County Community Involvement: Throughout all assessment and planning efforts, community involvement was the core, foundation and guiding principle that drove the process. The overall community was involved in a number of ways, but most notably serving, participating, and attending Assessment and Planning Community meetings and Public Health Services Advisory Board meetings. Defining Health and Wellness: Coinciding with the assessment and planning process is another new initiative introduced by Mayo Clinic called Destination Medical Center (DMC). DMC strives to secure Mayo Clinic s status as a global medical destination now and into the future. One early collaborative event revolved around Community Conversations to help define what health and wellness means to the community. It was apparent that the phrase health and wellness encompasses a variety of attributes, from: access to healthcare, to holistic health, to prevention, to mental health. It was also clear that accessibility and inclusivity are key components to ensuring health equity for all. As the assessment and planning process progresses, this definition will be important in considering future Community Health Needs Assessment indicators and Community Health Improvement Plan strategies. Challenges, Assumptions and Themes Identified Throughout the Planning Process: Awareness that this is the first true community plan we need to cast a wide net and be inclusive, but understand what it takes to manage the logistics with limited resources Initial effort should be placed on recognizing the tremendous work already happening in the community while also remembering to look proactively for future collaborative work The realization that the Community Health Improvement Plan needs to be a dynamic, evolving plan being the first community plan; knowing this is just the start and improvement will come with time The overall Community Health Improvement Plan and more specifically, the strategies need to be practical and realistic strive for no more than 2-3 strategies per priority area The understanding that each issue is at a different level of complexity, maturity in addressing, data availability to address progress, etc. therefore, strategies will be at different levels (i.e. process versus operational) The need to monitor and evaluate strategies and initiatives is critical, but the maturity of measurement will continue to evolve This Community Health Improvement Plan serves as the final stages of Phase I as the community of Olmsted County is now ready to move towards and into Phase II that revolves around implementation, monitoring and evaluation. Work into the future will strive to continually improve the overall assessment and planning process. 10

25 Assessment and Planning Process Timeline 11

26 Health Assessment and Planning Partnership Partnership Representation Team Vision and Goals The assessment and planning process strived to have membership, involvement and participation from all walks of life. The Large Group Health Assessment and Planning Partnership well defined multi-sector representation, and included a variety of individuals and organizations throughout the Olmsted County community. For a full listing of contributing organizations to the assessment and planning process, see Appendix E. Throughout the assessment and planning process, and explicitly seen within the Health Assessment and Planning Partnership Team, was alignment with national initiatives, specifically with Healthy People With this alignment, the team agreed upon adhering and supporting the following all-encompassing goals: Community Health Improvement Plan Overarching Goals Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death Promote quality of life, healthy development, and healthy behaviors across all life stages Create social and physical environments that promote good health for all Achieve health equity, eliminate disparities, and improve health of all groups 12

27 Community Health Priorities and Strategies Prioritization Process Once sufficient data was collected on each health indictor through the progression of the Community Health Needs Assessment, a process to prioritize the indicators was determined through the Community Health Needs Assessment Data Subgroup, and administered during Spring Each health indicator was scored on objective (at risk, affected, trend, and premature death) and subjective factors (quality of life, economic impact, community perception, ability to impact, and additional resources needed). Objective scores were predetermined and approved through the Community Health Needs Assessment Data Subgroup. Subjective scores were gathered through five separate groups: Community Healthcare Access Collaborative, Work Group Mayo Clinic, Employee and Community Health Executive Leadership* OCPHS, Public Health Services Advisory Board OCPHS, Strategic Management Committee Olmsted Medical Center, Leadership Council *completed a modified version of the above described process For a complete description and listing of the subjective and objective factors used in the prioritization process, please refer to Appendix F. Additionally, please refer to Appendix E for a listing of contributing organizations, including those that participated in the prioritization process. The results from each of the five subjective prioritizations were then compiled with the objective scores to determine an overall numerical ranking of the health indicators. This process allowed us to identify the top ten indicators with the highest community rankings: 1. Obesity 2. Mental Health 3. Vaccine Preventable Diseases 4. Homelessness 5. Diabetes 6. Financial Stress 7. Multiple Chronic Conditions 8. Educational Level 9. Poverty 10. Asthma In order to identify a manageable number of issues that could be addressed in the Community Health Improvement Plan, the Core Group and Data Subgroup further refined the priority list to the Top Five Community Health Priorities. While there are opportunities to improve the prioritization process used for this assessment and planning cycle, the hope is that this first integrated process serves as the foundation to better address the health concerns facing Olmsted County now, and into the future. 13

28 Community Health Priorities and Strategies Community Priorities The next several pages are devoted to the community s priorities. This section will focus on a summary of why the health issue is a community priority and then describe community level strategies to ultimately improve the status of the issue in Olmsted County. Within the health issue summary, the following will be described: Community Health Importance and Impact A description of why the issue is important to the health of the general community* and what else is associated and/or impacts the indicator *community health in general, not necessarily exclusive to Olmsted County The Priority in Olmsted County (i.e. Obesity in Olmsted County) Local, current data* from the recent Community Health Needs Assessment (2013) is presented for each priority *includes multiple quantitative and qualitative data sources Community Strengths A broad portrayal* of current community assets and resources, including current community programming, partnerships and/or resources *a non-exhaustive list After the portrayal of the health issue, community level strategies will be broadly described and include: Goal Desired long-term result for community priority Outcome Objective* Overall long-term intended effect from strategies *when applicable, written SMART to measure improvement in priority health status Strategy Broad community plan of action designed to achieve progress towards health priority Strategic Objective * Shorter-term intended effect from strategy initiatives and activities *when applicable, written SMART to measure improvement in status upstream from priority health area After describing the Five Community Health Priorities and Strategies, there will be a small section devoted to describing the need and illustrating four Overarching Community Health Improvement Plan Strategies. 14

29 Olmsted County, Minnesota Community Health Needs Assessment October 2013 TOP 5 COMMUNITY HEALTH PRIORITIES OBESITY DIABETES MENTAL HEALTH VACCINE PREVENTABLE DISEASES FINANCIAL STRESS/ HOMELESSNESS 64% of adults are overweight (BMI>25.0) With 28% being obese (BMI >30.0) 8% of population currently living with diabetes 20% of adults 65 years and older have diabetes 10% of youth feel sad all or most days Adults average 3 days of mental health issues monthly 76% of children are up to date with the recommend immunization series 60% of residents receive annual flu shot 26% of adults have had a time in the last year when they have been worried or stressed about having enough money to pay monthly bills

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31 Cost of Medical Care Lifestyle Farm to Table Fast Food BMI Glucose School Gardens Children Parks and Trails Heart Disease Active Classrooms Physical Education Physical Activity Safe Routes to School Obesity Teens Active Transportation Mental Health Active Recess Healthy Living Adults Hypertension Processed Foods School Breakfast Programs Diabetes Smart Snacks Portion Control Body Fat Weight Sedentary Safe places to exercise Chronic Disease Access to healthy foods 17

32 Community Health Importance and Impact The overall health and well-being of a community rely heavily on proper nutrition and adequate physical activity. Healthful diets and body weights are directly related to health status. Good nutrition is important to overall physical and developmental growth. Additionally, physical activity can improve the health and quality of life of all ages, regardless of the presence of a chronic disease or disability. Proper nutrition and physical activity have great community benefits. Healthy diets rich in fruits and vegetables have been shown to reduce many health conditions, including: overweight and obesity, heart disease, high blood pressure, dyslipidemia, type II diabetes, oral disease, and some cancers. Furthermore, physical activity can lower the risk of: early death, coronary heart disease, stroke, high blood pressure, type 2 diabetes, breast and colon cancer, falls, and depression. Unfortunately, many people do not meet the guidelines for physical activity or fruit and vegetable consumption; and these people are at an increased risk for obesity. Furthermore, obesity is associated with many additional health-related problems. These problems range from diabetes, heart disease, hypertension, premature mortality to mental health issues. Obesity increases the overall cost of health care placed on society. Many factors are associated with overeating and inadequate exercise that results in obesity. Factors may include lack of knowledge of caloric intake, lack of access to healthy foods, eating for psycho-social reasons, overfeeding by parents, or lack of safe places to exercise. There are many future health and life risks, implications, and consequences associated with consuming an unhealthy diet, which includes those without adequate fruits and vegetables. Community Health Priority: Obesity Obesity in Olmsted County Local obesity data is primarily from the community telephone survey to help inform the Community Health Needs Assessment. Information gathered from that survey indicates that 45% of survey respondents believe they are currently overweight. This figure rises considerably when looking at self-reported height and weight measurements (BMI calculations) 64% of Olmsted County adults are overweight, with 28% being obese. Obesity is a problem throughout all communities. However, among adults, the prevalence is highest for middle-aged people and for non- Hispanic black and Mexican American women. The association of income with obesity varies by age, gender, and race/ethnicity. Limited sub-population breakdown is available for Olmsted County; however, the 2013 Community Health Needs Assessment Survey shows the highest obesity disparity between Hispanic (47.1%) and non-hispanic (26.8%) individuals, which is consistent with national trends. 18

33 Community Health Priority: Obesity Goal Promote health and reduce chronic disease risk through the consumption of healthful diets and achievement and maintenance of healthy body weights Improve health, fitness, and quality of life through daily physical activity Outcome Objective By 2020, reduce the percentage of Olmsted County adults who are obese from 28.0% to 26.0% By 2020, reduce the percentage of Olmsted County adolescents who are obese from 7.4% to 7.0% By 2020, reduce the percentage of Olmsted County adults who are overweight from 64.0% to 60.0% Community Strengths Bicycle Master Plan Bicycle Pedestrian Advisory Council Community Education Complete Streets Policy Farmers Market Farm to Table Healthy Concessions Healthy Food Alliance of SE MN Healthy Living Rochester Coalition Mayo Clinic OCPHS Statewide Health Improvement Plan Rochester Area Family Y We Bike Rochester Worksite Wellness Strategy 1: Promote a culture of healthy eating By 2018, increase the percentage of Olmsted County adults who meet the recommended guidelines for fruit and vegetable consumption from 50.0% to 55.0% By 2018, increase the percentage of Olmsted County adolescents who meet the recommended guidelines for fruit and vegetable consumption from 21.1% to 25.0% Strategy 2: Promote a culture of physical activity By 2018, increase the percentage of Olmsted County adults who meet the recommended guidelines for moderate physical activity from 48.0% to 55.0% By 2018, increase the percentage of Olmsted County adolescents who meet the recommended guidelines for moderate physical activity from 48.2% to 55.0% 19

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35 Control Lifestyle Exercise Weight Loss Education Prevention Nutrition Blood Sugars Treatable Type I Muscle Complications Diabetes Quality of Life Diet Adult Onset Metabolism Pancreas Medications Type II Insulin Screening Obesity Gestational Carbohydrate Glucose 21

36 Community Health Importance and Impact Diabetes mellitus (DM) is a disease that affects how your body uses blood glucose, or blood sugar. Individuals who are diagnosed with DM have too much glucose in their blood. There are several different types of DM, including Type I, Type II and gestational diabetes. Diabetes affects an estimated 23.6 million people in the United States and is a top leading cause of death. Community Health Priority: Diabetes Diabetes in Olmsted County Approximately 8% of Olmsted County residents are currently living with diabetes. Differences in DM prevalence are apparent in local data specifically across gender and age cohorts. Men in Olmsted County have higher rates of diabetes as compared to women (8.9% vs. 6.6%, respectively). Additionally, the highest diabetes prevalence is seen in the oldest aged cohort adults 65 years of age and older at 20.2%. Currently, Type I DM is not preventable but treatable. Type II DM is closely associated with obesity and has been increasing in frequency for the past few decades. Type II DM key risk factors are a combination of genetic predisposition and obesity. The relative importance of the two is unknown; but preventing obesity can delay or prevent the onset of Type II DM. DM impacts all aspects of a patient s life from requiring changes in eating habits and daily monitoring of glucose levels to increasing risk for many other chronic conditions. The rapid, often termed epidemic, increase in DM puts high demand on health care services including patient education and forces the profession, including public health, to address the wide spread issues of low to modest health literacy. Because DM requires patients to manage their condition on a day to day basis, it is imperative that they understand their condition and self management goals and mechanisms. At a local, state-level, and nation overall, DM risk is higher among African Americans. Locally in Olmsted County, this disparity has been shown to be true for the recently arrived Somali immigrants with several cases of new onset Type II DM following arrival in the US and changes in diet and exercise. 2 in 10 adults age 65 and older have diabetes Data presented are overall DM disease prevalence; however, community strategies are focusing solely on Type II DM. 22

37 Community Health Priority: Diabetes Goal Reduce the disease and economic burden of diabetes mellitus (DM) and improve the quality of life for all persons who have, or are at risk for DM Outcome Objective By 2020, reduce the prevalence of adult DM from 7.6% to 7.0% Increase availability of diabetes screening and education in the community (baseline and target rate to be established) Community Strengths American Diabetic Association Community Health Services Inc. Good Samaritan Clinic Mayo Clinic Olmsted County Public Health Services Olmsted Medical Center Private Providers Rochester Area Family Y Senior Center Worksite Wellness Strategy 1: Promote and increase diabetes screening throughout the community By 2015, establish the baseline level for community diabetes screening rate By 2018, increase diabetes screening rate for high risk population (baseline and target rate to be established) Strategy 2: Improve collaboration to expand health education and awareness By 2018, improve the rates of formal diabetes education received by newly diagnosed diabetics (baseline and target rate to be established) 23

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39 Behavioral Advocacy Bipolar Chronic Illness Anxiety Suicide Stigma Mental Health Sadness Fear OCD ADD Therapy Developmental Eating Disorder Borderline Personality Disorder Panic PTSD ADHD Coping Stress Trauma Dental Health Resources Depression Quality of Life Isolation Addictions Emotional Self-Destruction Self-care Resiliency Wellness Activities Proper Diet Stable Housing Schizophrenia Autism Worry Physical Pain Support System Access to Care 25

40 Community Health Importance and Impact Mental health is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with challenges. Mental health is essential to personal well-being, family and interpersonal relationships, and the ability to contribute to community or society. Community Health Priority: Mental Health Mental Health in Olmsted County Recent data reports over 10% of all Olmsted County adolescents feel sad on all or most days. Regardless of grade in school, the magnitude and trend of self-reported depression continues to increase throughout the past several years. Mental illness affects every aspect of a person s and their family s life, as it impacts the former s ability to fulfill family, home, community and work roles. For many, mental illness continues to be associated with stigma that prevent discussion of the symptoms and may prevent seeking or receiving appropriate and needed health care services. For those who are chronically mentally ill, this can also disrupt having a home and a sense of any community. People with both acute and chronic mental health conditions are often under recognized and under treated, leaving them with a significant burden. People with chronic mental illnesses have a shortened life span, a lower rate of full-time and steady employment, and higher rates of homelessness. Mental health problems in children and adolescents have both short term and potentially long term consequences. Long term, children and adolescents with emotional, developmental or behavioral problems are less likely to attend college or trade school, less likely to hold full-time jobs, and more likely to spend time incarcerated. The costs of care for these problems are significant and insurance coverage is often limited. Over 1 in 10 adolescents report feeling sad on all or most days Adult mental health status and the frequency of visiting mental health providers were assessed during the 2013 Community Health Needs Assessment Survey. Key findings illustrated that: 57% of adults have felt worried, tense or anxious at least one day during the last 30 days; 31% of adults have felt their mental health has not been good for at least one day during the last 30 days, and; 13% of adults report seeing a mental health provider about their own personal health during the last year of those that did not see a mental health provider (87%), 5% believe they should have seen a health professional. Almost 6 in 10 adults felt worried, tense, or anxious at least 1 day in last 30 days 26

41 Community Health Priority: Mental Health Goal Promote a culture of mental health wellness and resilience Outcome Objective By 2016, complete the foundational work necessary to develop a set of mental health strategies for Olmsted County Community Strengths Children s Mental Health Collaborative Faith Communities Family Services Rochester Law Enforcement Legal Services Mayo Clinic NAMI SE Minnesota Olmsted County Community Services Olmsted County Public Health Services Olmsted Medical Center Private and Public School Districts Private Providers in Prevention and Treatment Zumbro Valley Mental Health Strategy 1: Develop a framework to improve mental health for all populations By 2016, assure the completed framework encompasses current gaps and challenges from prevention to treatment, including: Improving data collection, dissemination, coordination and reporting Promoting positive mental health and resiliency Enhancing strategies for the prevention and early identification of mental illness Facilitating access to mental health resources Addressing premature mortality of people with serious and persistent mental illness Recognizing unique needs of certain populations such as military veterans, cultural groups, refugees, and jail inmates Strategy 2: Engage collaboratives to enhance and connect current and future strategies within the framework developed By 2016, identify strategies that align with the framework for the Community Health Improvement Plan 27

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43 Varicella Outbreaks Emerging Threats Meningococcal Anti-Vaccine Polio HPV PVC DTaP Hib MMR Infectious Disease Hepatitis B Disability Vaccine Hesitancy Vaccine Preventable Diseases Td Influenza 29

44 Community Health Priority: Vaccine Preventable Diseases Community Health Importance and Impact The increase in life expectancy during the 20th century is largely due to improvements in child survival; this increase is associated with reductions in infectious disease mortality, largely due to immunizations. However, infectious diseases remain a major cause of illness, disability, and death. Immunization recommendations in the United States currently target 17 vaccine-preventable diseases across the lifespan. Vaccines are among the most cost-effective clinical preventive services and are a core component of any preventive services package. For example, childhood immunization programs provide a very high return on investment. For each birth cohort vaccinated with the routine immunization schedule: society saves 33,000 lives; prevents 14 million cases of disease; reduces direct health care costs by $9.9 billion, and; saves $33.4 billion in indirect costs. Vaccine Preventable Diseases in Olmsted County Childhood Immunization Series It is recommended that all children receive the childhood immunization series* to protect against a variety of vaccine-preventable diseases. The 2013 Olmsted County Community Health Needs Assessment reports that 76.7% of Olmsted County children ages months are fully vaccinated with the recommended childhood immunization series. *includes DTap, Td, Hib, Polio, MMR, Hepatitis B, and varicella vaccines Olmsted County is still below the HP 2020 goal, which ultimately leads to a greater number of vulnerable children during outbreak settings. Despite progress, approximately 42,000 adults and 300 children in the United States die each year from vaccine-preventable diseases. Communities with pockets of unvaccinated and under vaccinated populations are at increased risk for outbreaks of vaccine-preventable diseases. The emergence of new or replacement strains of vaccinepreventable disease can result in a significant increase in serious illnesses and death. Influenza Vaccine During the influenza season, approximately 60% of all Olmsted County residents (six months and older) received the influenza vaccine. Olmsted County s overall coverage is drastically higher than the US and State coverage rates (41.8% and 47.2%, respectively). However, when looking at children (6 months 17 years of age), this increase fades away Olmsted County, along with Minnesota and the US, hovers around 53% of children receiving their flu shots. 30

45 Goal Reduce the incidence of vaccine preventable diseases Community Health Priority: Vaccine Preventable Diseases Outcome Objective By 2020, reduce or maintain the number of reported vaccine preventable diseases in Olmsted County: Community Strengths Mayo Clinic Minnesota Vaccines for Children Olmsted County Public Health Services Olmsted Medical Center Private Provider Immunization Clinics School-Located Immunization Clinics Southeast Minnesota Immunization Connection (SEMIC) Strategy 1: Increase immunization rates By 2018, increase immunization rates of HPV, Influenza, Childhood Recommended Series (Dtap, Polio, MMR, Hep B, Varicella, Tdap), Adolescent Tdap, and Meningococcal to 80% For a list of current baseline immunization rates, see Appendix G Strategy 2: Develop innovative means to address vaccine hesitancy By 2018, decrease or maintain the percentage of conscientious objectors reported at kindergarten and seventh grade by 20% For a list of current baseline percentages of conscientious objectors see appendix G 31

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47 Physical Health Worry Food Violence Poverty Safety Unemployment Financial Stress/Homelessness Anxiety Education Mental Health Vulnerability Relationships Housing Crime Insecurity Basic Needs Stress Unhealthy Coping Behaviors Social Support System Medications Utility Bills Depression Medical Insurance 33

48 Community Health Priority: Financial Stress/Homelessness Community Health Importance and Impact Social determinants of health are directly correlated with health status. Poverty, unemployment, and lack of educational achievement affect access to care and a community s ability to engage in healthy behaviors. Without a network of support and a safe community, families cannot thrive. Ensuring access to social and economic resources provides a foundation for a healthy community. Financial stress is one of the leading causes of stress in America. It is linked to health problems such as anxiety, depression, and unhealthy coping behaviors. Financial instability affects everyone in a family and can lead to poor school attendance, crime, poverty, and an inability to meet basic needs. With less money in the budget, people tend to cut corners in areas of health care to pay for basic necessities (i.e. money for groceries over prescription medicine), which ultimately can lead to more serious health issues. People without homes cannot build productive lives physical and mental health deteriorate and it is difficult, if not impossible, to find and keep a job. Without income and a place to sleep at night, people are more likely to turn to crime; children cannot move forward with their education and they cannot develop healthy, sustainable relationships with their peers. For many city officials, community leaders, and even direct service providers, it often seems that placing homeless people in shelters is the most inexpensive way to meet the basic needs of people experiencing homelessness. However, the cost of homelessness can be quite high: hospitalization, medical treatment, incarceration, police intervention, and emergency shelter expenses can add up quickly, making homelessness surprisingly expensive for communities. Financial Stress/Homelessness in Olmsted County According to the 2013 Community Health Needs Assessment Survey, 26% of Olmsted County adults stated there has been a time in the past 12 months when they were worried or stressed about having enough money to pay their bills. One third of those individuals living in financial stress reported the stress was there every month, with the most concern over: utilities, rent/mortgage, credit cards, medical bills, groceries, and insurance. US Census data illustrates the share of Olmsted County households paying too much for housing has jumped from 7,900 households in 2000 to 14,900 households in More than one in five owner households and more than two in five renter households pay over 30% of their income for housing. Exactly how many people are homeless or at risk for homelessness in Olmsted County is difficult to say, but the data and opinions shared in the Families and Youth without Stable Housing in Rochester: A Needs Assessment suggests that an estimated 200 to 300 families are homeless or at imminent risk of homelessness each year in Rochester and Olmsted County. Two percent of Olmsted County adults have reported they have stayed in a shelter, somewhere not intended as a place to live, or at someone else s home because they had no other place to stay (over 2,000 adults have potentially been without housing in the past year). 34

49 Community Health Priority: Financial Stress/Homelessness Goal Create social (and physical) environments that promote good health for all Outcome Objective By 2020, decrease the percentage of Olmsted County adults reporting living in financial stress from 26.0% to 20.0% Community Strengths Community Action Program (CAP) Community Food Response Dorothy Day House Interfaith Hospitality Network Living Independently with Knowledge (LINK) Olmsted County Community Services Rochester School District Salvation Army United Way of Olmsted County Women s Shelter Strategy 1: Increase the availability of affordable housing By 2020, decrease the percentage of households paying more than 30% of their income for housing By 2015, evaluate and begin implementation of strategies identified in the Olmsted County Housing Plan that increase affordable housing for lower income levels Strategy 2: Ensure people have access to safety net programs By 2017, increase the Food Support Access Index from 60% to 65% By 2016, increase the participation rate in the federal Earned Income Tax Credit and the state Working Families Credit By 2016, decrease the number of uninsured people from 6% to 1% By 2016, improve community outreach, education, and access to all safety net programs, including food, cash, housing, and medical assistance Strategy 3: Increase the proportion of living wage jobs By 2020, increased the percentage of jobs in Olmsted County that pay a living wage from an estimated 62% to 70% 35

50 Overarching Strategies Each of the five Olmsted County priority area workgroups were able to identify issue-specific, broad, community strategies. In addition to the issue-specific strategies, each workgroup independently identified several overarching Community Health Improvement Plan strategies. Each workgroup was able to recognize the importance of broader community engagement, data and data sources, communication, and policy change. These overarching strategies reach across all five priority areas and therefore will be assessed and addressed at a community level implementation will not be placed on a specific priority workgroup. Community Health Improvement Plan Overarching Strategies Strategy 1 Evaluate local community capacity and improve community-wide partnership and engagement Strategy 2 Collect and evaluate local data sources Strategy 3 Develop community-wide communication and marketing Strategy 4 Explore policy changes needed to affect change 36

51 Alignment with State and National Priorities Throughout the assessment and planning process, Olmsted County has consistently aligned with State and National processes and priorities. Based on the statewide health assessment, Healthy MN 2020 is a framework for creating and improving health throughout the state of Minnesota. Healthy MN 2020 emphasizes creating conditions that allow people to be healthy, conditions that assure a healthy start and that set the stage for healthy choices throughout life. Currently, Healthy MN 2020 has 12 Topic Areas encompassing Chronic Disease and Injury locally, Obesity and Diabetes are aligned with statewide targets. Additionally, throughout Healthy MN 2020 health equity and social determinants of health are apparent across all topic areas. The US Department of Health and Human Service s Healthy People 2020 sets 10-year goals and objectives for health promotion and disease prevention. Currently, Healthy People 2020 has 42 topic areas that encompass a wide array of health issues. Locally, all five priority areas are aligned with the national topics and objectives that include: nutrition and weight status, diabetes, mental health and mental disorders, immunization and infectious diseases, and social determinants of health. For a more detailed matrix aligning Olmsted County s Community Health Improvement Plan Priorities with State and National Priorities, please refer to Appendix H. Olmsted County Priority Healthy Minnesota 2020 Healthy People 2020 Obesity Diabetes Mental Health Vaccine Preventable Diseases Financial Stress /Homelessness 37

52 Our Future Health: From Planning to Action Olmsted County will enter and begin Phase II of the community assessment and planning process immediately after dissemination of the Community Health Improvement Plan Community Strategies; Phase II will last throughout the three-year cyclic process. Throughout Phase II of the process (implementation, monitoring and evaluation), local concepts will align and integrate with the logic model framework. By using this framework, the community will be able to answer the following questions: What current (and new) initiatives are occurring in the community regarding the five priority areas? Who are the partner organizations involved in these initiatives? What are the anticipated (and eventual) results of the community initiatives? In addition, the full Health Assessment and Planning Partnership will take the current plan and focus on action and sustainability efforts, including: Continue to increase community engagement in the overall assessment and planning process Identify current initiatives that connect to the broad community-based Community Health Improvement Plan strategies Monitor status and progress of community activities via quarterly Assessment and Planning community meetings Measure and evaluate how well the Community Health Improvement Plan was implemented and whether the initiatives improved the health of the community Work towards community sustainability efforts for the complete assessment and planning process 38

53 Our Future Health: From Planning to Action Implementation The initial step in the implementation phase will be the identification of those organizations that play a role in reaching the community strategies (development of a community collection of assets) and formation of the full community workgroups. Once each workgroup is established, the next step in the implementation phase will include organizations involved in the workgroups completing all the corresponding information included in the implementation matrix, which is based on the logic model concept. Items within the table will include the following, and will serve as a preliminary plan of action: 1. Health Priority Acts as the table heading; describes the Community Health Improvement Plan community health priority along with the identified community goal and outcome objective. 2. Strategy Depicts the identified broad community-based strategy along with the strategy-specific objective. 3. Initiatives Describes the comprehensive series of related activities directed towards a related outcome. 4. Key Activities Portrays those specific activities that will take place to meet an initiative. Key activities will be briefly described with an implementation timeframe, identified if the activity has a policy component to it, and recognized if the activity is based on best practices and/or evidence-based. 5. Contact Lists those organizations involved in the planning and implementation of the activity and lead contact person. 6. Anticipated Results Short-term and long-term results will describe and illustrate how these results are upstream from the long-term outcome objective (performance measures, targets, etc. are not included in the implementation table for this information, please refer to the Monitoring and Evaluation section). 39

54 Our Future Health: From Planning to Action Monitoring and Evaluation In a similar fashion to the Community Health Improvement Plan implementation, evaluation will be based on the logic model concept. Within the evaluation stage, priority area workgroups will complete the corresponding information included in the evaluation matrix. Items within the table will include the following, and will serve as a preliminary plan of reporting and communicating Community Health Improvement Plan efforts and achievements: 1. Health Priority Acts as the table heading; describes the Community Health Improvement Plan community health priority along with the identified community goal and outcome objective. 2. Strategy Depicts the identified broad community-based strategy along with the strategy-specific objective. 3. Initiatives Describes the comprehensive series of related activities directed towards a related outcome. 4. Key Activities Portrays those specific activities that will take place to meet an initiative Key activities will be briefly described with an implementation timeframe and lead contact person (organization). Identification of activity inputs (resources, investments, etc.) and outputs (events, reach, etc.) will also be shared. 5. Anticipated Results Short-term and long-term results will be described and illustrate how these results are upstream from the long-term outcome objective. Specific detail to performance measures and outcomes will be described. For a template of the implementation and evaluation matrices, and an initial Vaccine Preventable Disease implementation example, please refer to Appendixes I, J and K. 40

55 Our Future Health: From Planning to Action Sustainability The current Community Health Improvement Plan reflects a coordinated health improvement effort that will last multiple cycles, and ultimately many years. In alignment with other initiatives, the Olmsted County community will follow a three-year cyclic assessment and planning process. Such aligned community initiatives include: Olmsted County Public Health Services commitment and compliance to the Minnesota Local Public Health Assessment and Planning Process Olmsted County Public Health Services pursuit of national public health accreditation through the Public Health Accreditation Board Mayo Clinic and Olmsted Medical Center s observing the Affordable Care Act requirements Commitment and charge of the Core Group to continually improve the process, and continued outreach and inclusion of all in the community In addition to the above mentioned aligned efforts, the following will serve to further support sustained action: Integration of the Centers for Disease Control and Prevention s Sustainability Planning Guide for Healthy Communities into the assessment and planning process Joint community funded Project Manager position with the goal of helping to sustain the community assessment and planning efforts Dedication and engagement from community organizations and individuals to consistently serve on the Data Subgroup Quarterly Assessment and Planning community meetings conveyed, coordinated and facilitated by Olmsted County Public Health Services Commitment and charge of the Coalition for Community Health Integration 41