Allegan General Hospital Community Health Needs Assessment

Allegan General Hospital Community Health Needs Assessment July 15, 2013 Prepared with consulting assistance from:

July 15, 2013 Dear Residents of the greater Allegan area, I am pleased to share with you the results from Allegan General Hospital s first Community Health Needs Assessment, which was completed in April of this year. Undertaken in part to make sure we meet new IRS requirements for maintaining our tax exempt status, this project has also helped us to better understand the people that we serve how healthy is our population, and how well are your health needs being met? Based on our data findings, plus results from a community survey and input from community leaders, the hospital has identified Accessibility & affordability for low income residents; Primary care; and Women s health services as significant areas of unmet health needs in our region. AGH leaders are committed to helping to address the issues that have been identified. During this process we learned that other groups and organizations in our area are also concerned about these issues and want to work with us to find effective and sustainable solutions. By pooling our ideas and resources, we believe that we can make real progress that has a positive impact on the people who live in our region. We are in the early stages of working with our community partners to develop action plans going forward. If you would like more information about the status of these projects or would like to be involved as a community partner, please feel free to contact me. Best regards, Gerald J. Barbini Chief Executive Officer

Table of Contents Introduction & Project Overview 4 Needs Assessment Methodology 10 Needs Assessment Key Findings 15 Process to Establish Health Improvement Priorities 35 Appendices 40 Appendix A: Community Definition and Profile 41 Appendix B: County Health Rankings 45 Appendix C: Mortality and Morbidity 51 Appendix D: Personal Health Behaviors 58 Appendix E: Clinical Care 61 Appendix F: Physical Environment and Public Safety 65 Appendix G: Community Survey Results 67 Appendix H: Community Leader Meeting 77 Appendix I: Additional Information 80

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5 Introduction & Project Overview Project Goals The Community Health Needs Assessment project completed by Allegan General Hospital (AGH) in early 2013 was designed to meet five major goals: 1. Better understand the community we serve how healthy is the population, and how well are their health needs being met? 2. Gain focus for the hospital s community health outreach efforts how can we best use our resources to address the most pressing needs? 3. Strengthen the community health component of the hospital s strategic plan how can we better align our community health activities with the overall goals and priorities of the organization? 4. Create synergies with other organizations working to address health issues what are the opportunities to work with other groups in the community to achieve shared goals? 5. Comply with requirements outlined in the Affordable Care Act (ACA) for non-profit 501(c)(3) hospitals to conduct a community health needs assessment and implement strategies to address identified needs. Additional information about ACA requirements can be found in Appendix I. Consulting Assistance AGH engaged Strategy Connections, a health care consulting company based in Fort Collins, Colorado, to provide consulting assistance for completing the CHNA project. Carol Davis, Owner and Principal Consultant, served as project leader and primary consultant throughout the project. A summary of Ms. Davis qualifications and experience is included in Appendix I.

6 Introduction & Project Overview Community Health Improvement Model AGH s model for community health improvement as shown below considers health status data, community survey results and community leader perspectives in determining priority health needs that the hospital will help to address over the next three years. On an annual basis as part of the budget development process, AGH will identify specific initiatives to be undertaken during the year that will help to address highest priority community health needs. Health Status Data Community Survey Leader Perspectives Priority Needs for AGH to Address Action Plan & Implementation

7 Introduction & Project Overview Project Timeline The CHNA project kicked off in January 2013 and concluded in April 2013, with timing of the various components as follows: Project Kick Off Meetings Planning Meeting with Community Leaders; Board Approval of Community Health Priorities Jan 2013 Feb 2013 Mar 2013 Apr 2013 Health Status Data Collection & Analysis; Community Survey Data Collection & Analysis

8 Introduction & Project Overview Definition of Community Zip Code Town 49010 Allegan 49055 Gobles 49078 Otsego 49026 Bloomingdale 49328 Hopkins 49450 Pullman

9 Introduction & Project Overview Demographic Overview 2013 Estimate Population Size 41,750 Median Age 39.7 Percent of Population 0-17 24.7% Percent of Population 18-44 31.9% Percent of Population 45-64 29.1% Percent of Population 65+ 14.3% Median Household Income $36,868 Racial & Ethnic Diversity White Hispanic African American American Indian Asian Other or Multi-Racial 90.9% 5.0% 1.4% 0.5% 0.4% 1.8% Source: The Nielsen Company (data retrieved 1/25/2013)

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11 Needs Assessment Methodology Secondary Data AGH analyzed both secondary and primary data in the CHNA process. Secondary data analysis uses data that was collected by others and is already in existence. A reference list of secondary data sources used in the needs assessment can be found on page 12. All statistics cited in the report are referenced. The availability of credible and objective measures of health status is essential to understanding overall health of the population. Without such data, the ability to prioritize health needs would be severely limited and based solely on small scale observations, anecdotal information, and personal opinions and agendas. This data, although critical to the integrity of the process, has important limitations that need to be acknowledged: Most health status data is collected and reported only at the county level. AGH s primary service area does not include all of Allegan County but extends south to Bloomingdale and Gobles, which are in Van Buren County. The characteristics of the population served by AGH could be quite different from the overall county profile. Data is not current. Most of the data used in this report is based on 2010 statistics. Although changes in specific indicators tend to be small from year to year, the lag time makes it especially difficult to identify potential trends in a timely manner or to determine whether targeted interventions are having the intended impact and should be continued, modified or discontinued. Secondary data sources in this assessment include the following: County Health Rankings 2013 (www.countyhealthrankings.org) Michigan Department of Community Health (www.mdch.state.mi.us) Dartmouth Atlas (www.dartmouthatlas.org) The Nielsen Company (www.nielsen.com) Allegan General Hospital

12 Needs Assessment Methodology Primary Data Primary data is new data that was collected by AGH via a community survey to gain additional insight into health status and perception of health needs. The survey, designed and tabulated by Strategy Connections, utilized a convenience sampling methodology, which means that the survey was available to all who wanted to participate. It was available both on-line (English)and in hard copy (English and Spanish). The survey was advertised and distributed as follows: Press release sent to area newspapers Messages posted on Twitter and Facebook Survey link and pdf versions of the survey available on hospital website Business cards with on-line survey address distributed at meetings of the Rotary Club and Multi-Agency Collaborative Committee E-mail messages with a link to the on-line survey sent to all hospital employees, board members, AGH Foundation board members and key constituents throughout the community Hard copies available at the hospital s information desk Hard copies of the survey along with postage paid envelopes provided to Allegan County Community Mental Health Hard copies of the survey distributed at meetings of Allegan Lifelong Learners and TOPS Hard copies of the Spanish survey distributed in Fennville and Pullman by a Spanish-speaking member of the community Hard copies of the Spanish survey provided to Intercare in Pullman

13 Needs Assessment Methodology Primary Data (continued) The survey was completed by 196 individuals. A profile of survey respondents is depicted on page 14, and detailed survey results can be reviewed in Appendix G. Community input received from the survey was invaluable to the needs assessment process, and AGH appreciates those who took time to share their opinions. It is important, however, to be cautious in reviewing and interpreting the results due to these limitations: Convenience sampling, while economical and helpful, does not produce statistically valid results that can be generalized to the overall target population. In other words, we can t say that results from this survey are representative of the entire population of the community, only that the findings are representative of those individuals who chose to participate. The profile of those who responded to the survey does not reflect overall demographics of the community. Approximately 20% of participants declined to provide demographic information. Those who did were disproportionately white and female with household income significantly higher than the median.

Needs Assessment Methodology Community Survey: 196 Respondents 14 No Answer: 20% Male: 25% No Answer: 19% 65+: 19% No Answer: 20% >4: 8% Female: 55% 45-64: 39% 3-4: 26% 2: 38% Sex Age 18-44: 23% # in Household 1: 8% Zip Code No Answer: 20% Other: 7% Other Allegan Co: 13% Other PSA Zip: 7% Otsego: 9% Allegan: 44% Diversity No Answer: 20% Asian: <1% Multi Racial: 1% Hispanic: 1% White: 77% Household Income No Answer: 23% >$100K: 14% $75-100K: 21% $50-75K: 19% $25-50K: 15% <$25K: 8%

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16 Needs Assessment Key Findings Health Status Data Favorable for Allegan County Health Indicator Allegan County Michigan % Better than MI Data Details 1. Drinking water safety issues 0% 1% 100.0% Page 66 2. Limited access to healthy foods 1.5% 5.7% 73.7% Page 66 3. Chlamydia 214.5 500.5 57.1% Page 55 4. Violent crimes 261.6 497.2 47.4% Page 66 5. Angina or coronary artery disease 2.6% 4.8% 45.8% Page 55 6. Any cardiovascular disease 5.6% 8.9% 37.1% Page 55 7. Preventable hospital admissions 170.0 268.4 36.7% Page 64 8. Heart attack 3.0% 4.6% 34.8% Page 55 9. Fast food restaurants 33.9% 48.8% 30.5% Page 66 10. No personal doctor or health care provider 9.0% 12.5% 28.0% Page 62 11. Fair to poor general health 10.7% 14.6% 26.7% Page 54 12. Poor physical health 8.3% 10.8% 23.1% Page 54 13. Hospital readmission of surgical patients 9.7% 12.6% 23.0% Page 63

17 Needs Assessment Key Findings Health Status Data Favorable for Allegan County Health Indicator Allegan County Michigan % Better than MI Data Details 14. Years of potential life lost 5,595 7,254 22.9% Page 52 15. Total hospital admissions 1,032.3 1,312.3 21.3% Page 57 16. Activity limitations 5.5% 7.0% 20.5% Page 54 17. Low birthweight babies 6.7% 8.4% 20.2% Page 54 18. Perinatal deaths 7.3 8.8 17.0% Page 52 19. Heart disease (deaths) 169.5 203.5 16.7% Page 53 20. Asthma 13.0% 15.6% 16.7% Page 55 21. Arthritis 27.2% 31.5% 13.7% Page 55 22. Per capita health care spending (Medicare) $8,676 $9,903 12.4% Page 63 23. Cancer (new cases) 423.4 482.1 12.2% Page 56 24. Colorectal cancer screening 71.8% 64.5% 11.3% Page 60 25. Cancer (deaths) 162.5 182.4 10.9% Page 53

18 Needs Assessment Key Findings Health Status Data Unfavorable for Allegan County Health Indicator Allegan County Michigan % Worse than MI Data Details 1. Dentists 22.2 35.4 63.9% Page 62 2. Primary care physicians 29.6 78.7 62.4% Page 62 3. Melanoma 27.9 19.3 44.6% Page 56 4. Heavy drinking 7.8% 5.4% 44.4% Page 59 5. Fitness & recreational facilities 5.4 9.1 40.7% Page 66 6. Current smokers 27.1% 19.7% 37.6% Page 59 7. Mental health providers 22.4 35.4 36.5% Page 62 8. Deaths from motor vehicle crashes 14.1 10.9 29.4% Page 52 9. Alzheimer s disease (deaths) 30.8 23.9 28.9% Page 53 10. Diabetes (deaths) 23.9 20.1 18.9% Page 53 11. Diabetes (prevalence) 10.9% 9.5% 14.7% Page 55 12. Air pollution 11.3 9.9 14.1% Page 66 13. Deaths from kidney disease 17.3 15.3 13.1% Page 53

19 Needs Assessment Key Findings Survey Highest Scores for Needs Being Met Survey Topic Score (1-10) 1. Hospice care 2. Outpatient testing 3. Outpatient rehabilitation 4. Prescription drugs 5. Ambulance/emergency transport 6. Hospital care overnight stays 7. Home health care 8. Dialysis 9. Cancer care 10. Chiropractic care 11. Vision care 12. Nursing home care 7.91 7.40 7.36 7.13 7.03 6.93 6.91 6.84 6.66 6.63 6.61 6.59

20 Needs Assessment Key Findings Survey Lowest Scores for Needs Being Met Survey Topic Score (1-10) 1. Substance abuse services 2. Mental health services 3. Pregnancy care 4. Urgent care services 5. Alternative medicine services 6. Communication & coordination among providers 7. Alzheimer s/dementia services 8. Services for people who lack health insurance 9. Specialty physicians 10. Obesity services 2.88 3.75 3.97 4.08 4.50 4.81 4.84 4.87 4.89 4.95

21 Needs Assessment Key Findings Survey Most Important for Improving Health Survey Topic Score (1-10) 1. Decrease substance abuse 2. Get prenatal care 3. Get screening exams 4. Improve diet & nutrition 5. Increase exercise & physical fitness 6. Get routine physicals & lab work 7. Decrease tobacco use 8. Get dental checkups 9. Achieve a healthy weight 10. Get recommended immunizations 9.50 9.41 9.32 9.30 9.28 9.28 9.18 9.13 9.11 9.01

Needs Assessment Key Findings Survey Results: One Thing to Most Improve Health? 22 Topic # of Mentions 1. Exercise & physical fitness 27 2. Community education, wellness & coordination of services 3. Availability of healthy food 14 4. Substance abuse & mental health services 9 5. Weight loss 8 6. Access to services, especially for low income 8 7. Personal ownership/accountability for health 8. Stop smoking 9. Transportation 10. Other 16 6 3 3 3

23 Needs Assessment Key Findings Community Health Needs Potential Priority Areas Data + Survey Results Mental health and substance abuse services Primary care Women s health services Healthy lifestyle Chronic diseases Common Theme across All: Affordability and Accessibility for Low Income Residents Urgent care

Mental Health & Substance Abuse Services How Important? Less Neutral More Data: 36% FEWER hospitalizations for psychosis Survey: Stress management #5 LEAST important for improving health Data Comparable to MI: Suicide rate Poor mental health days Binge drinking Survey: Suicide middle of the pack for improving health Data: 36% FEWER MH providers 44% HIGHER for heavy drinking Survey: SA #1 LOWEST score for needs being met MH #2 LOWEST score for needs being met SA #1 MOST important for improving health SA/MH #4 on 1 thing to most improve health

Primary Care How Important? Less Neutral More Data: 28% FEWER without PCP 37% FEWER preventable hospital stays Colorectal cancer screening 11% BETTER Data Comparable to MI: Pap tests Checkup in past year Flu shot in past year Pneumonia vaccine HbA1c for diabetes patients Survey: PC middle of the pack for needs being met Data: 62% FEWER PC physicians Survey: Screening exams #3 MOST important for improving health Routine physicals/lab work #6 MOST important for improving health Perceived needs from survey comments: OB/Gyn 15 (more later) Peds 9 IM 4

Women s Health Services How Important? Less Neutral More Data: 20% FEWER low birthweight babies 17% FEWER perinatal deaths Data Comparable to MI: Prenatal care during 1 st trimester Survey: Women s health middle of the pack for needs being met Survey: Pregnancy care #3 LOWEST score for meeting needs Prenatal care #2 MOST important for improving health 15 people identified need for women s health providers

Healthy Lifestyle How Important? Less Neutral More Data: 74% BETTER access to healthy foods 31% FEWER fast food restaurants Data Comparable to MI: No leisure time physical activity Survey: Middle of the pack for improving health: Access to recreational facilities Access to healthy food Streets & trails for walking & bicycling Data: 38% HIGHER smoking rate 41% FEWER fitness & rec facilities Survey: Diet & nutrition #4 MOST important for improving health & #3 on 1 thing to MOST improve health Exercise & fitness #5 MOST important for improving health & #1 on 1 thing to MOST improve health Tobacco use #7 MOST important for improving health & #8 on 1 thing to MOST improve health Community education, wellness & coordination of services #2 on 1 thing to MOST improve health

Chronic Medical Conditions: Heart Disease How Important? Less Neutral More Data: 17% FEWER deaths 46% LESS prevalence for angina/cad 37% LESS prevalence for any CV disease 35% LESS prevalence for heart attack 28% FEWER hospital stays 28% FEWER preventable hospital admissions for CHF Survey: Middle of the pack for needs being met Data: #1 cause of death MI & Allegan County #1 reason for hospital stays MI & #3 Allegan County

Chronic Medical Conditions: Cancer How Important? Less Neutral More Data: 17% FEWER deaths 12% FEWER new cancer cases 18% FEWER hospital stays Survey: #9 HIGHEST score for needs being met Data: #2 cause of death MI & Allegan County #7 reason for hospital stays MI & Allegan County 45% MORE new melanoma cases

Chronic Medical Conditions: Lower Respiratory How Important? Less Neutral More Data: 17% FEWER people with asthma 42% FEWER hospital stays for chronic bronchitis 65% FEWER preventable hospital stays for asthma 44% FEWER preventable hospital stays for COPD Data comparable to MI: Deaths Survey: Middle of the pack for needs being met Data: #3 cause of death MI & Allegan County #12 reason for hospital stays MI & Allegan County

Chronic Medical Conditions: Diabetes How Important? Less Neutral More Data: 19% FEWER preventable hospital stays Survey: Middle of the pack for needs being met Data: #7 cause of death MI & Allegan County 19% MORE deaths 15% more people with diagnosis #13 reason for hospital stays MI & #14 Allegan County

Chronic Medical Conditions: Obesity How Important? Less Neutral More Data comparable to MI: Obesity percent Overweight percent Data: 31% adults obese Additional 35% adults overweight Survey: #10 LOWEST score for needs being met Achieving healthy weight #9 MOST important for improving health & #5 on 1 thing to most improve health

Urgent Care How Important? Less Neutral More Survey: #4 LOWEST score for needs being met 25 people identified need for urgent care

Affordability/Accessibility Issues for Low Income How Important? Less Neutral More Data comparable to MI: Uninsured percent Needed care but couldn t afford it Data: 15% ages 18-64 with no health care coverage 15% needed care but couldn t afford it Survey: 14% went without needed services past 12 months 50% too expensive 32% no insurance Services for those without insurance #8 LOWEST score for needs being met Access to services #6 on 1 thing to MOST improve health

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36 Process to Establish Health Improvement Priorities Community Leader Meeting AGH leaders hosted a meeting of invited community representatives to share key findings from the health needs assessment and to seek input on which health needs are the most important to address. The priority-setting meeting was held on Wednesday, April 10, 2013 from 6:00-8:00 p.m. at a local restaurant. Twenty-five individuals representing 18 organizations participated in the meeting. A complete list of organizations invited to the meeting, along with a list of actual attendees, including job title and organization, is located in Appendix H. The agenda consisted of the following segments: Welcome and introductory remarks by Jerry Barbini, CEO of Allegan General Hospital Presentation of key findings from health needs assessment Audience discussion and voting on perceived priority of community health needs Additional discussion Next steps and concluding remarks

Process to Establish Health Improvement Priorities Health Needs Presented for Community Leader Input 37 Data + Survey Results Mental health and substance abuse services Primary care Women s health services Healthy lifestyle Chronic diseases Common Theme across All: Affordability and Accessibility for Low Income Residents Urgent care

38 Process to Establish Health Improvement Priorities Results of Community Leader Voting After the list of 7 community health needs was presented, attendees had an opportunity for questions and large group discussion. Twenty-three voting participants (AGH management staff did not vote) were then asked to rate the importance of each issue on a scale from 1 ( very low priority ) to 5 ( very high priority ) using audience response technology and based on the following criteria: Does this issue affect a large number of individuals and families? Does the community have (or can we acquire) the necessary skills and resources to make a difference? Results from the voting exercise were as follows: Topic 1. Accessibility & affordability for low income residents 2. Mental health & substance abuse services Mean Score Frequency Distribution 5 4 3 2 1 4.74 18 4 1 0 0 4.17 10 9 3 0 1 3. Healthy lifestyle 4.13 9 8 6 0 0 4. Urgent care 4.04 8 10 3 2 0 5. Women s health services 3.87 4 12 7 0 0 6. Primary care 3.48 4 5 12 2 0 7. Chronic diseases 3.48 5 8 8 2 0

39 Process to Establish Health Improvement Priorities AGH Board Decision and Next Steps At its monthly meeting on April 30, 2013, the Allegan General Hospital Board of Directors reviewed key findings from the health needs assessment process, including results from the community leader meeting that was held on April 10, 2013. The Board then considered and passed the following motion: To accept and develop an action plan based on the following three community health needs identified in the Community Health Needs Assessment: Accessibility & affordability for low income residents; Primary care; and Women s health services Initial implementation activities include the following projects to be completed by the end of the current fiscal year, which is December 31, 2013: Accessibility & affordability for Low Income Residents 1. Development of multidisciplinary teams to address the identified needs. The teams will include representatives from Allegan General Hospital, The Allegan General Hospital Foundation, Allegan Professional Health Services, and appropriate community agencies. 2. Participate in a collaborative effort to develop a comprehensive community education program regarding the insurance benefits available in 2014 and beyond under the Affordable Care Act. 3. Participate in the development of a plan within the community to fill the Navigator function. This service will assist community members to access available resources. 4. Work closely with the local free clinics to coordinate efforts at improving access to care, free screenings, and other available services.

40 Process to Establish Health Improvement Priorities AGH Board Decision and Next Steps (continued) Primary Care 1. Review the current supply of primary care providers based on demographic information, succession planning, etc. 2. Evaluate the potential for increased need/demand in future years based on Medicaid/insurance expansion and projected population changes. 3. Develop appropriate recruitment plans based on the analysis. 4. Evaluate other strategies to enhance accessibility of existing providers.

41 Process to Establish Health Improvement Priorities AGH Board Decision and Next Steps (continued) Women s Health Services 1. A focused effort by Allegan General Hospital as well as APHS providers, community practices/agencies/initiatives will take place in order to define what women s health looks like in our community. 2. As a collaborative effort, Allegan General Hospital will take a close look within their own organization as well as partner with APHS providers, community practices/agencies/initiatives to recognize and highlight services offered within the community in addition to identifying ways to align, navigate and promote women s health. 3. A virtual women s health model to be established with the following mission: The Allegan General Hospital Women s Health model aims to offer innovative programs, educational initiatives and accessible service lines that result in better health outcomes for women and their families in this community. 4. Increase awareness of available women s health service lines and initiatives in this community through education, promotional materials and through collaborative efforts. 5. In addition to women s health services lines currently offered in this community AGH plans are underway to initiate a Pelvic Wellness Center to include assessment, education, behavior modification and conservative treatment options. Implementation plans with specific projects and resource requirements for subsequent years will be developed annually during the Hospital s budget planning process for the next fiscal year. An action plan for FY2014 will be adopted by the Board no later than December 31, 2013.

42 Process to Establish Health Improvement Priorities AGH Board Decision and Next Steps (continued) Accessibility & Affordability for Low Income Residents Development of multidisciplinary teams to address the identified needs. The teams will include representatives from Allegan General Hospital, Allegan Professional Health Services, The Allegan General Hospital Foundation, and appropriate community agencies. Complete Participate in a collaborative effort to develop a comprehensive community education program regarding the insurance benefits available in 2014 and beyond under the Affordable Care Act. Complete Participate in the development of a plan within the community to fill the Navigator function. This service will assist community members to access available resources. Complete Work closely with the local free clinics to coordinate efforts at improving access to care, free screenings, and other available services. Ongoing

43 Process to Establish Health Improvement Priorities AGH Board Decision and Next Steps (continued) Primary Care Review the current supply of primary care providers based on demographic information, succession planning, etc. Complete Evaluate the potential for increased need/demand in future years based on Medicaid/insurance expansion and projected population changes. Complete Develop appropriate recruitment plans based on the analysis. Primary Care recruitment is ongoing Evaluate other strategies to enhance accessibility of existing providers. Ongoing

44 Process to Establish Health Improvement Priorities AGH Board Decision and Next Steps (continued) Women s Health Services A focused effort by Allegan General Hospital as well as APHS providers, community practices/agencies/initiatives will take place in order to define what women s health looks like in our community. Ongoing As a collaborative effort, Allegan General Hospital will take a close look within their own organization as well as partner with APHS providers, community practices/agencies/initiatives to recognize and highlight services offered within the community in addition to identifying ways to align, navigate and promote women s health. Ongoing A virtual women s health model to be established with the following mission: The Allegan General Hospital Women s Health model aims to offer innovative programs, educational initiatives and accessible service lines that result in better health outcomes for women and their families in this community. Ongoing Increase awareness of available women s health service lines and initiatives in this community through education, promotional materials and through collaborative efforts. Ongoing In addition to women s health services lines currently offered in this community AGH plans are underway to initiate a Pelvic Wellness Center to include assessment, education, behavior modification and conservative treatment options. In the planning stage.

45 Process to Establish Health Improvement Priorities AGH Board Decision and Next Steps (continued) 2014 Community Health Needs Assessment Objectives Accessibility & Affordability for Low Income Residents Continued participation and development of the multiagency team that was initiated in 2013. Ongoing Continue the community education activities including hosting an event at Allegan General Hospital. Complete Maintain the availability and increase the exposure of Certified Application Counselors on the AGH campus. Discontinued Continue to work closely with the local free clinics to coordinate care including diagnostic services. Ongoing Continue and expand free screenings throughout the community. Complete Continue funding of the Pink Allegan program to provide access to mammography services for low income residents. Complete Continue to work towards implementation of an urgent care service on the AGH/APHS campus. Complete

46 Process to Establish Health Improvement Priorities AGH Board Decision and Next Steps (continued) Primary Care Build on recent recruiting success by searching for additional Primary Care Physicians. Ongoing Enhance recruitment efforts for midlevel providers to increase local access to primary care services. Ongoing Continue to explore additional delivery models to increase local capacity of existing primary care resources. Ongoing

47 Process to Establish Health Improvement Priorities AGH Board Decision and Next Steps (continued) Women s Health Services In collaboration with APHS establish the Pelvic Wellness Center to include assessment, education, behavior modification and conservative treatment options. Complete Continue to develop and expand the virtual women s health model. Complete Continued development of the Spirit of Women program including access to screenings and educational services. Complete Enhanced community education of women s health needs and the services available. Complete

48 Process to Establish Health Improvement Priorities AGH Board Decision and Next Steps (continued) 2015 Objectives Accessibility & Affordability for Low Income Residents Continued participation in community based collaborative efforts. Hospital representatives have been actively involved in discussions concerning ways to provide improved care and services for underserved populations regarding both dental care and mental health services. A collaborative group also continues meet and conduct education and communities outreach activities concerning nutrition and physical activity among young people and their families. This group involves area schools, intermediate school district representatives, the Great Start Collaborative, United Way, the health department, pediatricians, mental health professionals, and others. Representatives of Allegan General Hospital and Allegan Professional Health Services physicians actively participated in priority-setting conducted in November, 2014 by the Allegan County Health Department. Hospital leaders and the county health officer actively discuss congruence between priorities of the public and private sector, and the intention to coordinate and cooperate for future needs assessment and planning activities. We continue to be an active partner in the Healthy Allegan County Coalition, convened by the Allegan County United Way. Topics of focus include collaborating to provide education and resources for enrollment in Affordable Care Act-enabled health coverage, and providing online information and resources concerning health and area providers. Representatives include FQHC personnel, health department personnel, other health and human services agency personnel, and members of the hospital and clinic community. A member of the United Way staff is specifically assigned to help coordinate and facilitate collaboration through the coalition.

49 Process to Establish Health Improvement Priorities AGH Board Decision and Next Steps (continued) Continue to work closely with the local free clinics to coordinate care including diagnostic services. We anticipate ongoing dialogue regarding opportunities to coordinate services to underserved populations between the hospital and Renewed Hope (area free clinic) and InterCare (FQHC provider). Continue and expand free screenings throughout the community. HeartCaring screenings have been conducted in multiple sites to identify potentials cardiovascular healthy programs and make connections to primary care physicians. These have been presented as part of the ongoing Spirit of Women program, which now numbers more than 2000 area women and their families. Based on a model developed by the Robert Wood Johnson Foundation, classes called How to Get the Most Out of Your Doctor Visit have are being presented by the hospital to provide community members tools to optimize their relationship with physicians and other providers, and their levels of satisfaction as they seek health care services. Continue funding of the Pink Allegan program to provide access to mammography services for low income residents. Continue to develop the Walk in Center.

50 Process to Establish Health Improvement Priorities AGH Board Decision and Next Steps (continued) Primary Care Build on recent recruiting success by searching for additional Primary Care Physicians. Enhance recruitment efforts for midlevel providers to increase local access to primary care services. Continue to explore additional delivery models to increase local capacity of existing primary care resources.

51 Process to Establish Health Improvement Priorities AGH Board Decision and Next Steps (continued) Women s Health Services In collaboration with APHS expand the Pelvic Wellness Center to include assessment, education, behavior modification and conservative treatment options. Continue to develop and expand the virtual women s health model. Continued development of the Spirit of Women program including access to screenings and educational services. Enhanced community education of women s health needs and the services available.

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Community Definition and Profile Map of Defined Community 54 For purposes of the community health needs assessment, Allegan General Hospital defined the community as the six zip codes that collectively account for 81% of the hospital s inpatient admissions, 80% of the hospital s ER patient visits, and 73% of Allegan Medical Clinic s patient visits. This area is also referred to as the hospital s primary service area (PSA). 49010 Allegan 49055 Gobles 49078 Otsego 49026 Bloomingdale 49328 Hopkins 49450 Pullman Source for patient origin data: Allegan General Hospital Source for map boundaries: Microsoft MapPoint 2011

55 Community Definition and Profile Allegan Health System Patient Origin (2012) Zip Code Town Inpatient Discharges from AGH ER Visits to AGH Visits to Allegan Medical Clinic 49010 Allegan 457 7,276 29,974 49078 Otsego 58 598 6,346 49055 Gobles 51 792 5,814 49328 Hopkins 37 327 1,662 49450 Pullman 31 710 1,308 49026 Bloomingdale 18 310 1,919 All other zip codes 149 2,546 17,297 Totals 652 12,559 64,320 Source: Allegan General Hospital

56 Community Definition and Profile Demographic Overview 2013 Estimated 2018 Projected 5 Year Change 5 Year Change % Population Size 41,750 41,212-538 -1.3% Median Age 39.7 39.9 +0.2 +0.5% Percent of Population 0-17 24.7% 23.8% -480-4.7% Percent of Population 18-44 31.9% 31.8% -185-1.4% Percent of Population 45-64 29.1% 27.7% -742-6.1% Percent of Population 65+ 14.3% 16.6% +869 +14.5% Median Household Income $36,868 $32,748 -$4,120-11.2% Racial & Ethnic Diversity White 90.9% 90.8% -553-1.5% Hispanic 5.0% 5.2% +50 +2.4% African American 1.4% 1.2% -73-12.7% American Indian 0.5% 0.5% -7-3.4% Asian 0.4% 0.4% -1-0.6% Other or Multi-Racial 1.8% 1.9% +46 +6.2% Source: The Nielsen Company (data retrieved 1/25/2013)

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58 County Health Rankings Introduction to County Health Rankings County Health Rankings is a collaboration between the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation. The project publishes an annual report that assesses the overall health of nearly every county in all 50 states, using a standard way to measure how healthy people are and how long they live. Results are aggregated into two overall categories: 1) health outcomes, and 2) health factors. Ranking for health outcomes is based on mortality and morbidity data. Ranking for health factors considers data on health behaviors, clinical care, social and economic factors, and physical environment.

59 County Health Rankings Michigan Maps for Health Outcomes and Health Factors Source: County Health Rankings 2013; data retrieved from www.countyhealthrankings.org on 3/20/2013.

60 County Health Rankings Allegan County Data Allegan County Error Margin Michigan National Benchmark Allegan County Rank 1-82 (1=most favorable) Health Outcomes 11 Mortality 8 Premature death (years of potential life lost per 100,000 population) 5,595 5,111-6,080 7,254 5,317 Morbidity 20 Poor or fair health (percent of adults) 13% 9-18% 14% 10% Poor physical health days in past month 3.0 2.4-3.6 3.5 2.6 Poor mental health days in past month 3.5 2.7-4.3 3.7 2.3 Low birthweight babies (percent of total live births) 6.7% 6.2-7.2% 8.4% 6.0% Health Factors 21 Health Behaviors 43 Smoking (percent of total adults) 23% 19-27% 20% 13% Obesity (percent of total adults) 32% 28-37% 25% 32% Physical inactivity (percent of total adults) 24% 20-28% 21% 25% Excessive drinking (percent of total adults) 20% 16-25% 19% 7% Motor vehicle crash death rate per 100,000 population 14 11-17 11 10 Sexually transmitted infections per 100,000 population (chlamydia) 215 92 500 Teen births per 1,000 females ages 15-19 33 31-35 32 21 Notes: National benchmark reflects 90 th percentile; i.e., only 10% are better. Blank values reflect unreliable or missing data. Source: County Health Rankings 2013; data retrieved from www.countyhealthrankings.org on 3/20/2013.

61 County Health Rankings Allegan County Data Allegan County Error Margin Michigan National Benchmark Allegan County Rank 1-82 (1=most favorable) Clinical Care 47 Uninsured (% of total population) 15% 13-16% 14% 11% Population per primary care physician 3,379:1 1,271:1 1,067:1 Population per dentist 4,499:1 1,626:1 1,516:1 Preventable hospital stays per 1,000 Medicare enrollees 64 59-70 70 47 Diabetic testing of blood sugar levels (% of people with diabetes) 88% 82-93% 86% 90% Mammography screening (% of women Medicare enrollees) 68% 61-75% 67% 73% Social & Economic Factors 14 High school graduation (% of population ages 25+) 81% 74% Some college (% of population ages 25+) 56% 53-59% 64% 70% Unemployment (% of total workforce) 8.7% 10.3% 5.0% Children in poverty (% of total children) 18% 14-22% 25% 14% Inadequate social support (% of total adults) 15% 12-20% 20% 14% Children in single-parent households (% of total children) 24% 22-27% 33% 20% Violent crimes per 100,000 population 262 497 66 Notes: National benchmark reflects 90 th percentile; i.e., only 10% are better. Blank values reflect unreliable or missing data. Source: County Health Rankings 2013; data retrieved from www.countyhealthrankings.org on 3/20/2013.

62 County Health Rankings Allegan County Data Allegan County Error Margin Michigan National Benchmark Allegan County Rank 1-82 (1=most favorable) Physical Environment 36 Fine particulate matter (daily average in micrograms per cubic meter) 11.3 11.2-11.4 9.9 8.8 Drinking water safety (% of population exposed to water exceeding a violation standard) 0% 1% 0% Number of fitness and recreational facilities per 100,000 population 5 9 16 Limited access to healthy foods (% of population based on formula that considers poverty level and geographic isolation) 1% 6% 1% Fast food restaurants (% of total restaurants) 34% 49% 27% Notes: National benchmark reflects 90 th percentile; i.e., only 10% are better. Blank values reflect unreliable or missing data. Source: County Health Rankings 2013; data retrieved from www.countyhealthrankings.org on 3/20/2013.

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64 Mortality and Morbidity Mortality Measures 1. Years of potential life lost due to premature death (per 100,000 population 2. Perinatal deaths (rate per 1,000 live births + fetal losses at 28+ weeks gestation) 3. Total deaths, all causes (rate per 100,000 population and age-adjusted) 4. Motor vehicle crash deaths (rate per 100,000 population) Allegan County # Rate Michigan Rate Allegan County Rank (1=most favorable) N/A 5,595 7,254 8/82 counties 10 (2 in PSA) 908 (376 in PSA) 7.3 8.8 N/A 771.9 784.3 N/A 110 14.1 10.9 45/78 counties County number is FAVORABLE (>10% positive variation from state number) but not necessarily statistically significant County number is UNFAVORABLE (>10% negative variation from state number) but not necessarily statistically significant Source for #1, 4: County Health Rankings 2013; data retrieved from www.countyhealthrankings.org on 3/20/2013. Source for #2-3: Profiles of Michigan & Allegan County 2010; Michigan Department of Community Health; data retrieved from www.mdch.state.mi.us on 3/15/2013.

Mortality and Morbidity Mortality Data for 10 Leading Causes of Death 65 1. Heart disease 2. Cancer 3. Chronic lower respiratory diseases 4. Accidents 5. Stroke 6. Alzheimer s disease 7. Diabetes 8. Kidney disease 9. Influenza & pneumonia 10. Suicide County number is FAVORABLE (>10% positive variation from state number) but not necessarily statistically significant Allegan County # Rate 201 (94 in PSA) 197 (82 in PSA) 58 (26 in PSA) 45 (23 in PSA) 44 (12 in PSA) 35 (6 in PSA) 29 (17 in PSA) 20 (10 in PSA) 19 (7 in PSA) 17 (9 in PSA) Michigan Rate 169.5 203.5 162.5 182.4 48.1 45.5 39.1 36.1 37.6 39.4 30.8 23.9 23.9 20.1 17.3 15.3 N/A 13.5 N/A 12.5 County number is UNFAVORABLE (>10% negative variation from state number) but not necessarily statistically significant Note: All rates per 100,000 population and age-adjusted. Source: Profiles of Michigan & Allegan County 2010; Michigan Department of Community Health; data retrieved from www.mdch.state.mi.us on 3/15/2013.

66 Mortality and Morbidity Overall Health Status and Limitations Allegan County Michigan Allegan County Rank (1=most favorable) 1. Percent of adults reporting fair to poor general health 2. Percent of adults reporting 14+ poor physical health days in past month 10.7% 14.6% 8/46 local health depts. 8.3% 10.8% 7/46 local health depts. 3. Percent of adults reporting 14+ days with activity limitation in past month 5.5% 7.0% 16/46 local health depts. (tie) 4. Percent of live births with low birthweight (<2,500 grams) 6.7% 8.4% 29/82 counties 5. Percent of adults satisfied or very satisfied with life 6. Percent of adults reporting 14+ poor mental health days in past month 95.0% 93.7% 11.2% 10.8% 14/46 local health depts. (tie) 26/46 local health depts. (tie) County number is FAVORABLE (>10% positive variation from state number) but not necessarily statistically significant County number is UNFAVORABLE (>10% negative variation from state number) but not necessarily statistically significant Source for #1-3, 5-6: Behavioral Risk Factor Surveys 2008-2010; Michigan Department of Community Health; data retrieved from www.michigan.gov on 3/1/2013. Source for #4: County Health Rankings 2013; data retrieved from www.countyhealthrankings.org on 3/20/2013.

67 Mortality and Morbidity Health Conditions 1. Percent of adults with angina or coronary artery disease 2. Percent of adults with any cardiovascular disease 3. Percent of adults who have had a heart attack Allegan County Michigan 2.6% 4.8% Allegan County Rank (1=most favorable) 2/46 local health depts. (tie) 5.6% 8.9% 2/46 local health depts. 3.0% 4.6% 4/46 local health depts. (tie) 4. Percent of adults with asthma 13.0% 15.6% 5/46 local health depts. 5. Percent of adults with arthritis 27.2% 31.5% 8/46 local health depts. 6. Chlamydia cases per 100,000 population 7. Percent of adults who are obese 30.7% 30.9% 8. Percent of adults who are overweight not obese 9. Percent of adults who have had a stroke 10. Percent of adults diagnosed with diabetes 214.5 500.5 58/83 counties 38.5% 35.3% 2.9% 2.8% 10.9% 9.5% 23/46 local health depts. (tie) 37/46 local health depts. 26/46 local health depts. 36/46 local health depts. County number is FAVORABLE (>10% positive variation from state number) but not necessarily statistically significant County number is UNFAVORABLE (>10% negative variation from state number) but not necessarily statistically significant Source for #1-5, 7-10: Behavioral Risk Factor Surveys 2008-2010; Michigan Department of Community Health; data retrieved from www.michigan.gov on 3/1/2013. Source for #6: County Health Rankings 2013; data retrieved from www.countyhealthrankings.org on 3/20/2013.

68 Mortality and Morbidity Age-Adjusted Rates of New Cancer Cases Allegan County # Rate Michigan Rate 1. All Cancers 497 423.4 482.1 2. Prostate (males only) 77 137.0 162.2 3. Female Breast 76 121.2 118.8 4. Lung and Bronchus 62 51.4 69.9 5. Colon and Rectum 40 33.5 45.1 6. Melanoma 32 27.9 19.3 7. Oral Cavity and Pharynx 11 9.3 10.9 County number is FAVORABLE (>10% positive variation from state number) but not necessarily statistically significant County number is UNFAVORABLE (>10% negative variation from state number) but not necessarily statistically significant Note: All rates per 100,000 population and age-adjusted based on new cancer cases reported for 2007-2009. Source: Selected Chronic Disease Indicators 2008-2010; Michigan Department of Community Health; data retrieved from www.mdch.state.mi.us on 3/15/2013.

69 Mortality and Morbidity Leading Reasons for Hospitalization among Allegan County Residents # Allegan County Rate per 10,000 population Michigan Rate per 10,000 population Total hospital discharges 11,501 1,032.3 1,312.3 Newborns and neonates 1,375 123.4 117.6 Females with deliveries 1,323 118.8 113.0 Heart diseases 1,120 100.5 140.0 Injury and poisoning 883 79.3 103.9 Osteoarthritis and allied disorders 453 40.7 39.6 Infectious and parasitic diseases 425 38.2 54.3 Cancer 368 33.0 40.0 Psychoses 343 30.8 48.5 Pneumonia 331 29.7 34.8 Cerebrovascular diseases 303 27.2 34.3 Diseases of the skin and subcutaneous tissue 196 17.6 26.3 Chronic bronchitis 164 14.7 25.4 Intervertebral disc disorders 160 14.4 15.1 Diabetes mellitus 158 14.2 18.6 Chest pain 130 11.7 17.9 Diseases of arteries, arterioles and capillaries 126 11.3 <12.0 Kidney and urinary infections 116 10.4 18.2 Diseases of the blood/blood-forming organs 111 10.0 15.6 County number is FAVORABLE (>10% positive variation from state number) but not necessarily statistically significant County number is UNFAVORABLE (>10% negative variation from state number) but not necessarily statistically significant Source: Twenty Leading Diagnoses for Hospitalizations 2010; Michigan Department of Community Health; data retrieved from www.mdch.state.mi.us on 3/15/2013.

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71 Personal Health Behaviors Lifestyle Measures Allegan County Michigan Allegan County Rank (1=most favorable) 1. No leisure time physical activity 25.8% 24.3% 26/46 local health depts. 2. Always use seat belts 84.5% 88.3% 3. Teen births (births per 1,000 females ages 15-19) 35/46 local health depts. (tie) 33.2 32.5 46/82 counties 4. Binge drinking 16.8% 16.6% 26/46 local health depts. 5. Heavy drinking 7.8% 5.4% 40/46 local health depts. (tie) 6. Currently smoke 27.1% 19.7% 44/46 local health depts. County number is FAVORABLE (>10% positive variation from state number) but not necessarily statistically significant County number is UNFAVORABLE (>10% negative variation from state number) but not necessarily statistically significant Source for #1-2, 4-6: Behavioral Risk Factor Surveys 2008-2010; Michigan Department of Community Health; data retrieved from www.michigan.gov on 3/1/2013. Source for #3: County Health Rankings 2013; data retrieved from www.countyhealthrankings.org on 3/20/2013.

72 Personal Health Behaviors Prevention and Wellness Measures 1. Appropriately timed colorectal cancer screening (ages 50+) Allegan County Michigan Allegan County Rank (1=most favorable) 71.8% 64.5% 4/46 local health depts. 2. Appropriately timed Pap test (women ages 18+) 82.4% 79.3% 9/46 local health depts. 3. HbA1c screening for Medicare enrollees with diabetes 87.6% 85.5% 41/83 counties 4. No routine checkup in past year 32.3% 32.3% 5. No dental visit in past year 27.4% 26.2% 6. Flu shot in past year (ages 65+) 64.2% 68.9% 7. Ever had a pneumonia vaccine (ages 65+) 62.5% 67.1% 22/46 local health depts. 26/46 local health depts. 31/46 local health depts. (tie) 36/46 local health depts. (tie) 8. Prostate cancer screening in past year (men ages 50+) Not available 59.0% N/A 9. Prenatal care during 1 st trimester 78.0% (72.0% in PSA) 74.3% N/A County number is FAVORABLE (>10% positive variation from state number) but not necessarily statistically significant County number is UNFAVORABLE (>10% negative variation from state number) but not necessarily statistically significant Source for #1-2, 4-8: Behavioral Risk Factor Surveys 2008-2010; Michigan Department of Community Health; data retrieved from www.michigan.gov on 3/1/2013. Source for #3: County Health Rankings 2013; data retrieved from www.countyhealthrankings.org on 3/20/2013. Source for #9: Profiles of Michigan & Allegan County 2010; Michigan Department of Community Health; data retrieved from www.mdch.state.mi.us on 3/15/2013.

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74 Clinical Care Availability and Accessibility of Care Allegan County Michigan Allegan County Rank (1=most favorable) 1. Percent of population with no personal doctor or health care provider 2. Percent of population ages 18-64 with no health care coverage 3. Percent of population that needed to see a doctor but couldn t afford it during past year 9.0% 12.5% 15.4% 15.1% 14.7% 13.4% 7/46 local health depts. 25/46 local health depts. (tie) 31/46 local health depts. 4. Mental health providers per 100,000 population 22.4 35.4 19/70 counties 5. Dentists per 100,000 population 22.2 61.5 76/83 counties 6. Primary care physicians per 100,000 population 29.6 78.7 76/81 counties County number is FAVORABLE (>10% positive variation from state number) but not necessarily statistically significant County number is UNFAVORABLE (>10% negative variation from state number) but not necessarily statistically significant Source for #1-3: Behavioral Risk Factor Surveys 2008-2010; Michigan Department of Community Health; data retrieved from www.michigan.gov on 3/1/2013. Source for #4-6: County Health Rankings 2013; data retrieved from www.countyhealthrankings.org on 3/20/2013.

75 Clinical Care Effectiveness of Care Allegan County Michigan Allegan County Rank (1=most favorable) 1. Total health care spending per Medicare enrollee $8,676 $9,903 37/83 counties 2. Surgical patients readmitted within 30 days of hospital discharge (Medicare only) 3. Preventable hospital admissions per 1,000 Medicare enrollees 4. Surgical patients with an ER visit within 30 days of hospital discharge (Medicare only) 5. Medical patients readmitted within 30 days of hospital discharge (Medicare only) 6. Medical patients with an ER visit within 30 days of hospital discharge (Medicare only) 9.7% 12.6% 11/71 counties 64.3 69.8 46/83 counties 15.0% 15.4% 38/71 counties 15.9% 16.1% 52/77 counties 20.0% 18.8% 59/80 counties County number is FAVORABLE (>10% positive variation from state number) but not necessarily statistically significant County number is UNFAVORABLE (>10% negative variation from state number) but not necessarily statistically significant Source for #1, 3: County Health Rankings 2013; data retrieved from www.countyhealthrankings.org on 3/20/2013. Source for #2, 4-6: Dartmouth Atlas; data for 2010 retrieved from www.dartmouthatlas.org on 3/15/2013.

76 Clinical Care Preventable Hospitalizations of Allegan County Residents Allegan County (2010) # Rate per 10,000 population Michigan Rate per 10,000 population (2010) All ambulatory care sensitive conditions 1,894 170.0 268.4 Congestive heart failure 299 26.8 37.1 Bacterial pneumonia 295 26.5 30.9 Chronic obstructive pulmonary disease 166 14.9 26.4 Cellulitis 145 13.0 16.5 Diabetes 125 11.2 13.8 Kidney and urinary infections 116 10.4 18.2 Asthma 61 5.5 15.7 Grand mal and other epileptic conditions 58 5.2 7.7 Dehydration 32 2.9 6.5 Gastroenteritis 19 1.7 4.0 All other ambulatory care sensitive conditions 578 51.9 91.8 County number is FAVORABLE (>10% positive variation from state number) but not necessarily statistically significant County number is UNFAVORABLE (>10% negative variation from state number) but not necessarily statistically significant Source: Ambulatory Care Sensitive Hospitalizations; Michigan Department of Community Health; data retrieved from www.mdch.state.mi.us on 3/15/2013.

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78 Physical Environment and Public Safety Physical Environment and Crime Allegan County Michigan Allegan County Rank (1=most favorable) 1. Drinking water safety: Percent of population exposed to water exceeding a violation standard 0% 1% 54/83 counties had 0% 2. Percent of population with limited access to healthy foods 1.5% 5.7% 10/83 counties 3. Percent of all restaurants that are fast food 33.9% 48.8% 22/83 counties 4. Violent crimes per 100,000 population 261.6 497.2 55/83 counties 5. Number of fitness and recreational facilities per 100,000 population 6. Air pollution: Daily average of fine particulates in micrograms per cubic meter County number is FAVORABLE (>10% positive variation from state number) but not necessarily statistically significant 5.4 9.1 58/83 counties 11.3 9.9 67/83 counties County number is UNFAVORABLE (>10% negative variation from state number) but not necessarily statistically significant Source: County Health Rankings 2013; data retrieved from www.countyhealthrankings.org on 3/20/2013.

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80 Community Survey Results How well are needs for health care services being met in greater Allegan area? Excellent Very Good Score (0=low, 10=high) Good Score (0=low, 10=high) Fair Score (0=low, 10=high) Poor None Hospice 7.91 Women's health 5.59 Mental health 3.66 None Outpatient testing 7.40 Primary care 5.25 Substance abuse 2.82 Outpatient rehabilitation 7.36 Specialty physicians 4.89 Prescription drugs 7.13 Communication & coordination 4.81 Ambulance/emergency transport 7.03 Alternative medicine 4.50 Hospital care overnight 6.93 Urgent care 4.08 Home health 6.91 Dialysis 6.84 Chiropractic 6.63 Vision 6.61 Nursing home 6.59 Medical equipment 6.50 Hospital care - ER 6.50 Assisted living 6.30 Dental 6.29 Note: Excludes no opinion responses. Source: Based on results from online and paper survey advertised by Allegan General Hospital and completed by 196 respondents between 2/15/2013 and 3/21/2013. Survey administered by Strategy Connections.

Community Survey Results How well are health care needs being met for specific populations? 81 Excellent Very Good Score (0=low, 10=high) Good Score (0=low, 10=high) Fair Poor None Seniors 6.44 Racial & ethnic minorities 5.86 None None Visitors & seasonal residents 6.35 Persons with disabilities 5.78 Young families 5.55 Military veterans 5.45 Children 5.31 Low income 5.02 People without health insurance 4.87 Note: Excludes no opinion responses. Source: Based on results from online and paper survey advertised by Allegan General Hospital and completed by 196 respondents between 2/15/2013 and 3/21/2013. Survey administered by Strategy Connections.

82 Community Survey Results How well are health care needs being met for patients & families with specific health conditions? Excellent Very Good Score (0=low, 10=high) Good Score (0=low, 10=high) Fair Score (0=low, 10=high) Poor None Cancer 6.66 Diabetes 5.85 Pregnancy 3.97 None Heart disease 6.16 Stroke & other neurological disorders 5.48 Mental health conditions 3.84 Asthma, COPD, respiratory diseases 6.03 Chronic pain 5.00 Substance abuse & addictions 2.93 Obesity 4.95 Alzheimer s disease & other dementias 4.84 Note: Excludes no opinion responses. Source: Based on results from online and paper survey advertised by Allegan General Hospital and completed by 196 respondents between 2/15/2013 and 3/21/2013. Survey administered by Strategy Connections.

83 Community Survey Results Health Care Obstacles A. In the past 12 months, did anyone in your household go without health care services that they needed? # of Responses % of Total Yes 28 14.3% No 138 70.4% Did Not Answer 30 15.3% Total 196 100.0% B. Please identify the issues that caused you or a member of your household NOT to get the care they needed during the past 12 months. (Respondents could select more than one answer.) # of Responses % of Total Yes Respondents Too expensive 14 50.0% Service wasn t available locally 9 32.1% Didn t have health insurance 9 32.1% Couldn t get a convenient appointment time 7 25.0% Not satisfied with choice of providers 4 14.3% Didn t know who to call 3 10.7% Didn t have transportation 2 7.1% Language barriers 1 3.6% Other 8 28.6% Note: Excludes no opinion responses. Source: Based on results from online and paper survey advertised by Allegan General Hospital and completed by 196 respondents between 2/15/2013 and 3/21/2013. Survey administered by Strategy Connections.

84 Community Survey Results Health Care Obstacles (continued) C. What types of health care services were needed but not obtained? # of Responses Primary care 7 Dental care 6 Surgery/other treatment 5 Specialty care 4 Diagnostic testing 3 Vision care 1 Mental health/substance abuse services 1 Medical equipment 1 Emergency/urgent care 1 Other 1 Note: Excludes no opinion responses. Source: Based on results from online and paper survey advertised by Allegan General Hospital and completed by 196 respondents between 2/15/2013 and 3/21/2013. Survey administered by Strategy Connections.

Community Survey Results How important are these goals & activities to improving overall health of the population? 85 Top Quartile Score (0=low, 10=high) 2 nd Quartile Score (0=low, 10=high) 3 rd Quartile Score (0=low, 10=high 4 th Quartile Score (0=low, 10=high) Decrease substance abuse 9.50 Get dental checkups 9.13 Reduce teen pregnancy 8.67 Improve stress management 8.22 Get prenatal care 9.41 Achieve a healthy weight 9.11 Get eye exams 8.64 Use seat belts & car seats 7.62 Get screening exams 9.32 Get recommended immunizations 9.01 Increase access to healthy food 8.63 Improve water quality 7.56 Improve diet & nutrition 9.30 Decrease suicides 8.84 Develop streets & trails to promote walking & bicycling 8.31 Improve air quality 7.42 Increase exercise & physical fitness 9.28 Increase access to recreational facilities 8.79 Reduce motor vehicle accidents 8.31 Increase spiritual connections 7.18 Get routine physicals & lab work 9.18 Increase community safety 8.31 Decrease tobacco use 9.18 Note: Excludes no opinion responses. Source: Based on results from online and paper survey advertised by Allegan General Hospital and completed by 196 respondents between 2/15/2013 and 3/21/2013. Survey administered by Strategy Connections.

Community Survey Results In your opinion, what is the one thing that would most improve the health of people who live in the greater Allegan area? Topic # of Mentions 1. Exercise & physical fitness 27 2. Community education, wellness & coordination of services 3. Availability of healthy food 14 4. Substance abuse & mental health services 9 5. Weight loss 8 6. Access to services, especially for low income 8 7. Personal ownership/accountability for health 8. Stop smoking 9. Transportation 10. Other 16 6 3 3 3 86 Source: Based on results from online and paper survey advertised by Allegan General Hospital and completed by 196 respondents between 2/15/2013 and 3/21/2013. Survey administered by Strategy Connections.

87 Community Survey Results Demographic Profile of Survey Respondents (N=196) Sex # of Responses % of Total Male 50 25.5% Female 107 54.6% Did Not Answer 39 19.9% Total 196 100.0% Age # of Responses % of Total Under 18 0 0% 18-44 45 23.0% 45-64 76 38.8% 65+ 37 18.9% Did Not Answer 38 19.4% Total 196 100.0% # in Household # of Responses % of Total 1 16 8.2% 2 74 37.8% 3-4 51 26.0% More than 4 16 8.2% Did Not Answer 39 19.9% Total 196 100.0% Zip Code # of Responses % of Total Allegan 85 43.4% Otsego 18 9.2% Hopkins 6 3.1% Gobles 3 1.5% Bloomingdale 2 1.0% Pullman 2 1.0% Other Allegan County 26 13.3% Other Van Buren County 1 0.5% Other 13 6.6% Did Not Answer 40 20.4% Total 196 100.0% Residency # of Responses % of Total Full Time Resident 134 68.4% Part Time or Seasonal Resident 3 1.5% Don t Live Here At All 18 9.2% Did Not Answer 41 20.9% Total 196 100.0%

88 Community Survey Results Demographic Profile of Survey Respondents (N=196) Diversity # of Responses % of Total White 151 77.0% Hispanic of any race 2 1.0% Multi-racial 2 1.0% Asian 1 0.5% Black 0 0% American Indian/Alaska Native 0 0% Did Not Answer 40 20.4% Total 196 100.0% Household Income # of Responses % of Total <$25,000 16 8.2% $25,000-$50,000 30 15.3% $50,000-$75,000 36 18.4% $75,000-$100,000 42 21.4% >$100,000 27 13.8% Did Not Answer 45 23.0% Total 196 100.0% Health Plans # of Responses % of Total Group insurance 126 54.3% Traditional Medicare 23 9.9% Medicare HMO/PPO 14 6.0% Individual policy 8 3.4% Medicaid 7 3.0% No coverage 5 2.2% MIChild 4 1.7% Other coverage 5 2.2% Did Not Answer 40 17.2% Total 232 100.0% Note: Respondents could select multiple answers.

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90 Appendix H: Community Leader Meeting List of Organizations Invited to Participate Allegan Area Educational Service Agency Area Agency on Aging of Western Michigan Michigan Department of Human Services Allegan Chamber of Commerce Association for the Blind Michigan State University Extension Allegan Community Foundation Bethany Christian Services Michigan Works Allegan County Administrator Big Brothers Big Sisters Ministry Alliance Allegan County Board of Commissioners Bloomingdale Fire Department Otsego Chamber of Commerce Allegan County Court System Briarwood Assisted Living Otsego Fire Department Allegan County Community Mental Health Catholic Family Services Otsego Mayor & City Manager Allegan County Health Department Christian Neighbors Southeast Otsego Police Department Allegan County Resource Development Committee Disability Network Lakeshore Otsego Public Schools Allegan County Senior/Veteran s Services Evergreen Commons Ottagan Addictions Recovery Allegan County Sheriff s Department Gobles Pine Grove Fire Department Pathways, MI Allegan County Transportation Department Gobles Public Schools Perrigo Company Charitable Foundation Allegan County United Way Hopkins Fire Department Renewed Hope Free Clinic Allegan County Youth Home Hopkins Public Schools Safe Harbor Children s Advocacy Center Allegan Fire Department Hopkins Village President Sylvia s Place Allegan General Hospital Foundation InterCare Community Health Network The Arc Allegan Mayor & City Manager Lakeshore Coordinating Council The DeLano Foundation Allegan Public Schools Life EMS Wings of Hope Hospice American Red Cross Mediation Services

91 Appendix H: Community Leader Meeting List of Community Meeting Participants Name Title Organization Armintrout, Christine Community Education Coordinator Wings of Hope Hospice Balgoyen-Williams, Nora Manager, Michigan Works Allegan Area Educational Service Agency Bray, Theresa CEO Allegan County Community Foundation Burns, Terry Therapist Lakeshore Counseling Service Bursma, Penny Program Officer Perrigo Foundation Clark, Linda Chair Allegan Area Arts Council Clark, Tom Member, City Council City of Allegan Cook, Charlie Safe House Manager Sylvia s Place Decker, Sara Business Manager Briarwood Assisted Living Forrest, Heather Executive Director Sylvia s Place Gabriel, Mimi Executive Director Allegan County United Way Hancock, Karen Campaign Manager Allegan County United Way Hassing, Christine Director, Demand Management Perrigo Company/AGH Board of Directors Hekker, Bill Administration Allegan County Medical Care Community Kerber, Brad Physical Therapy Assistant West Michigan Rehabilitation LaChapelle, Sarah Director Allegan County Head Start McDaniel, Betty Mayor City of Allegan Sanchez, Colleen Director Allegan County Early Head Start Schmitt, Laurie Assistant Superintendent Allegan Area Educational Service Agency Shaw, Bart Retired AGH Foundation Board/Drug Court Shaw, Sheila Retired Stap, Lovedia Branch Manager Chemical Bank Travis, Rashmi Health Officer Allegan County Health Department Tuleja, Sandra Family Services Specialist Allegan County Head Start Vasquez, Ami Great Start Collaboration Director Allegan Area Educational Service Agency

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Appendix I: Additional Information Health Care Services Available to Meet Community Health Needs Type of Service(s) Acute Care Hospital Source: www.allegangeneral.org # of Facilities Additional Information or Providers 1 Allegan General Hospital is a 25 bed critical access hospital that provides: 24 hour emergency services Medical/surgical inpatient care Critical care unit Bariatric services Joint Academy/orthopedics Surgical services Endoscopy Laboratory services Radiology Respiratory services Infusion center Physical rehabilitation services Cardiac rehabilitation Pulmonary rehabilitation Wound healing center Sleep disorder center Outpatient psychological medicine clinic Home health services Occupational health Diabetes education Community-based health and wellness programs 93

Appendix I: Additional Information Health Care Services Available to Meet Community Health Needs Type of Service(s) Primary Care Providers Source: www.allegangeneral.org # of Facilities Additional Information or Providers 22+ AGH medical staff includes 10 family physicians, 3 internists, 1 pediatrician and 8 primary care nonphysician providers (i.e., nurse practitioners and physician assistants). There are additional primary care providers with a clinical practice in the greater Allegan area who do not have privileges at AGH. 94 Medical Subspecialty Services Source: www.allegangeneral.org Surgical Services Source: www.allegangeneral.org 9+ AGH medical staff includes 9 physicians who are medical subspecialists: 2 cardiologists, 2 neurologists, 1 dermatologist, 1 oncologist, 1 occupational medicine physician, 1 physiatrist and 1 psychiatrist. There may be additional medical subspecialists with a clinical practice in the greater Allegan area who do not have privileges at AGH. 15+ AGH medical staff includes 15 surgeons: 3 general surgeons, 2 orthopedic surgeons, 2 vascular surgeons, 3 ENT surgeons, 2 podiatrists, 1 urologist, 1 neurosurgeon and 1 obstetrics/gynecology physician. There may be additional surgeons with a clinical practice in the greater Allegan area who do not have privileges at AGH.

Appendix I: Additional Information Health Care Services Available to Meet Community Health Needs 95 Type of Service(s) Federally Qualified Health Center Source: www.intercare.org # of Facilities or Providers 7 fixed sites (1 in AGH s service area) + 2 mobile vans Additional Information Intercare Community Health Network (clinic site in Pullman) Public Health Services Source: www.allegancounty.org Free Clinics Source: www.renewedhopehealth.org Urgent Care Centers Source: Google search Home Health Agencies Medicare Certified Source: Allegan General Hospital 1 location Allegan County Health Department provides: Immunizations Maternal and infant health services Children s special health care services Communicable disease services Sexually transmitted disease services Vision and hearing screening Breast and cervical cancer screening Family planning services Health education and promotion services 1 Renewed Hope Health Clinic is open from 9-5 on Monday s and Thursday s. 0 No services available 16 Allegan County patients have a choice of 16 Medicarecertified home health agencies.

Appendix I: Additional Information Health Care Services Available to Meet Community Health Needs 96 Type of Service(s) Dialysis Source: www.medicare.gov # of Facilities or Providers 1 facility with 12 stations Additional Information Fresenius Medical Care Nursing Homes Source: www.medicare.gov Hospice and Palliative Care Source: www.wingsofhopehospice.com Dentists Source: www.healthgrades.com Mental Health & Substance Abuse Source: www.samhsa.gov Outpatient Pharmacies Source: Google search 3 Allegan County Medical Care Community Ely Manor Meadow Woods Nursing and Rehabilitation Center (Bloomingdale) 1 Wings of Hope 5 Allegan 3 Otsego 2 2 Allegan County Community Mental Health Services Pathways MI 5 Allegan Community Pharmacy Allegan Medical Center Pharmacy Rite Aid Value Drugs Gobles Pharmacy (Gobles)

Appendix I: Additional Information Health Care Services Available to Meet Community Health Needs 97 Type of Service(s) Medical Equipment Source: www.medicare.gov Vision Care Source: www.healthgrades.com Ambulance and Emergency Transport Source: Google search Assisted Living Facilities Source: Allegan General Hospital Chiropractors Source: www.healthgrades.com # of Facilities Additional Information or Providers 2 Airlink Homecare Rite Aid 3 Allegan 3 optometrists 2 Life EMS Ambulance Coloma Emergency Ambulance Services (Gobles) 1 Allegan County has at least 1 assisted living facilities. 6 Allegan 3 Otsego 3

98 Appendix I: Additional Information AGH s Role in Addressing Other Identified Needs Community Health Needs 1. Accessibility & affordability for low income residents 2. Mental health & substance abuse services 3. Healthy lifestyle 4. Urgent care 5. Women s health services 6. Primary care 7. Chronic diseases Mean Score (see p. 38 for details) 4.74 4.17 4.13 4.04 3.87 3.48 3.48 During the next three years, AGH will focus on helping to address three community health priorities adopted by the Board of Directors on April 30, 2013 and previously discussed in this report: Accessibility & affordability for low income residents; Primary care; and Women s health services. Our efforts will require a significant commitment of time and resources to be successful. For the other four areas listed above, we will continue to monitor the issues and assist with resources when it is consistent with our mission and within our capabilities to do so. We will evaluate our current activities related to these community health needs and identify opportunities to improve and expand our efforts. We will consider unmet needs as we develop new clinical services and community outreach programs.

99 Appendix I: Additional Information Consulting Assistance Carol Davis offers 22 years of health care consulting and management experience. She engages clients in understanding their critical strategic issues and implementing collaborative solutions with measurable results. Carol has been recognized by clients for excellence in customer service, group facilitation, physician relations, board development and project management. Community Health Experience Carol has assisted a number of hospitals with conducting a community health needs assessment and developing a strategic plan to address identified needs as required for 501(c)(3) hospitals under national health care reform legislation passed in March 2010. These projects require strong analytic as well as group facilitation skills, along with the ability to customize each engagement to reflect the organization s unique mission, capabilities and resources. Carol s interest and experience with community health projects is long standing. As a health system executive in 1992, she persuaded the organization to designate community health improvement as a strategic priority. She championed community health initiatives both internally as well as across the community to address pressing needs. In 1998, she was recognized as a Public Health Hero for efforts to assure primary health care access to low income and uninsured members of the community. Selected community health activities: Member of Leadership Council for community-wide initiative for prevention of substance abuse Co-founder and President of non-profit organization that successfully expanded access to primary care services Co-founder of coalition that completed inaugural community health assessment and improvement plan Member of Community Benefit Steering Committee for VHA regional initiative Strategy Consulting Experience With experience as an independent consultant as well as with a national health care consulting company, Carol has served as project leader for over 250 strategy engagements with 85 hospitals and health systems located in 23 states. Areas of expertise include organizational strategy, hospital-physician integration strategy and community health strategy.

100 Appendix I: Additional Information Consulting Assistance Selected consulting engagements: Led efforts by a community hospital to implement an integration strategy with independent physicians Assessed market potential of building an acute care hospital in an underserved community Evaluated market potential of reopening an acute care hospital that had closed due to bankruptcy Developed patient volume projections to support building replacement hospitals in rural markets Worked with two competing hospitals to explore a potential merger Worked with an American Indian tribe to resolve funding issues with the Indian Health Service under a Self- Governance Compact Health System Experience As executive leader for strategic services in a 220 bed regional referral hospital for seven years, Carol was responsible for strategic planning, business development, marketing, community health improvement and information technology. Education Carol earned an M.S. in Health Administration from the University of Colorado at Denver, and a B.M.E. in Music Therapy from the University of Kansas. Professional Memberships American College of Healthcare Executives Society for Healthcare Strategy and Market Development Healthcare Financial Management Association Association for Community Health Improvement Colorado Health Administration Alumni Association Additional Information Company website: www.strategy-connect.com Linked In profile: www.linkedin.com/pub/carol-davis/6/76a/78a/