Community Health Needs Assessment 2016

Community Health Needs Assessment 2016

Contents Introduction... 1 Summary of Community Health Needs Assessment... 2 Summary of Findings... 3 General Description of the Hospital... 4 Community Served by the Hospital... 5 Defined Community... 5 Community Details... 7 Community Population and Demographics... 8 Socioeconomic Characteristics of the Community... 12 Income and Employment... 12 Unemployment Rate... 13 Poverty... 13 Uninsured... 14 Medicaid... 15 Education... 16 Physical Environment of the Community... 17 Grocery Store Access... 17 Food Access/Food Deserts... 18 Recreation and Fitness Facility Access... 18 Clinical Care of the Community... 20 Access to Primary Care... 20 Lack of a Consistent Source of Primary Care... 21 Health Professional Shortage... 21 Preventable Hospital Events... 22 Health Status of the Community... 23 Leading Causes of Death... 25 Health Outcomes and Factors... 26 Diabetes... 30 High Blood Pressure... 30 Obesity... 31 Poor Dental Health... 31 Low Birth Weight... 32

Health Care Resources... 33 Hospitals... 33 Other Health Care Facilities... 35 Community Input-Project HOPE Assessment... 36 Methodology... 36 Key Informant Profiles... 36 Key Informant Interview Results... 37 Health Issues of Vulnerable Populations... 38 Information Gaps... 39 Prioritization of Identified Health Needs... 40 Appendices... 44 Analysis of Data... 46 Sources... 47 Dignity Health CNI Report... 48

Introduction As a result of the Affordable Care Act, tax-exempt hospitals are required to assess the health needs of their communities and adopt implementation strategies to address identified needs. Compliance with section 501(r) of the Internal Revenue Code (IRC) requires that a tax-exempt hospital facility: Conduct a community health needs assessment every three years. Adopt an implementation strategy to meet the community health needs identified through the assessment. Report and evaluate how it is addressing the needs identified in the community health needs assessment and a description of needs that are not being addressed with the reasons why such needs are not being addressed. The community health needs assessment must take into account input from persons who represent the broad interest of the community served by the hospital facility, including those with special knowledge of or expertise in public health. The hospital facility must make the community health needs assessment widely available to the public. This community health needs assessment is intended to document University Health Shreveport s (Hospital) compliance with IRC Section 501(r). Health needs of the community have been identified and prioritized so that University Health - Shreveport may adopt an implementation strategy to address specific needs of the community. The process involved: Collection and analysis of a large range of data, including demographic, socioeconomic and health statistics, health care resources and patient use rates. Review and incorporation of a needs assessment conducted by Project HOPE on behalf of University Health System. This document is a summary of all the available evidence collected during the initial cycle of community health needs assessments required by the IRS. It will serve as a compliance document as well as a resource until the next assessment cycle. 1

Summary of Community Health Needs Assessment The purpose of the community health needs assessment is to understand the unique health needs of the community served by the University Health - Shreveport and to document compliance with new federal laws outlined above. The Hospital engaged BKD, LLP to conduct a formal community health needs assessment. BKD, LLP is one of the largest CPA and advisory firms in the United States, with approximately 2,250 partners and employees in 34 offices. BKD serves more than 900 hospitals and health care systems across the country. The community health needs assessment was conducted from May 2015 through April 2016. Based on current literature and other guidance from the U.S Treasury Department and the IRS, the following steps were conducted as part of the Hospital s community health needs assessment: The community served by the Hospital was defined by utilizing Hospital statistics from medical records. This process is further described in the section entitled Community Served by the Hospital. Population demographics and socioeconomic characteristics of the community were gathered and reported utilizing Community Commons and County Health Rankings. The health status of the community was then reviewed. Information on the leading causes of death and morbidity information was analyzed in conjunction with health outcomes and factors reported for the community by CountyHealthrankings.org. Health factors with significant opportunity for improvement were noted. An inventory of health care facilities and other community resources was prepared Findings and results from the Project HOPE assessment were reviewed and incorporated into the community health needs assessment The Project HOPE assessment provides: o Additional health data for the community, including information on health disparities. o Community input provided by 49 key informants who represent a) broad interests of the community, b) populations of need or c) persons with specialized knowledge in public health. Information gathered in the above steps was analyzed and reviewed to identify health issues of uninsured persons, low-income persons and minority groups and the community as a whole. Health needs were ranked utilizing a weighting method that weighs 1) the size of the problem, 2) the seriousness of the problem, 3) the impact of the issues on vulnerable populations, 4) the prevalence of common themes and 5) how important the issue is to the community. Health needs were then prioritized taking into account the perceived degree of influence the Hospital has to impact the need and the health needs impact on overall health for the community. Information gaps identified during the prioritization process have been reported. 2

Summary of Findings The following significant health needs were identified based on the information gathered and analyzed through the Community Health Needs Assessment conducted by the Hospital. These needs have been prioritized based on information gathered through the Community Health Needs Assessment. Identified Community Health Needs 1. Poor nutrition/limited access to healthy food options 2. Lack of access to services 3. Cost of prescription drugs 4. Healthy behaviors/lifestyle choices 5. Lack of primary care physicians/hours 6. Children in poverty/homelessness 7. Physical inactivity 8. Lack of health knowledge/education 9. Obesity 10. Lack of dental services 11. Utilization of emergency room for episodic care 12. Uninsured/Limited Insurance 13. Lack of mental health services 14. Transportation 15. Diabetes These identified community health needs are discussed in greater detail later in this report. 3

General Description of the Hospital The Hospital is located in Shreveport, Louisiana, and is part of University Health System, a clinical partner and hospital for the LSU Health Shreveport School of Medicine. The Hospital is an integrated health care provider serving residents of North Louisiana. The Hospital proudly offers a wide range of services and specialties to meet the needs of the citizens of University Health Shreveport. As an academic hospital, University Health upholds a strong commitment to stateof-the art treatment, clinical research and community education and prevention programs. The Hospital is home to state-designated Centers of Excellence including the Feist-Weiller Cancer Center and a Center of Excellence in Arthritis and Rheumatology. On our main campus you also will find an accredited Children s Hospital, a regional Burn Center and a Trauma Center serving communities across North Louisiana, East Texas and Southwest Arkansas. The Hospital is one of only six hospitals in the nation affiliated with St. Jude Children s Research Hospital. University Health Conway is home to health care providers committed to improving the health of all local citizens. Profits are reinvested in our communities, allowing preservation of the safety net mission, along with facility and technology improvements. 4

Community Served by the Hospital The Hospital is located in Shreveport, Louisiana, in Caddo Parish. The Hospital is located near Interstates 49 and 20 and other state routes that service the Northern part of Louisiana. The map pinpoints the Hospital s location and can be identified by the red plus symbol. Defined Community A community is defined as the geographic area from which a significant number of the patients utilizing hospital services reside. While the community health needs assessment considers other types of health care providers, the Hospital is the single largest provider of acute care services. For this reason, the utilization of hospital services provides the clearest definition of the community. Based on the patient origin of acute care inpatient discharges from October 1, 2013 through September 30, 2014, management has identified the community to include the corresponding counties for zip codes listed in Exhibit 1 (Community). These parishes are listed with corresponding demographic information in Exhibits 2 through 5. The map below displays the Hospital s geographic relationship to the Community, as well as significant roads and highways. The geographic area of the defined community based on the identified zip codes includes Caddo, Bossier, De Soto, Ouachita, Webster and Natchitoches parishes. The community health needs assessment will utilize these six parishes with all or significant portions included in the community.. 5

Exhibit 1 University Health - Shreveport: CHNA Community Summary of Inpatient Discharges by Zip Code 10/01/2013-09/30/2014 Percent of Total Zip Code City Discharges Discharges Caddo Parish: 71109 Shreveport 1,530 7.4% 71107 Shreveport 1,475 7.1% 71106 Shreveport 1,418 6.8% 71108 Shreveport 1,344 6.5% 71101 Shreveport 926 4.5% 71103 Shreveport 814 3.9% 71104 Shreveport 602 2.9% 71129 Shreveport 404 2.0% 71118 Shreveport 395 1.9% 71119 Shreveport 311 1.5% 71105 Shreveport 289 1.4% 71047 Keithville 220 1.1% 71115 Shreveport 167 0.8% 71082 Vivian 136 0.7% Other Caddo 306 1.5% Total Caddo 10,337 49.9% Bossier Parish: 71111 Bossier City 1,001 4.8% 71112 Bossier City 718 3.5% 71037 Haughton 352 1.7% 71006 Benton 179 0.9% 71064 Plain Dealing 115 0.6% Other Bossier 203 1.0% Total Bossier 2,568 12.4% De Soto Parish: 71052 Mansfield 385 1.9% Other De Soto 394 1.9% Total De Soto 779 3.8% Ouachita Parish: 71202 Monroe 238 1.1% 71203 Monroe 164 0.8% 71291 West Monroe 146 0.7% 71292 West Monroe 141 0.7% Other Ouachita 87 0.4% Total Ouachita 776 3.7% Webster Parish: 71055 Minden 377 1.8% Other Webster 296 1.4% Total Webster 673 3.2% Natchitoches Parish: 71457 Cypress 272 1.3% Other Natchitoches 162 0.8% Total Natchitoches 434 2.1% Total Other Discharges 5,148 24.9% Total 20,715 100.0% Source: University Health - Shreveport 6

Community Details Identification and Description of Geographical Community The following map geographically illustrates the Hospital s community by showing the community zip codes shaded by number of inpatient discharges. 7

Community Population and Demographics The U.S. Bureau of Census has compiled population and demographic data. Exhibit 2 below shows the total population of the community. It also provides the breakout of the Community between the male and female population. Exhibit 2 University Health - Shreveport Estimated 2015 Population and Projected 2020 Population Under 15-44 45-64 65 years Parish 15 years years years and over Total Male Female Estimated 2015 Population Caddo 52,194 99,528 63,959 37,533 253,214 120,623 132,591 Bossier 31,630 47,635 30,299 16,602 126,166 62,410 63,756 De Soto 5,404 9,893 7,486 4,454 27,237 13,094 14,143 Ouachita 33,741 64,550 37,903 21,221 157,415 75,612 81,803 Webster 7,665 14,580 10,654 7,424 40,323 19,730 20,593 Natchitoches 7,558 16,540 8,791 5,932 38,821 18,494 20,327 REPO RT AREA 138,192 252,726 159,092 93,166 643,176 309,963 333,213 Projected 2020 Population Caddo 52,121 98,999 59,489 42,487 253,096 121,034 132,062 Bossier 27,629 54,580 31,563 19,822 133,594 66,115 67,479 De Soto 5,364 10,213 7,138 5,227 27,942 13,449 14,493 Ouachita 33,909 66,266 37,335 24,492 162,002 78,117 83,885 Webster 7,491 14,553 9,825 8,098 39,967 19,602 20,365 Natchitoches 7,305 16,656 8,094 6,508 38,563 18,405 20,158 REPO RT AREA 133,819 261,267 153,444 106,634 655,164 316,722 338,442 Source: The Nielsen Company Exhibit 2.1 provides the percent difference for the Community from estimated 2015 to projected 2020 as well as a comparison to state and national changes. Exhibit 2.1 illustrates that the overall population is projected to increase at rates consistent with both state and national projections. Note that the age category that utilizes health care services the most, 65 years and over, is projected to increase by more than 14%. This increase in the 65 year and over category will have a dramatic impact on both the amount and type of services required by the community. 8

Exhibit 2.1 University Health - Shreveport Estimated 2015 Population vs Projected 2020 Population Percent Difference Under 15-44 45-64 65 years Parish 15 years years years and over Total Male Female Percent Difference Caddo -0.1% -0.5% -7.0% 13.2% 0.0% 0.3% -0.4% Bossier -12.6% 14.6% 4.2% 19.4% 5.9% 5.9% 5.8% De Soto -0.7% 3.2% -4.6% 17.4% 2.6% 2.7% 2.5% Ouachita 0.5% 2.7% -1.5% 15.4% 2.9% 3.3% 2.5% Webster -2.3% -0.2% -7.8% 9.1% -0.9% -0.6% -1.1% Natchitoches -3.3% 0.7% -7.9% 9.7% -0.7% -0.5% -0.8% PROVIDER SERVICE AREA -3.2% 3.4% -3.6% 14.5% 1.9% 2.2% 1.6% LOUISIANA 2015 ESTIMATED (1,000s) 936,769 1,882,529 1,196,011 647,560 4,662,869 2,283,540 2,379,329 LOUISIANA 2020 PROJECTED (1,000s) 946,435 1,921,115 1,167,296 765,184 4,800,030 2,353,621 2,446,409 PERCENT DIFFERENCE 1.0% 2.0% -2.4% 18.2% 2.9% 3.1% 2.8% UNITED STATES 2015 ESTIMATED (1,000s) 61,091,731 127,455,944 84,035,345 46,876,971 319,459,991 157,270,864 162,189,127 UNITED STATES 2020 PROJECTED (1,000s) 61,149,695 129,602,782 84,781,967 55,154,921 330,689,365 162,910,597 167,778,768 PERCENT DIFFERENCE 0.1% 1.7% 0.9% 17.7% 3.5% 3.6% 3.4% Source: The Nielsen Company Certain characteristics of a population can be factors in determining the health care services required by a community. Exhibit 2.2 is an analysis of the age distribution of the population for the primary community. The analysis is provided by county and provides a comparison to Louisiana and the United States. Exhibit 2.2 University Health - Shreveport Estimated 2015 Population vs Projected 2020 Population with Percent Totals Under 15-44 45-64 65 years Parish 15 years years years and over Total Male Female Estimated 2015 Population Caddo 20.6% 39.3% 25.3% 14.8% 100.0% 47.6% 52.4% Bossier 25.1% 37.8% 24.0% 13.2% 100.0% 49.5% 50.5% De Soto 19.8% 36.3% 27.5% 16.4% 100.0% 48.1% 51.9% Ouachita 21.4% 41.0% 24.1% 13.5% 100.0% 48.0% 52.0% Webster 19.0% 36.2% 26.4% 18.4% 100.0% 48.9% 51.1% Natchitoches 19.5% 42.6% 22.6% 15.3% 100.0% 47.6% 52.4% TO TAL REPO RT AREA 21.5% 39.3% 24.7% 14.5% 100.0% 48.2% 51.8% 9

Exhibit 2.2 (Continued) University Health - Shreveport Estimated 2015 Population vs Projected 2020 Population with Percent Totals Under 15-44 45-64 65 years Parish 15 years years years and over Total Male Female Projected 2020 Population Caddo 20.6% 39.1% 23.5% 16.8% 100.0% 47.8% 52.2% Bossier 20.7% 40.9% 23.6% 14.8% 100.0% 49.5% 50.5% De Soto 19.2% 36.6% 25.5% 18.7% 100.0% 48.1% 51.9% Ouachita 20.9% 40.9% 23.0% 15.1% 100.0% 48.2% 51.8% Webster 18.7% 36.4% 24.6% 20.3% 100.0% 49.0% 51.0% Natchitoches 18.9% 43.2% 21.0% 16.9% 100.0% 47.7% 52.3% TO TAL REPO RT AREA 20.4% 39.9% 23.4% 16.3% 100.0% 48.3% 51.7% ESTIMATED 2015 PO PULATIO N 21.5% 39.3% 24.7% 14.5% 100.0% 48.2% 51.8% PRO JECTED 2020 PO PULATIO N 20.4% 39.9% 23.4% 16.3% 100.0% 48.3% 51.7% PERCENT DIFFERENCE -1.1% 0.6% -1.3% 1.8% 0.2% -0.2% LO UISIANA 2015 ESTIMATED 20.1% 40.4% 25.6% 13.9% 100.0% 49.0% 51.0% LO UISIANA 2020 PRO JECTED 19.7% 40.0% 24.3% 15.9% 100.0% 49.0% 51.0% UNITED STATES 2015 ESTIMATED 19.1% 39.9% 26.3% 14.7% 100.0% 49.2% 50.8% UNITED STATES 2020 PRO JECTED 18.5% 39.2% 25.6% 16.7% 100.0% 49.3% 50.7% Source: The Nielsen Company While the relative age of the community population can impact community health needs, so can the ethnicity and race of a population. The following Exhibit 3 shows the population of the Community by ethnicity by illustrating the Hispanic versus non-hispanic residents. The percentage of Hispanic residents in the CHNA community approximates 2.9%, which is lower than the state and national averages of 4.4% and 16.6% respectively. Exhibit 3 University Health - Shreveport Hispanic Population Non- Parish Hispanic Hispanic Total Caddo 6,461 249,090 255,551 Bossier 7,286 112,661 119,947 De Soto 689 26,124 26,813 Ouachita 3,010 151,631 154,641 Webster 708 40,331 41,039 Natchitoches 767 38,636 39,403 REPO RT AREA 18,921 618,473 637,394 LO UISIANA (1,000s) 202,145 4,365,823 4,567,968 UNITED STATES (1,000s) 51,786,608 259,750,000 311,536,608 Source: Community commons 10

Exhibit 4 shows the population of the Community by race and illustrates different categories of race such as, white, black, Asian, other and multiple races. Exhibit 4 University Health - Shreveport Total Population by Race Native Native Hawaiin/ America/ Pacific Some O ther Multiple Parish White Black Asian Alaska Native Islander Race Races Total Caddo 124,201 121,275 2,870 947 137 2,408 3,713 255,551 Bossier 86,661 25,582 1,685 895 42 2,499 2,582 119,946 De Soto 15,480 10,429 56 243 15 279 311 26,813 Ouachita 93,433 57,052 1,419 487 22 862 1,366 154,641 Webster 26,287 13,901 154 140-162 395 41,039 Natchitoches 21,532 16,308 208 319 18 206 812 39,403 REPORT AREA 367,594 244,547 6,392 3,031 234 6,416 9,179 637,393 LOUISIANA (1,000s) 2,874,235 1,463,345 73,460 28,466 2,141 51,142 75,179 4,567,968 UNITED STATES (1,000s) 230,592,576 39,167,008 15,231,962 2,540,309 526,347 14,746,054 8,732,333 311,536,589 Source: Community Commons Exhibit 5 reports the percentage of population living in urban and rural areas. Urban areas are identified using population density, count, and size thresholds. Urban areas also include territory with a high degree of impervious surface (development). Rural areas are all areas that are not urban. This table helps to understand why transportation is one of the highest ranking needs within the Community. Exhibit 5 University Health - Shreveport Rural/Urban Population Parish Percent Urban Percent Rural Caddo 85.56% 14.44% Bossier 75.66% 24.34% De Soto 22.74% 77.26% Ouachita 75.81% 24.19% Webster 46.96% 53.04% Natchitoches 49.95% 50.05% LO UISIANA 73.19% 26.81% UNITED STATES 80.89% 19.11% Source: Community Commons 11

Socioeconomic Characteristics of the Community The socioeconomic characteristics of a geographic area influence the way residents access health care services and perceive the need for health care services within society. The economic status of an area may be assessed by examining multiple variables within the community. The following exhibits are a compilation of data that includes household per capita income, employment rates, uninsured population poverty and educational attainment for the Community. These standard measures will be used to compare the socioeconomic status of the Community to the state of Louisiana and the United States. Income and Employment Exhibit 6 presents the per capita income for the CHNA community. This includes all reported income from wages and salaries as well as income from self-employment, interest or dividends, public assistance, retirement, and other sources. The per capita income in this exhibit is the average (mean) income computed for every man, woman and child in the specified area. The only parish within the Community that is above the state of Louisiana is Bossier Parish. Exhibit 6 University Health - Shreveport Per Capita Income Parish Total Population Total Income ($) Per Capita Income ($) Caddo 255,551 $ 6,211,864,064 $ 24,307 Bossier 119,947 $ 3,290,071,808 $ 27,429 De Soto 26,813 $ 577,752,576 $ 21,547 Ouachita 154,641 $ 3,389,239,808 $ 21,916 Webster 41,039 $ 815,467,072 $ 19,870 Natchitoches 39,403 $ 819,672,576 $ 20,802 LO UISIANA 4,567,968 $ 111,650,398,208 $ 24,442 UNITED STATES 311,536,608 $ 8,771,308,355,584 $ 28,154 Source: Community Commons 12

Unemployment Rate Exhibit 7 presents the average annual unemployment rate from 2004 2013 for the Community defined as the Community, as well as the trend for Louisiana and the United States. On average, the unemployment rate is stronger than the United States and slightly higher than the state of Louisiana, although, although the past few years have remained relatively level. Exhibit 7 Data Source: US Department of Labor, Bureau of Labor Statistics. 2015 - May. Source geography: County Poverty Exhibit 8 presents the percentage of total population below 100% FPL (Federal Poverty Level). Poverty is a key driver a health status and is relevant because poverty creates barriers to access including health services, healthy food choices and other factors that contribute to poor health status. Exhibit 8 Total Population Population in Poverty Percent Population in Poverty Total CHNA Community 619,797 124,425 20.08% Bossier 117,923 16,848 14.29% Caddo 249,726 48,657 19.48% De Soto 26,407 5,978 22.64% Natchitoches 38,250 9,963 26.05% Ouachita 147,680 34,274 23.21% Webster 39,811 8,705 21.87% Louisiana 4,438,263 846,780 19.08% United States 303,692,064 46,663,432 15.37% Data Source: US Census Bureau, American Community Survey. 2009-13. Source geography: Tract 13

Uninsured Exhibit 9 reports the percentage of the total civilian non-institutionalized population without health insurance coverage according to the most recent available data from the American Community Survey. This indicator is relevant because lack of insurance is a primary barrier to healthcare access including regular primary care, specialty care, and other health services that contributes to poor health status. The lack of health insurance is considered a key driver of health status. It should be noted the 2015 uninsured rate is estimated to have decreased three to five percent for each of the parishes in the CHNA Community, per www.enrollamerica.org. Based on the current estimates of uninsured rates reported for each county in the CHNA Community, the current estimate of uninsured population is approximately 89,000, a decrease of almost 23,000 uninsured persons, primarily the result of the Affordable Care Act. Exhibit 9 Total Population (For Whom Insurance Status is Determined) Total Uninsured Population Percent Uninsured Population Percent Uninsured Population Total CHNA Community 622,259 112,134 18.02% Bossier 117,524 16,774 14.27% Caddo 250,313 43,301 17.30% De Soto 26,753 4,559 17.04% Natchitoches 38,644 7,291 18.87% Ouachita 149,050 32,634 21.89% Webster 39,975 7,575 18.95% Total CHNA Community (18.85%) Louisiana (17.1%) United States (14.87%) Louisiana 4,497,703 747,454 16.62% United States 309,082,272 43,878,140 14.20% Data Source: US Census Bureau, American Community Survey. 2010-14. Source geography: Tract 14

Medicaid The Medicaid indicator reports the percentage of the population with insurance enrolled in Medicaid (or other means-tested public health insurance). This is relevant because it assesses vulnerable populations which are more likely to have multiple health access, health status, and social support needs; when combined with poverty data, providers can use this measure to identify gaps in eligibility and enrollment. Exhibit 10 shows only Bossier Parish compares favorably to the state of Louisiana. Exhibit 10 Total Population (For Whom Insurance Status is Determined) Population with Any Health Insurance Population Receiving Medicaid Percent of Insured Population Receiving Medicaid Percent of Insured Population Receiving Medicaid Total CHNA Community 620,548 503,586 135,904 26.99% Bossier 115,573 97,938 18,893 19.29% Caddo 250,031 204,686 58,759 28.71% De Soto 26,537 21,804 6,919 31.73% Natchitoches 38,634 31,329 9,707 30.98% Total CHNA Community (26.99%) Louisiana (25.7%) United States (20.21%) Ouachita 149,634 115,674 31,668 27.38% Webster 40,139 32,155 9,958 30.97% Louisiana 4,463,986 3,700,431 951,048 25.7% United States 306,448,480 260,878,816 52,714,280 20.21% Data Source: US Census Bureau, American Community Survey. 2009-13. Source geography: Tract 15

Education Exhibit 12 presents the population with an Associate s level degree or higher in each Parish versus Louisiana and the United States. Exhibit 12 Total Population Age 25 Population Age 25 with Associate's Degree or Higher Percent Population Age 25 with Associate's Degree or Higher Percent Population Age 25 with Associate's Degree or Higher Total CHNA Community 411,873 113,816 27.63% Bossier 77,493 24,818 32.03% Caddo 167,699 48,289 28.8% De Soto 17,940 3,031 16.9% Natchitoches 23,578 6,162 26.13% Ouachita 97,301 26,337 27.07% Total CHNA Community (27.63%) Louisiana (27.01%) United States (36.65%) Webster 27,862 5,179 18.59% Louisiana 2,977,813 804,346 27.01% United States 206,587,856 75,718,936 36.65% Data Source: US Census Bureau, American Community Survey. 2009-13. Source geography: Tract Education levels obtained by community residents may impact the local economy. Higher levels of education generally lead to higher wages, less unemployment and job stability. These factors may indirectly influence community health. As noted in Exhibit 11, the percent of residents within the CHNA community obtaining an Associate s degree or higher is above the state percentage. 16

Physical Environment of the Community A community s health also is affected by the physical environment. A safe, clean environment that provides access to healthy food and recreational opportunities is important to maintaining and improving community health. This section will touch on a few of the elements that relate to some needs mentioned throughout the report. Grocery Store Access Exhibit 13 reports the number of grocery stores per 100,000-population. Grocery stores are defined as supermarkets and smaller grocery stores primarily engaged in retailing a general line of food, such as canned and frozen foods; fresh fruits and vegetables; and fresh and prepared meats, fish, and poultry. Included are delicatessen-type establishments. Convenience stores and large general merchandise stores that also retail food, such as supercenters and warehouse club stores are excluded. This indicator is relevant because it provides a measure of healthy food access and environmental influences on dietary behaviors. Exhibit 13 Total CHNA Community Total Population Number of Establishments 633,097 83 13.11 Establishments, Rate per 100,000 Population Grocery Stores, Rate (Per 100,000 Population) Bossier 116,979 18 15.39 Caddo 254,969 29 11.37 De Soto 26,656 2 7.50 Natchitoches 39,566 7 17.69 Ouachita 153,720 20 13.01 Webster 41,207 7 16.99 Louisiana 4,533,372 992 21.88 United States 312,732,537 66,286 21.2 Data Source: US Census Bureau, County Business Patterns. Additional data analysis by CARES. 2013. Source geography: County Total CHNA Community (13.11) Louisiana (21.88) United States (21.2) 17

Food Access/Food Deserts This indicator reports the percentage of the population living in census tracts designated as food deserts. A food desert is defined as a low-income census tract (where a substantial number or share of residents has low access to a supermarket or large grocery store. The information in Exhibit 14 below is relevant because it highlights populations and geographies facing food insecurity. Exhibit 14 Total CHNA Community Total Population Population with Low Food Access 633,097 218,172 34.46% Percent Population with Low Food Access Percent Population with Low Food Access Bossier 116,979 29,073 24.85% Caddo 254,969 93,319 36.6% De Soto 26,656 6,587 24.71% Natchitoches 39,566 12,788 32.32% Ouachita 153,720 66,043 42.96% Webster 41,207 10,362 25.15% Louisiana 4,533,372 1,295,100 28.57% Total CHNA Community (34.46%) Louisiana (28.57%) United States (23.61%) United States 308,745,538 72,905,540 23.61% Data Source: US Department of Agriculture, Economic Research Service, USDA - Food Access Research Atlas. 2010. Source geography: Tract Recreation and Fitness Facility Access This indicator reports the number per 100,000-population of recreation and fitness facilities as defined by North American Industry Classification System (NAICS) Code 713940. It is relevant because access to recreation and fitness facilities encourages physical activity and other healthy behaviors. Exhibit 15 shows there are some parishes that do not have any fitness establishments available to the residents. Exhibit 15 Total CHNA Community Total Population Number of Establishments 633,097 56 8.85 Establishments, Rate per 100,000 Population Recreation and Fitness Facilities, Rate (Per 100,000 Population) Bossier 116,979 10 8.55 Caddo 254,969 29 11.37 De Soto 26,656 3 11.25 Natchitoches 39,566 3 7.58 Ouachita 153,720 11 7.16 Webster 41,207 0 0 Louisiana 4,533,372 435 9.6 United States 312,732,537 30,393 9.72 Data Source: US Census Bureau, County Business Patterns. Additional data analysis by CARES. 2013. Source geography: County Total CHNA Community (8.85) Louisiana (9.6) United States (9.72) 18

The trend graph below (Exhibit 16) shows the percent of adults who are physically inactive by year for the Community and compared to Louisiana and the United States. Since 2008, the CHNA community has had a higher percentage of adults who are physically inactive compared to both the state of Louisiana and the United States. Exhibit 16 Percent Adults Physically Inactive by Year, 2004 through 2013 Data Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2013. Source geography: County 19

Clinical Care of the Community A lack of access to care presents barriers to good health. The supply and accessibility of facilities and physicians, the rate of un-insurance, financial hardship, transportation barriers, cultural competency and coverage limitations affect access. Rates of morbidity, mortality and emergency hospitalizations can be reduced if community residents access services such as health screenings, routine tests and vaccinations. Prevention indicators can call attention to a lack of access or knowledge regarding one or more health issues and can inform program interventions. Access to Primary Care Exhibit 17 shows the number of primary care physicians per 100,000-population. Doctors classified as "primary care physicians" by the AMA include: General Family Medicine MDs and DOs, General Practice MDs and DOs, General Internal Medicine MDs and General Pediatrics MDs. Physicians age 75 and over and physicians practicing sub-specialties within the listed specialties are excluded. This indicator is relevant because a shortage of health professionals contributes to access and health status issues. Exhibit 17 Total Population, 2012 Primary Care Physicians, 2012 Primary Care Physicians, Rate per 100,000 Pop. Total CHNA Community 641,992 499 77.73 Bossier 122,197 50 40.92 Caddo 257,093 269 104.63 De Soto 26,963 6 22.25 Natchitoches 39,436 23 58.32 Ouachita 155,363 127 81.74 Webster 40,940 24 58.62 Louisiana 4,601,893 2,960 64.32 United States 313,914,040 233,862 74.5 Data Source: US Department of Health Human Services, Health Resources and Services Administration, Area Health Resource File. 2012. Source geography: County 20

Lack of a Consistent Source of Primary Care Exhibit 18 reports the percentage of adults aged 18 and older who self-report that they do not have at least one person who they think of as their personal doctor or health care provider. This indicator is relevant because access to regular primary care is important to preventing major health issues and emergency department visits. Exhibit 18 Survey Population (Adults Age 18 ) Total Adults Without Any Regular Doctor Percent Adults Without Any Regular Doctor Total CHNA Community 448,574 115,927 25.84% Bossier 70,103 18,145 25.88% Caddo 177,096 50,933 28.76% De Soto 25,779 4,616 17.91% Natchitoches 35,014 8,793 25.11% Ouachita 102,037 28,109 27.55% Webster 38,545 5,331 13.83% Louisiana 3,413,356 822,186 24.09% United States 236,884,668 52,290,932 22.07% Data Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System. Additional data analysis by CARES. 2011-12. Source geography: County Population Living in a Health Professional Shortage Area This indicator reports the percentage of the population that is living in a geographic area designated as a Health Professional Shortage Area (HPSA), defined as having a shortage of primary medical care, dental or mental health professionals. This indicator is relevant because a shortage of health professionals contributes to access and health status issues. As Exhibit 19 below shows, 100% of the residents from many of the parishes within the Community are living in a health professional shortage area. Exhibit 19 Total Area Population Population Living in a HPSA Percentage of Population Living in a HPSA Total CHNA Community 633,097 516,118 81.52% Bossier 116,979 0 0% Caddo 254,969 254,969 100% De Soto 26,656 26,656 100% Natchitoches 39,566 39,566 100% Ouachita 153,720 153,720 100% Webster 41,207 41,207 100% Louisiana 4,533,372 3,360,481 75.21% United States 308,745,538 105,203,742 33.13% Note: This indicator is compared with the state average. Data Source: US Department of Health & Human Services, Health Resources and Services Administration, Health Professional Shortage Areas. April 2016. Source geography: HPSA 21

Preventable Hospital Events Exhibit 20 reports the discharge rate (per 1,000 Medicare enrollees) for conditions that are ambulatory care sensitive (ACS). ACS conditions include pneumonia, dehydration, asthma, diabetes and other conditions which could have been prevented if adequate primary care resources were available and accessed by those patients. This indicator is relevant because analysis of ACS discharges allows demonstrating a possible return on investment from interventions that reduce admissions (for example, for uninsured or Medicaid patients) through better access to primary care resources. Exhibit 20 Total Medicare Part A Enrollees Ambulatory Care Sensitive Condition Hospital Discharges Ambulatory Care Sensitive Condition Discharge Rate Total CHNA Community 68,604 5,623 81.97 Bossier 11,616 929 80.01 Caddo 27,618 2,028 73.43 De Soto 3,503 342 97.88 Natchitoches 4,689 413 88.14 Ouachita 15,142 1,276 84.3 Webster 6,036 633 104.88 Louisiana 396,767 31,863 80.31 United States 58,209,898 3,448,111 59.24 Note: This indicator is compared with the state average. Data Source: Dartmouth College Institute for Health Policy & Clinical Practice, Dartmouth Atlas of Health Care. 2012. Source geography: County 22

Health Status of the Community This section of the assessment reviews the health status of Bossier, Caddo, De Soto, Natchitoches, Ouachita and Webster Parish residents. As in the previous section, comparisons are provided with the state of Louisiana and the United States. This in-depth assessment of the mortality and morbidity data, health outcomes, health factors and mental health indicators of the county residents that make up the Community will enable the Hospital to identify priority health issues related to the health status of its residents. Good health can be defined as a state of physical, mental and social well-being, rather than the absence of disease or infirmity. According to Healthy People 2020, the national health objectives released by the U.S. Department of Health and Human Services, individual health is closely linked to community health. Community health, which includes both the physical and social environment in which individuals live, work and play, is profoundly affected by the collective behaviors, attitudes, and beliefs of everyone who lives in the community. Healthy people are among a community s most essential resources. Numerous factors have a significant impact on an individual s health status: lifestyle and behavior, human biology, environmental and socioeconomic conditions, as well as access to adequate and appropriate health care and medical services. Studies by the American Society of Internal Medicine conclude that up to 70% of an individual s health status is directly attributable to personal lifestyle decisions and attitudes. Persons who do not smoke, who drink in moderation (if at all), use automobile seat belts (car seats for infants and small children), maintain a nutritious low-fat, high-fiber diet, reduce excess stress in daily living and exercise regularly have a significantly greater potential of avoiding debilitating diseases, infirmities and premature death. The interrelationship among lifestyle/behavior, personal health attitude and poor health status is gaining recognition and acceptance by both the general public and health care providers. Some examples of lifestyle/behavior and related health care problems include the following: Smoking Alcohol/drug abuse Poor nutrition Lifestyle Lung cancer Cardiovascular disease Emphysema Chronic bronchitis Cirrhosis of liver Motor vehicle crashes Unintentional injuries Malnutrition Suicide Homicide Mental illness Obesity Digestive disease Depression Primary Disease Factor Driving at excessive speeds Trauma Motor vehicle crashes 23

Lack of exercise Overstressed Cardiovascular disease Depression Mental illness Alcohol/drug abuse Cardiovascular disease Health problems should be examined in terms of morbidity as well as mortality. Morbidity is defined as the incidence of illness or injury and mortality is defined as the incidence of death. Such information provides useful indicators of health status trends and permits an assessment of the impact of changes in health services on a resident population during an established period of time. Community attention and health care resources may then be directed to those areas of greatest impact and concern. 24

Leading Causes of Death and Health Outcomes Exhibit 21 reflects the leading causes of death for the Community and compares the rates to the state of Louisiana and the United States. Exhibit 21 University Health - Shreveport Selected Causes of Resident Deaths: Crude Rate Bossier Parish Caddo Parish De Soto Parish Natchitoches Parish O uachita Parish Webster Parish Louisiana United States Cancer 168.93 228.45 252.85 191.07 202.86 271.17 202.88 185.81 Coronary Heart Disease 185.37 227.98 282.20 235.78 192.00 328.42 225.45 197.50 Ischaemic Heart Disease 91.73 109.22 174.59 138.73 53.49 163.97 125.25 127.43 Lung Disease 53.65 63.67 64.72 44.21 54.54 75.68 41.51 44.86 Stroke 34.62 47.60 56.44 30.49 42.90 64.03 46.14 42.90 Unintentional Injury 44.14 50.67 60.96 56.41 49.83 48.03 49.56 39.87 Motor Vehicle Accident 7.10 7.41 7.53 20.83 6.02 7.76 7.75 7.69 Homicide 6.06 12.69 8.28 9.15 7.85 N/A 12.63 5.58 Suicide 11.08 10.87 13.55 9.65 13.86 12.13 11.93 12.10 Source: Community Commons The table above shows leading causes of death within each parish as compared to the state of Louisiana and also to the United States. The crude rate is shown per 100,000 residents. The rates highlighted in yellow represent the parish and corresponding leading cause of death that is greater than the national rate. As the table indicates, there are more leading causes of death above the national rate than there are at or below. Bossier Parish has fewer highlighted cells than the other parishes in the CHNA community. 25

Health Outcomes and Factors An analysis of various health outcomes and factors for a particular community can, if improved, help make the community a healthier place to live, learn, work and play. A better understanding of the factors that affect the health of the community will assist with how to improve the community s habits, culture and environment. This portion of the community health needs assessment utilizes information from County Health Rankings, a key component of the Mobilizing Action Toward Community Health (MATCH) project, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. The County Health Rankings model is grounded in the belief that programs and policies implemented at the local, state and federal levels have an impact on the variety of factors that, in turn, determine the health outcomes for communities across the nation. The model provides a ranking method that ranks all 50 states and the counties within each state, based on the measurement of two types of health outcomes for each county: how long people live (mortality) and how healthy people feel (morbidity). These outcomes are the result of a collection of health factors and are influenced by programs and policies at the local, state and federal levels. Counties in each of the 50 states are ranked according to summaries of a variety of health measures. Those having high ranks, e.g. 1 or 2, are considered to be the healthiest. Counties are ranked relative to the health of other counties in the same state on the following summary measures: Health Outcomes--rankings are based on an equal weighting of one length of life (mortality) measure and four quality of life (morbidity) measures. Health Factors--rankings are based on weighted scores of four types of factors: o o o o Health behaviors (nine measures) Clinical care (seven measures) Social and economic (eight measures) Physical environment (five measures) A more detailed discussion about the ranking system, data sources and measures, data quality and calculating scores and ranks can be found at the website for County Health Rankings (www.countyhealthrankings.org). As part of the analysis of the needs assessment for the Community, the six parishes that comprise the majority of the Community will be used to compare the relative health status of to the state of Louisiana as well as to a national benchmark. A better understanding of the factors that affect the health of the Community will assist with how to improve the Community s habits, culture and environment. The following tables, from County Health Rankings, summarize the 2015 health outcomes for the six parishes that comprise the majority of the CHNA community for University Health Shreveport. The tables on the following pages highlight the health factors and outcomes for the Community and show the parishes that have significant room for improvement and in which areas. 26

Exhibit 22 University Health - Shreveport County Health Rankings - Health Outcomes (2015) Bossier Parish Caddo Parish De Soto Parish Natchitoches Parish Ouachita Parish Webster Parish Louisiana Top US Performers Mortality Premature death - Years of potential life lost before age 75 per 100,000 population (age-adjusted) 7,414 10,447 12,201 9,447 9,282 9,990 9,131 5,200 Morbidity Poor or fair health - Percent of adults reporting fair or poor health (age-adjusted) 17% 17% 19% 22% 20% 23% 20% 10% Poor physical health days - Average number of physically unhealthy days reported in past 30 days (ageadjusted) 3.2 3.4 3.3 4.3 3.8 4.0 3.8 2.5 Poor mental health days - Average number of mentally unhealthy days reported in past 30 days (age-adjusted) 3.6 2.9 4.3 4.6 3.4 2.9 3.5 2.3 Low birthweight - Percent of live births with low birthweight (<2500 grams) 10.6% 14.6% 14.2% 12.0% 12.9% 12.7% 10.9% 5.9% Source: countyhealthrankings.org As can be seen from the yellow highlighted cells, there are numerous areas of the Community that have room for improvement when compared to the state statistics. Out of the six parishes within the Community, Bossier Parish is performing at or higher than the state averages for more than half of the outcomes and factors listed. 27

Exhibit 23 University Health - Shreveport County Health Rankings - Health Factors (2015) Bossier Parish Caddo Parish De Soto Parish Natchitoches Parish Ouachita Parish Webster Parish Louisiana Top US Performers Health Behaviors Adult smoking - Percent of adults that report smoking at least 100 cigarettes and that they currently smoke 26% 22% 28% 27% 21% 26% 22% 14% Adult obesity - Percent of adults that report a BMI >= 30 34% 34% 35% 37% 34% 35% 34% 25% Food Environment Index - Index of factors that contribute to a healthy food environment, 0 (worst) to 10 (best) 7.7 5.8 6.6 5.3 5.3 6.5 6.8 8.4 Physical Inactivity - Percentage of adults aged 20 and over reporting no leisure-time physical activity 25% 33% 33% 31% 32% 36% 30% 20% Access to Exercise Opportunities - Percentage of population with adequate access to locations for physical activity 85% 82% 57% 59% 74% 56% 76% 92% Excessive drinking - Percent of adults that report excessive drinking in the past 30 days 16% 13% 12% 12% 11% 8% 16% 10% Alcohol-Impaired Driving Deaths - Percentage of driving deaths with alcohol involvement 17% 20% 50% 28% 20% 16% 33% 14% Sexually transmitted infections - Chlamydia rate per 100K population 393 943 716 956 1,067 813 594 138 Teen birth rate - Per 1,000 female population, ages 15-19 49 65 64 44 57 61 50 20 Clinical Care Uninsured adults - Percent of population under age 65 without health insurance 18% 19% 18% 20% 21% 21% 19% 11% Primary care physicians - Ratio of population to primary care physicians 2,444:1 956:1 4.494:1 1.715:1 1,223:1 1,706:1 1,555:1 1,045:1 Dentists - Ratio of population to dentists 2,099:1 1.393:1 9.028:1 3.558:1 1,817:1 4,068: 1,976:1 1,377:1 Mental Health Providers - ratio of population to mental health providers 1,876:1 531:1 6.771:1 910:1 673:1 1,769:1 859:1 386:1 Preventable hospital stays - Hospitalization rate for ambulatory-care sensitive conditions per 1,000 Medicare enrollees 80 73 98 88 84 105 80 41 Diabetic screening - Percent of diabetic Medicare enrollees that receive HbA1c screening 83% 82% 77% 83% 78% 82% 82% 90% Mammography screening - Percent of female Medicare enrollees that receive mammography screening 58.7% 59.7% 59.7% 56.6% 59.1% 56.9% 59.8% 70.7% 28

Exhibit 23 continued University Health - Shreveport County Health Rankings - Health Factors (2015) Bossier De Soto Natchitoches Ouachita Webster Top US Parish Caddo Parish Parish Parish Parish Parish Louisiana Performers Social & Economic Factors High school graduation - Percent of ninth grade cohort that graduates in 4 years 74% 63% 77% 75% 70% 72% 73% N/A Some college - Percent of adults aged 25-44 years with some postsecondary education 62.4% 57.0% 47.3% 50.0% 54.2% 39.6% 54.8% 71.0% Unemployment - Percentage of population ages 16 and older unemployed but seeking work 5.7% 7.1% 7.8% 7.6% 6.5% 7.1% 6.2% 4.0% Children in poverty - Percent of children under age 18 in poverty 20% 33% 34% 37% 35% 37% 28% 13% Income Inequality - Ratio of household iincome at the 80th percentile to income at the 20th percentile 5% 5% 6% 7% 6% 5% 6% 4% Children in single-parent households - Percent of children that live in household headed by single parent 36% 55% 49% 47% 50% 47% 43% 20% Social associations - Number of membership associations per 10,000 population 7.8 12.7 15.9 15 14.4 13.4 9.9 22 Violent crime rate - Violent crime rate per 100,000 population 361 638 1,333 617 534 271 536 59 Injury Deaths - Number of deaths due to injury per 100,000 population 59 74 85 76 69 69 75 50 Physical Environment Air pollution-particulate matter days - Annual number of unhealthy air quality days due to fine particulate matter 10.8 10.6 10.1 10.1 11.4 11.0 10.8 9.5 Drinking water violations - Percentage of population potentially exposed to water exceeding a violation limit during the past year 20% 44% 37% 35% 36% 18% 15% 0% Severe housing problems - Percentage of household with at least 1 of 4 housing problems: overcrowding, high housing costs, or lack of kitchen or plumbing facilities 13% 17% 15% 21% 16% 13% 16% 9% Driving alone to work - Percentage of the workforce that drives alone to work 87% 85% 85% 81% 87% 85% 82% 71% Long commute - driving alone - Among workers who commute in their car alone, the percentage that commute more than 30 minutes Source: Countyhealthrankings.org 25% 19% 44% 27% 20% 36% 32% 15% 29

The following exhibits show a more detailed view of certain health outcomes and factors. The percentages for each parish and the Community as a whole are compared to the state of Louisiana. Diabetes (Adult) Exhibit 24 reports the percentage of adults aged 20 and older who have ever been told by a doctor that they have diabetes. This indicator is relevant because diabetes is a prevalent problem in the U.S.; it may indicate an unhealthy lifestyle and puts individuals at risk for further health issues. Exhibit 24 Total CHNA Community Total Population Age 20 Population with Diagnosed Diabetes 464,941 56,194 11.32% Population with Diagnosed Diabetes, Age-Adjusted Rate Percent Adults with Diagnosed Diabetes (Age-Adjusted) Bossier 88,876 9,332 10.30% Caddo 187,528 23,441 11.60% De Soto 19,658 2,988 13.30% Natchitoches 28,104 3,513 11.70% Ouachita 110,322 12,687 10.90% Webster 30,453 4,233 12.10% Louisiana 3,363,441 410,234 11.53% Report Area (11.32%) Louisiana (11.53%) United States (9.11%) United States 234,058,710 23,059,940 9.11% Data Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2012. Source geography: County High Blood Pressure (Adult) Per Exhibit 25 below, 163,775 or 34.77% of adults aged 18 and older have ever been told by a doctor that they have high blood pressure or hypertension. The Community percentage of high blood pressure among adults is greater than the percentage of Louisiana and the United States. Exhibit 25 Total CHNA Community Total Population (Age 18 ) Total Adults with High Blood Pressure 470,976 163,775 34.77% Percent Adults with High Blood Pressure Percent Adults with High Blood Pressure Bossier 85,844 28,929 33.7% Caddo 191,220 64,632 33.8% De Soto 19,917 6,971 35% Natchitoches 29,782 10,841 36.4% Ouachita 112,754 39,126 34.7% Webster 31,459 13,276 42.2% Louisiana 3,372,863 1,150,146 34.1% Total CHNA Community (34.77%) Louisiana (34.1%) United States (28.16%) United States 232,556,016 65,476,522 28.16% Data Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System. Additional data analysis by CARES. 2006-12. Source geography: County 30

Obesity 34.79% of adults aged 20 and older self-report that they have a Body Mass Index (BMI) greater than 30.0 (obese) in the Community per Exhibit 26. Excess weight may indicate an unhealthy lifestyle and puts individuals at risk for further health issues. While there are a couple of parishes that have a BMI less than the obesity rate, the majority of the parishes in the Community have a BMI percentage greater than the state rate. Exhibit 26 Total CHNA Community Total Population Age 20 Adults with BMI > 30.0 (Obese) 465,834 162,227 34.79% Percent Adults with BMI > 30.0 (Obese) Percent Adults with BMI > 30.0 (Obese) Bossier 89,070 30,462 34% Caddo 187,945 65,029 34.6% De Soto 19,736 7,243 36.6% Natchitoches 28,067 10,525 37.7% Ouachita 110,571 38,921 35.2% Webster 30,445 10,047 33% Louisiana 3,364,737 1,155,621 34.14% Total CHNA Community (34.79%) Louisiana (34.14%) United States (27.14%) United States 231,417,834 63,336,403 27.14% Data Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2012. Source geography: County Poor Dental Health This indicator is relevant because it indicates lack of access to dental care and/or social barriers to utilization of dental services. Exhibit 27 shows the total Community has a greater percentage of adults with poor health than that of Louisiana. Exhibit 27 Total CHNA Community Total Population (Age 18 ) Total Adults with Poor Dental Health 467,401 90,010 19.26% Percent Adults with Poor Dental Health Percent Adults with Poor Dental Health Bossier 84,324 13,904 16.49% Caddo 190,262 39,365 20.69% De Soto 19,751 4,315 21.85% Natchitoches 29,597 4,400 14.87% Ouachita 112,061 19,812 17.68% Webster 31,406 8,214 26.15% Louisiana 3,372,863 630,688 18.7% Total CHNA Community (19.26%) Louisiana (18.7%) United States (15.65%) United States 235,375,690 36,842,620 15.65% Data Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System. Additional data analysis by CARES. 2006-10. Source geography: County 31

Low Birth Weight Exhibit 28 reports the percentage of total births that are low birth weight (Under 2500g). This indicator is relevant because low birth weight infants are at high risk for health problems. This indicator can also highlight the existence of health disparities. Exhibit 28 Total CHNA Community Total Live Births Low Weight Births (Under 2500g) 65,338 8,600 13.16% Low Weight Births, Percent of Total Percent Low Birth Weight Births Bossier 11,760 1,247 10.6% Caddo 26,544 3,875 14.6% De Soto 2,604 370 14.2% Natchitoches 4,088 491 12% Ouachita 16,541 2,134 12.9% Webster 3,801 483 12.7% Louisiana 451,262 49,188 10.9% United States 29,300,495 2,402,641 8.2% Total CHNA Community (13.16%) Louisiana (10.9%) United States (8.2%) HP 2020 Target <= 7.8% Data Source: US Department of Health Human Services, Health Indicators Warehouse. Centers for Disease Control and Prevention, National Vital Statistics System. Accessed via CDC WONDER. 2006-12. Source geography: County 32

Health Care Resources The availability of health resources is a critical component to the health of a county s residents and a measure of the soundness of the area s health care delivery system. An adequate number of health care facilities and health care providers are vital for sustaining a community s health status. Fewer health care facilities and health care providers can impact the timely delivery of services. A limited supply of health resources, especially providers, results in the limited capacity of the health care delivery system to absorb charity and indigent care as there are fewer providers upon which to distribute the burden of indigent care. This section will address the availability of health care resources to the residents of the six parishes in which the community resides. Hospitals and Health Centers The Hospital has 424 acute beds and is one of the acute care hospitals located in the Community. Residents of the Community also take advantage of services provided by hospitals in neighboring parishes, as well as services offered by other facilities and providers. Exhibit 29 summarizes health services available to the residents of the six parishes in which the Community resides: 33

Exhibit 29 University Health Shreveport Summary of Area Hospitals and Health Centers Facility Hospital Address Parish Type Size Bed Cornerstone Hospital of Bossier City 4900 Medical Drive, Bossier City, LA 71112 Bossier Acute Care 62 Willis-Knighton Bossier Health Center 2400 Hospital Drive, Bossier City, LA 71111 Bossier Acute Care 166 University Health Shreveport 1501 Kings Highway, Shreveport, LA 71130 Caddo Acute Care 424 North Caddo Medical Center 1000 South Spruce Street, Vivian, LA 71082 Caddo Critical Access 25 Dubuis Hospital Of Shreveport One Saint Mary Place, Shreveport, LA 71101 Caddo Acute Care 36 Brentwood Hospital Shreveport 1006 Highland Avenue, Shreveport, LA 71101 Caddo Behavioral Health 200 Specialists Hospital Shreveport 1500 Line Avenue Suite 206, Shreveport, LA 71101 Caddo Acute Care 30 Promise Hospital of Louisiana 1800 Irving Place, Shreveport, LA 71101 Caddo Acute Care 196 Willis-Knighton Medical Center 2600 Greenwood Road, Shreveport, LA 71103 Caddo Acute Care 662 LSU Health Sciences Center Shreveport 1501 Kings Highway, Shreveport, LA 71103 Caddo Acute Care 429 Shriners Hospitals for Children 3100 Samford Avenue, Shreveport, LA 71103 Caddo Childrens 45 Physicians Behavioral Hospital 2025 Desoto Street, Shreveport, LA 71103 Caddo Psychiatric 24 Christus Schumpert Medical Center One Saint Mary Place, Shreveport, LA 71101 Caddo Acute Care 623 Lifecare Hospital of Shreveport 9320 Linwood Avenue, Shreveport, LA 71106 Caddo Acute Care 119 Overton Brooks VA Medical Center 510 East Stoner Avenue, Shreveport, LA 71101 Caddo Acute Care 111 DeSoto Regional Health System 207 Jefferson Street, Mansfield, LA 71052 DeSoto Acute Care 38 Natchitoches Regional Medical Center 501 Keyser Avenue, Natchitoches, LA 71457 Natchitoches Acute Care 81 Cornerstone Hospital of West Monroe 6198 Cypress Street, West Monroe, LA 71291 Ouachita Acute Care 47 Glenwood Regional Medical Center 503 McMillian Road, West Monroe, LA 71291 Ouachita Acute Care 268 Monroe Surgical Hospital 2408 Broadmoor Boulevard, Monroe, LA 71201 Ouachita Acute Care 10 St. Francis Medical Center North 3421 Medical Park Drive, Monroe, LA 71203 Ouachita Acute Care 259 Ouachita Community Hospital 1275 Glenwood Drive, West Monroe, LA 71291 Ouachita Acute Care 10 St. Francis Medical Center 309 Jackson Street, Monroe, LA 71201 Ouachita Acute Care 468 University Health - Monroe 4864 Jackson Street, Monroe, LA 71020 Ouachita Acute Care 125 Minden Medical Center 1 Medical Plaza, Minden, LA 71055 Webster Acute Care 161 Source: Costreportdata.com 34

Other Health Care Facilities Short-term acute care hospital services are not the only health services available to members of the Hospital s community. Exhibit 29.1 provides a listing of additional health services providers within the Hospital s community. The Hospital s CHNA community also has a number of clinics inside various retail facilities including Walgreens, Kroger, CVS and Rite-Aide. These clinics are expanding past providing only flu shots to providing checkups and treatments to a growing list of ailments. Exhibit 29.1 University Health - Shreveport Summary of Other Health Care Facilities Facility Facility Type Address Parish North Caddo Medical Center Rural Health Clinic 1003 S. Spruce Street, Vivian, LA 71082 Caddo Minden Family Care/Park City Health Center RHC Rural Health Clinic 208 Morris Drive, Minden, LA 71055 Webster North Caddo Medical Center Plain Dealing Rural Health Clinic 108 N. Louisiana Street, Plain Dealing, LA 71064 Bossier Minden Ladies Rural Health Clinic Rural Health Clinic 427 Homer Road, Minden, LA 71055 Webster Family Medicine Associates Rural Health Clinic 111 Homer Road, Minden, LA 71055 Webster Desota Regional Family Medicine Mansfield Rural Health Clinic 130 Jefferson Street, Mansfield, LA 71052 DeSota Plain Dealing Rural Health Clinic 110 Forest Street, Plain Dealing, LA 71064 Bossier CASSA Community Health Institute Federally Qualified Heath Center 907 Polk Street, Mansfield, LA 71052 DeSota CASSA Bert Kouns Clinic Site Federally Qualified Heath Center 2120 Bert Kouns Industrial Loop, Shreveport, LA 71118 Caddo David Raines Community Health Center Corporate Office Federally Qualified Heath Center 3041 Dr. Martin Luther King Jr. Drive, Shreveport, LA 71107 Caddo David Raines Community Health Center Gilliam Federally Qualified Heath Center 12763 Lay Street, Gilliam, LA 71029 Caddo David Raines Community Health Center West 70th Federally Qualified Heath Center 3021 W. 70th Street, Shreveport, LA 71108 Caddo David Raines Community Health Center Shreveport Federally Qualified Heath Center 1625 David Raines Road, Shreveport, LA 71107 Caddo David Raines Community Health Center Bossier Federally Qualified Heath Center 1514 Doctors Drive, Bossier City, LA 71111 Bossier Natchitoches Outpatient Medical Center Federally Qualified Heath Center 1640 Breazeale Springs Street, Natchitoches, LA 71457 Natchitoches PHSC Dental Clinic Federally Qualified Heath Center 2914 Betin Avenue, Monroe, LA 71201 Ouachita Desiard Street Clinic Federally Qualified Heath Center 2913 Desiard Street, Monroe, LA 71201 Ouachita Family Justice Center Clinic Federally Qualified Heath Center 620 Riverside Dr, Monroe, LA 71201 Ouachita PHSC Wellness Clinic Federally Qualified Heath Center 2915 Betin Avenue, Monroe, LA 71201 Ouachita PHSC Mobile Health Unit #2 Federally Qualified Heath Center 2913 Desiard Street, Monroe, LA 71201 Ouachita PHSC D Hill Clinic Federally Qualified Heath Center 850 S. 2nd Street, Monroe, LA 71202 Ouachita Primary Health Services Center Federally Qualified Heath Center 2913 Betin Avenue, Monroe, LA 71201 Ouachita Source: http://www.lrha.org/rural_healthclinics.htm http://www.lpca.net/uploads/file/fqha 35

Community Input - Project HOPE Assessment A health needs assessment was conducted by Project HOPE on behalf of the University Health System between December 2014 and February 2015. The assessment covered the communities of Shreveport and Monroe, Louisiana and the University Health System facilities in those communities. Community input provided as part of the Project HOPE Assessment is summarized on the following page. Interviewing key informants (community stakeholders that represent the broad interest of the community with knowledge of or expertise in public health) is a technique employed to assess public perceptions of the county s health status and unmet needs. These interviews are intended to ascertain opinions among individuals likely to be knowledgeable about the community and influential over the opinions of others about health concerns in the Community. Methodology Interviews were performed with 49 key informants including a focus group with nursing staff and patient one-on-one interviews. Informants were determined based on their a.) specialized knowledge or expertise in public health, b.) affiliation with local government, schools and industry or c.) involvement with underserved and minority populations. All interviews were conducted by Project HOPE personnel. Participants provided comments on the following issues: Health and quality of life for residents of the primary community Barriers to improving health and quality of life for residents of the primary community Opinions regarding the important health issues that affect Community residents and the types of services that are important for addressing these issues This technique does not provide a quantitative analysis of the leaders opinions, but reveals community input for some of the factors affecting the views and sentiments about overall health and quality of life within the community. Key Informant Profiles Key informants from the community worked for the following types of organizations and agencies: University Health System Social service agencies Local school systems and universities Public health agencies Other medical providers 36

Key Informant Interview Results The issues identified most frequently were: The Community is very poor and there are huge income gaps. Many white people have fled to the suburbs. More accessible ambulatory care is needed. Convenient hours need to be offered to patients. The Emergency Department is the Community s Urgent Care. The Emergency Room is used as an outpatient clinic. Education on health issues and preventative care is limited. There is a significant need for community outreach programs aimed to educate patients and those within the Community. There is a lack of mental and behavioral health services. Diabetes, asthma, cardiovascular disease and obesity are considered as a health and quality of life issue. Increased access to dental services is needed. Almost half of those interviewed stated transportation was a barrier to health. Transportation is an issue for people and prevents them from seeking care or making their appointments or receiving follow-up care. Low birth weight is related to a need for more pre-natal care and women s health. Access to care is an issue due to multiple factors: not enough physicians or specialists, those living in poverty and homelessness have barriers to making appointments, etc. Large proportion of patients are uninsured or on Medicare/Medicaid. Patient follow-up is lacking homeless patients have nowhere to go during the day. The ED is our urgent care. Sometimes the ambulance is the only form of transportation. Access to dentists and costs of dental care are huge barriers to good dental health. 37

Health Issues of Vulnerable Populations According to Dignity Health s Community Need Index (see Appendices), the Hospital s community has a high-level of need. The CNI score is an average of five different barrier scores that measure socioeconomic indicators of each community (income, cultural, education, insurance and housing). The parishes with the highest number of discharges (Caddo, Bossier and De Soto) have 10 zip codes that rate above a 4.2 or highest need. Three zip codes have a CNI score of 5. Those zip codes are 71052, 71103 and 71109. Based on information obtained through Project Hope s key informant interviews the following populations are considered to be vulnerable or underserved in the Community and the identified needs are listed: Uninsured/Working Poor Population o o o o o o o Transportation Access to primary care physicians High cost of healthcare prevents needs from being met Education Access to food Lack of mental health services Cost and access to prescription drugs Youth o o o o Chronic Hunger Asthma Oral Health Lack of mental health services Homeless o o Lack of mental health services Lack of dental services 38

Information Gaps Community Health Needs Assessment 2016 This assessment was designed to provide a comprehensive and broad picture of the health in the overall community served by University Health - Shreveport. However, there may be a number of medical conditions that are not specifically addressed in this report due to various factors including but not limited to publically available information or limited community input. In addition, certain population groups might not be identifiable or might not be represented in numbers sufficient for independent analysis. Examples include homeless, institutionalized persons, undocumented residents and members of certain ethnic groups who do not speak English or Spanish. Efforts were made to obtain input from these specific populations through Key Informant Interviews. 39

Prioritization of Identified Health Needs Using findings obtained through the collection of primary and secondary data, the Hospital completed an analysis of these inputs (see Appendices) to identify community health needs. The following data was analyzed to identify health needs for the Community: Leading Causes of Death Leading causes of death for the Community and the death rates for the leading causes of death for each county within the Hospital CHNA community were compared to U.S. adjusted death rates. Causes of death in which the county rate compared unfavorably to the U.S. adjusted death rate resulted in a health need for the Hospital CHNA community. Health Outcomes and Factors An analysis of the County Health Rankings health outcomes and factors data was prepared for each county within the Hospital CHNA community. County rates and measurements for health behaviors, clinical care, social and economic factors and the physical environment were compared to state benchmarks. County rankings in which the county rate compared unfavorably (by greater than 30% of the national benchmark) resulted in an identified health need. Primary Data Health needs identified through key informant interviews were included as health needs. Needs for vulnerable populations were separately reported on the analysis in order to facilitate the prioritization process. 40

As a result, the following summary list of needs was identified: Community Health Needs Assessment 2016 Lack of Access to Services Cost of Prescription Drugs Healthy Behaviors/Lifestyle Choices Transportation Poor Nutrition/Limited Access to Healthy Food Options Low Birth Weight/Need for Pre-Natal Care Physical Inactivity Heart Disease Lack of Primary Care Physicians/Hours Adult Smoking/Tobacco Use Lack of Health Knowledge/Education Cancer Obesity Children in Single-Parent Households Children in Poverty/Homelessness Stroke Utilization of Emergency Room for Episodic Care Lack of Dental Services Uninsured/Limited Insurance Diabetes Lack of Mental Health Services Lung Disease Violent Crime Rate Preventable Hospital Stays Asthma Sexually Transmitted Infections Teen Birth Rate To facilitate prioritization of identified health needs, a ranking and prioritization process was used. Health needs were ranked based on the following five factors. Each factor received a score between 0 and 5. 1) How many people are affected by the issue or size of the issue? For this factor ratings were based on the percentage of the Community who are impacted by the identified need. The following scale was utilized. >25% of the Community= 5; >15% and <25%=4; >10% and <15%=3; >5% and <10%=2 and <5%=1. 2) What are the consequences of not addressing this problem? Identified health needs which have a high death rate or have a high impact on chronic diseases received a higher rating. 3) The impact of the problem on vulnerable populations. Needs identified which pertained to vulnerable populations were rated for this factor. 4) How important the problem is to the community. Needs identified through Community surveys and/or focus groups were rated for this factor. 5) Prevalence of common themes. The rating for this factor was determined by how many sources of data (Leading Causes of Death, Primary Causes for Inpatient Hospitalization, Health Outcomes and Factors and Primary Data) identified the need. Each need was ranked based on the five prioritization metrics. 41

Exhibit 30 University Health-Shreveport Prioritization of Health Needs How Many People Are Affected by the Issue? What Are the Consequences of Not Addressing This Problem? What is the Impact on Vulnerable Populations? How Important is it to the Community? How Many Sources Identified the Need? Total Score * Poor Nutrition/Limited access to Healthy Food Options 5 3 4 5 3 20 Lack of Access to Services (Cost) 5 3 4 4 3 19 Cost of Prescription Drugs 5 3 5 5 1 19 Healthy Behaviors/Lifestyle Choices 5 4 3 3 3 18 Lack of Primary Care Physicians/Hours 5 2 4 4 3 18 Children in Poverty/Homelessness 4 2 5 4 3 18 Physical Inactivity 5 3 3 3 3 17 Lack of Health Knowledge/Education 5 1 3 4 3 16 Obesity 5 5 0 3 3 16 Lack of Dental Services 3 3 4 3 3 16 Utilization of Emergency Room for Episodic Care 3 2 5 3 2 15 Uninsured/Limited Insurance 4 1 4 3 3 15 Lack of Mental Health Services 3 3 4 3 2 15 Transportation 3 1 5 5 1 15 Diabetes 3 3 3 3 2 14 Low Birth Weight/Need for Pre-natal care 2 4 3 2 2 13 Heart Disease 3 4 0 3 2 12 Adult Smoking/Tobacco Use 5 4 0 2 1 12 Cancer 3 4 0 2 1 10 Children in Single-Parent Households 5 2 0 2 1 10 Stroke 2 3 0 2 1 8 Lung Disease 2 4 0 1 1 8 Violent Crime Rate 2 1 3 1 1 8 Preventable Hospital Stays 2 2 0 2 1 7 Asthma 2 3 0 1 1 7 Sexually Transmitted Infections 2 1 0 1 1 5 Teen Birth Rate 2 1 0 1 1 5 *Highest potential score = 25 42

As a result of the analysis described, Hospital management identified the following health needs as the most significant health needs for the community: 1. Poor nutrition/limited access to healthy food options 2. Lack of access to services 3. Cost of prescription drugs 4. Healthy behaviors/lifestyle choices 5. Lack of primary care physicians/hours 6. Children in poverty/homelessness 7. Physical inactivity 8. Lack of health knowledge/education 9. Obesity 10. Lack of dental services 11. Utilization of emergency room for episodic care 12. Uninsured/Limited Insurance 13. Lack of mental health services 14. Transportation 15. Diabetes The Hospital s next steps include determining priority areas and developing an implementation strategy to address these priority areas. 43

APPENDICES Community Health Needs Assessment 2016

University Health - Shreveport Analysis of CHNA Data Analysis of Health Status-Leading Causes of Death Community Health Needs Assessment 2016 (A) (B) U.S. Age Adjusted Death Rates 10% of U.S. Adjusted Death Rate County Rate County Rate Less U.S. Adjusted Death Rate If (B)>(A), then "Health Need" Caddo Parish: Cancer 185.8 18.6 228.5 42.6 Health Need Heart Disease 197.5 19.8 228.0 30.5 Health Need Lung Disease 44.9 4.5 63.7 18.8 Health Need Stroke 42.9 4.3 47.6 4.7 Health Need Unintentional Injury 39.9 4.0 50.7 10.8 Health Need Bossier Parish: Cancer 185.8 18.6 168.9-16.9 Heart Disease 197.5 19.8 185.4-12.1 Lung Disease 44.9 4.5 53.7 8.8 Health Need Stroke 42.9 4.3 34.6-8.3 Unintentional Injury 39.9 4.0 44.1 4.3 Health Need De Soto Prrish: Cancer 185.8 18.6 252.9 67.0 Health Need Heart Disease 197.5 19.8 282.2 84.7 Health Need Lung Disease 44.9 4.5 64.7 19.9 Health Need Stroke 42.9 4.3 56.4 13.5 Health Need Unintentional Injury 39.9 4.0 61.0 21.1 Health Need *Analysis prepared for three Parish's with highest discharges. 44

Analysis of Health Outcomes and Factors National Benchmark (A) 30% of National Benchmark County Rate (B) County Rate Less If (B)>(A), National then "Health Benchmark Need" Caddo Parish: Adult Smoking 14.0% 4.2% 22.0% 8.0% Health Need Adult Obesity 25.0% 7.5% 34.0% 9.0% Health Need Food Environment Index 8.4 3 5.8 3 Health Need Physical Inactivity 20.0% 6.0% 33.0% 13.0% Health Need Access to Exercise Opportunities 92.0% 27.6% 82.0% 10.0% Excessive Drinking 10.0% 3.0% 13.0% 3.0% Alcohol-Impaired Driving Deaths 14.0% 4.2% 20.0% 6% Health Need Sexually Transmitted Infections 138 41 943 805 Health Need Teen Birth Rate 20 6 65 45 Health Need Uninsured 11.0% 3.3% 19.0% 8.0% Health Need Primary Care Physicians 1045 314 956-89 Dentists 1377 413 1393 16 Mental Health Providers 386 116 531 145 Health Need Preventable Hospital Stays 41 12 73 32 Health Need Diabetic Screen Rate 90.0% 27.0% 82.0% 8.0% Mammography Screening 70.7% 21.2% 59.7% 11.0% Violent Crime Rate 59 18 638 579 Health Need Children in Poverty 13.0% 3.9% 33.0% 20.0% Health Need Children in Single-Parent Households 20.0% 6.0% 55.0% 35.0% Health Need Bossier Parish: Adult Smoking 14.0% 4.2% 26.0% 12.0% Health Need Adult Obesity 25.0% 7.5% 36.0% 11.0% Health Need Food Environment Index 8.4 3 7.7 1 Physical Inactivity 20.0% 6.0% 25.0% 5.0% Access to Exercise Opportunities 92.0% 27.6% 85.0% 7.0% Excessive Drinking 10.0% 3.0% 16.0% 6.0% Health Need Alcohol-Impaired Driving Deaths 14.0% 4.2% 17.0% 3% Sexually Transmitted Infections 138 41 393 255 Health Need Teen Birth Rate 20 6 49 29 Health Need Uninsured 11.0% 3.3% 18.0% 7.0% Health Need Primary Care Physicians 1045 314 2444 1399 Health Need Dentists 1377 413 2099 722 Health Need Mental Health Providers 386 116 1876 1490 Health Need Preventable Hospital Stays 41 12 80 39 Health Need Diabetic Screen Rate 90.0% 27.0% 83.0% 7.0% Mammography Screening 70.7% 21.2% 58.7% 12.0% Violent Crime Rate 59 18 361 302 Health Need Children in Poverty 13.0% 3.9% 20.0% 7.0% Health Need Children in Single-Parent Households 20.0% 6.0% 36.0% 16.0% Health Need De Soto Parish: Adult Smoking 14.0% 4.2% 28.0% 14.0% Health Need Adult Obesity 25.0% 7.5% 35.0% 10.0% Health Need Food Environment Index 8.4 3 6.6 2 Physical Inactivity 20.0% 6.0% 33.0% 13.0% Health Need Access to Exercise Opportunities 92.0% 27.6% 57.0% 35.0% Health Need Excessive Drinking 10.0% 3.0% 12.0% 2.0% Alcohol-Impaired Driving Deaths 14.0% 4.2% 50.0% 36% Health Need Sexually Transmitted Infections 138 41 716 578 Health Need Teen Birth Rate 20 6 64 44 Health Need Uninsured 11.0% 3.3% 18.0% 7.0% Health Need Primary Care Physicians 1045 314 4494 3449 Health Need Dentists 1377 413 9028 7651 Health Need Mental Health Providers 386 116 6771 6385 Health Need Preventable Hospital Stays 41 12 98 57 Health Need Diabetic Screen Rate 90.0% 27.0% 77.0% 13.0% Mammography Screening 70.7% 21.2% 59.7% 11.0% Violent Crime Rate 59 18 361 302 Health Need Children in Poverty 13.0% 3.9% 20.0% 7.0% Health Need Children in Single-Parent Households 20.0% 6.0% 36.0% 16.0% Health Need *Analysis prepared for three Parish's with highest discharges. 45

Analysis of Primary Data-Project HOPE Key Informant Interviews Poverty Lack of Convenient Ambulatory Care Emergency Room Utilization Lack of Health Knowledge/Education Healthy Behaviors/Lifestyle Choices Lack of Mental Health Services Chornic Diseases (Diabetes, Asthma, Cardiovascular Disease) Obesity Poor Nutrition/Lack of Healthy Food Options Transportation Shortage of Dental Services Low-Birth Weight/Pre-natal Care Uninsured Lack of Physicians 46

SOURCES Community Health Needs Assessment 2016

DATA TYPE SOURCE YEAR(S) Discharges by Zip Code Hospital FY 2015 Population Estimates The Nielsen Company 2015 Demographics -Race/Ethnicity Community Commons via American Community Survey http://www.communitycommons.org/ 2015 Demographics - Income Community Commons via American Community Survey http://www.communitycommons.org/ 2009-2013 Unemployment Community Commons via US Department of Labor http://www.communitycommons.org/ 2015 Poverty Uninsured Status Community Commons via US Census Bureau, Small Areas Estimates Branch http://www.census.gov Community Commons via US Census Bureau, Small area Helath Insurance Estimates http://www.communitycommons.org/ 2009-2013 2010-2014 Medicaid Education Physical Environment - Grocery Store Access Physical Environment - Food Access/Food Deserts Physical Environment - Recreation and Fitness Facilities Physical Environment - Phsyically Inactive Clinical Care - Access to Primary Care Clinical Care - Lack of a Consistent Source of Primary Care Clinical Care - Population Living in a Health Professional Shortage Area Community Commons via American Community Survey http://www.communitycommons.org/ Community Commons via American Community Survey http://www.communitycommons.org/ Community Commons via US Cenus Bureau, County Business Patterns http://www.communitycommons.org/ Community Commons via US Department of Agriculture http://www.communitycommons.org/ Community Commons via US Cenus Bureau, County Business Patterns http://www.communitycommons.org/ Community Commons via US Centers for Disease control and Prevention http://www.communitycommons.org/ Community Commons via US Department of Health & Human Services http://www.communitycommons.org/ Community Commons via US Department of Health & Human Services http://www.communitycommons.org/ Community Commons via US Department of Health & Human Services http://www.communitycommons.org/ 2009-2013 2009-2013 2013 2010 2013 2013 2012 2011-2012 2016 Clinical Care - Preventable Hospital Events Leading Causes of Death Health Outcomes and Factors Health Care Resources Community Commons via Dartmouth College Institute for Health Policy & Clinical Practice http://www.communitycommons.org/ Community Commons via CDC national Bital Statistics System http://www.communitycommons.org/ County Health Rankings http://www.countyhealthrankings.org/ & Community Commons http://www.communitycommons.org/ Hospital 2012 2007-2011 2015 & 2006-2012 47

DIGNITY HEALTH CNI REPORT Community Health Needs Assessment 2016

48