COMMUNITY HEALTH NEEDS ASSESSMENT

2016 COMMUNITY HEALTH NEEDS ASSESSMENT St. Mary's Detroit Lakes

2016 Community Health Needs Assessment Essentia Health St. Mary s West Region Essentia Health St. Mary s-detroit Lakes 1027 Washington Avenue Detroit Lakes, Minnesota 56501 EH St. Mary s-detroit Lakes is an 87-bed acute care facility in Detroit Lakes, Minn. It is part of Essentia Health, a nonprofit integrated health system caring for patients in Minnesota, Wisconsin, North Dakota and Idaho. Headquartered in Duluth, Minnesota, Essentia Health combines the strengths and talents of 14,000 employees, who serve our patients and communities through the mission of being called to make a healthy difference in people s lives. EH St. Mary s-detroit Lakes has been providing health care to the community since 1886 when Dr. L.C. Weeks set up the first clinic. While part of Essentia Health, St. Mary s retains its Benedictine alignment and Catholic heritage, which began in 1939. EH St. Mary s-detroit Lakes provides both primary and select secondary patient services, including a 12-bed women s unit with four birthing rooms, three operating rooms and full imaging and laboratory services. Outpatient and Urgent Care services are provided in our new clinic adjacent to the hospital. Additional satellite clinics are located in Pelican Rapids, Park Rapids, Menahga, Frazee, Mahnomen, and Lake Park. St. Mary s Therapy Center offers physical, occupational and speech therapy services to all ages and includes a pediatric and outpatient gym, kitchen and sleep center. In providing the full spectrum of care, EH St. Mary s-detroit Lakes also has Home Health, senior living, assisted living as well as transitional and long-term care services in a close-knit community. EH St. Mary s-detroit Lakes has a Level III Trauma designation, is a Primary Stroke Center hospital and has been awarded the Gold Seal of Approval by JCAHO for demonstrated commitment to standards of performance. LEAD PARTIES ON THE ASSESSMENT Peter Jacobson, Senior Vice President of Primary Care and Administrator Karen Crabtree, Community Health Program Manager Ann Malmberg, Regional Director of Community Health, West Region TABLE OF CONTENTS... 2 Essentia Health: Here With You... 2 Executive Summary... 3 Caring for our Community... 3 Progress to Date on 2013 Community Health Needs Assessment... 4 2016 Community Health Needs Assessment... 6 Objectives... 6 Description of Community Served by Essentia Health St. Mary s... 6 Process Overview... 9 Assessment Process... 12 Phase 1: Assessment... 12 Phase 2: Prioritization... 12 Phase 3: Design of Strategy and Implementation Plan... 13 Conclusion... 15 Appendix A: Essentia Health St. Mary s -- Top 80 percent of 2015 discharges by ZIP code... 16 Appendix B: Methodology Appendix C: Stakeholder Meetings Appendix D: Asset Map 1

2016 Community Health Needs Assessment Essentia Health St. Mary s Essentia Health: Here With You At Essentia Health, our mission and values guide us every day. Together, we deliver on our promise to be here with our patients and members of our communities from the beginning to the end of life, both in our facilities and where they live, work and play. As a Catholic facility sponsored by the Benedictine Sisters of the St. Scholastica Monastery, Essentia Health St. Mary s- Detroit Lakes promotes Christ s ministry of holistic healing for all human life with special concern for the poor and powerless. Mission We are called to make a healthy difference in people's lives. Vision Essentia Health will be a national leader in providing high quality, cost effective, integrated health care services. Values Quality Hospitality Respect Justice Stewardship Teamwork Belief Statements Our highest priority is the people we serve. We believe that the highest quality health care requires a regard for both the soul and science of healing and a focus on continuous improvement. We believe in the synergy of sponsorship among faith-based and secular organizations. We believe in the value of integrated health care services. We believe in having a meaningful presence in the communities we serve. 2

2016 Community Health Needs Assessment Essentia Health St. Mary s Executive Summary The 2016-2019 Becker County Community Health Needs Assessment was conducted as a partnership between EH St. Mary s-detroit Lakes with Sanford Health, Becker County Public Health and Partnership 4 Health. The goal was to identify primary health issues, current health status and needs. The results enable community members to strategically establish priorities, develop interventions and direct resources to improve the health of the people living in the community. The CHNA survey was completed in late 2015. In early 2016, a Community Health steering committee developed Becker County Energize as a means to create a united approach to improve health and wellness in the community. The steering committee consists of a representative from all the major health organizations; representatives from non-profit, for-profit, and private organizations; local business representatives; local government and representatives from the state health improvement initiative. EH St. Mary s-detroit Lakes and Partnership 4 Health leaders co-facilitate the steering committee. After prioritizing, the steering committee revealed 12 distinct issues in Becker County and developed three goal groups to address the top issues in the community. The Goal Groups are: 1. Healthier choices 2. Mental fitness 3. Community connections Methodology, Prioritization Process and Action Planning Participatory Action Research is a best practice used to facilitate the group work of the Becker County Energize steering committee. The committee used a group exercise to update an asset inventory of the service area that will be utilized for a community event for Becker County Energize. The committee also identified liabilities, potential funding sources, processes to keep citizens engaged in feedback and considerations for branding and marketing. Leadership and facilitation training to support committee members was given. The Becker County Energize community event will further engage residents in facilitated discussion around the three focus groups to build community strategies to address them. The full three-year implementation plan will be completed by November 1, 2016. Caring for our Community Our commitment to community health and wellness goes well beyond the work of the Community Health Needs Assessment. Through donations of funds, along with employees time and talents, Essentia Health invests in a variety of programs and outreach efforts. Across the organization, we support community coalitions, housing, food shelves, mental health, congregational outreach, community infrastructure, public health, education, safety and other nonprofit organizations. These investments are designed to promote better health, help lessen inequities in our communities, improve access to health care and strengthen relationships with those we serve. 3

2016 Community Health Needs Assessment Essentia Health St. Mary s Progress to Date on 2013 Community Health Needs Assessment EH St. Mary s-detroit Lakes initially partnered with the University of Minnesota, which provided a National Diabetes Prevention Program (NDPP) lifestyle coach. This best-practice program from the Centers for Disease Control and Prevention is evidence-based and has measurable outcomes. In 2015, the hospital hired a community health facilitator to teach NDPP classes. The first class is underway and 32 participants had lost more than 200 pounds by week 10 of the program. Additional Accomplishments: Stakeholder Engagement EH St. Mary s-detroit Lakes conducted stakeholder interviews with approximately 30 key community members to gain a better understanding of the community s definition of community health, identify community assets, develop a list of priorities and define the community s health-related issues. This resulted in the overarching development of a work plan surrounding the following five areas: Chronic disease prevention Senior health and wellness Mental health Worksite wellness Primary care integration Preventative Care EH St. Mary s-detroit Lakes developed several additional classes targeting chronic disease prevention and management for adults and youth. Four classes have been completed, including diabetes prevention, diabetes self-management and chronic disease management. Additional community outreach and chronic disease prevention actions are being considered and developed. This includes a Go Wild youth nutrition class in the school district and a Cooking Matters course for adults. Senior Health and Wellness EH St. Mary s-detroit Lakes has shifted focus to become more proactive and preventative in the area of senior health. The community paramedic program is in the final stages of implementation. The hospital has partnered with Ecumen, a local health organization with services for seniors, to be a Dementia Capable Care Community. The hospital organized and led a community conference for senior health and wellness on May 7, 2015, to identify innovative solutions to address the needs of the senior population. The EH St. Mary s-detroit Lakes Clinic opened a memory clinic one day per week to improve services for those suffering from any stage of memory loss. This has also resulted in three groups working on the priorities of advanced care planning, volunteerism, and education and advocacy. Mental Health EH St. Mary s-detroit Lakes was selected as a national finalist for the Jackson Healthcare Community Health Award for integrating a mental health crisis team in the health system and across the community in 2014 and 2015. Staff has been trained in utilization of the mental health crisis team. The hospital hosted a conference in May 2015 with law enforcement, county and tribal entities, schools, mental health agencies and community partners to create solutions to improve mental health awareness and prevention services in our community. EH St. Mary s-detroit Lakes also expanded community education on mental health. 4

2016 Community Health Needs Assessment Essentia Health St. Mary s Worksite Wellness The hospital s worksite wellness initiatives are directed to improve eating habits and increase physical activity. Initiatives include removing beverages containing sugar from the hospital cafeteria and offering healthy choices in vending machines. EH St. Mary s-detroit Lakes is partnering to provide a weekly farmers market on campus in the summer and participating in community-supported agriculture (CSA) to enable employees to gain easy access to healthy foods. The hospital also has a healthy choice cafeteria system to promote eating well and participates in a local food hub. Primary Care Integration EH St. Mary s-detroit Lakes is looking to improve patient and family wellness by increasing access to mental health for community members. It is in the process of integrating a licensed social worker into the primary care clinic. This will allow a focus on advanced care planning, immediate addressing of psychosocial need and child protection. Reduction of Excessive/Binge Drinking The hospital has worked with community partners to increase the stop points for alcohol testing on county highways by law enforcement. A community chemical dependency committee meets quarterly to improve communication and coordination across agencies to improve efforts against alcohol and drugs. Immunizations The hospital worked with its clinic to increase the percentage of immunizations provided. Access to Healthcare EH St. Mary s-detroit Lakes collaborated with its clinic to increase the number of medical professionals available to individuals in the service area. It has also worked to decrease the number of uninsured patients in the community. The hospital has increased access to mental health with the mobile crisis team policy. The hospital has created a memory care clinic, rehabilitation care for Parkinson s disease and stroke as well as an optometry clinic. The hospital is partnering with Appletree Dental to provide an outpatient dental clinic. Tobacco Use The hospital has increased the number of inpatients provided with tobacco-cessation counseling during the past fiscal year. Outpatient tobacco-cessation counseling in collaboration with the Minnesota Quit Plan is also offered. Secondary Prevention/Screening The hospital worked collaboratively with community members to conduct the annual Rotary Club Blood Screening event. This event reached more than 2,400 people. Our CHNA activities are available on the website with updates reported annually. No written comments have been submitted at the time of this report. 5

2016 Community Health Needs Assessment 2016 Community Health Needs Assessment Essentia Health St. Mary s Objectives Essentia Health is called to make a healthy difference in people s lives. To fulfill that mission, we seek opportunities to both enhance the care we provide and improve the health of our communities. In conducting the Community Health Needs Assessment, Essentia Health has collaborated with community partners to embrace these guiding principles: Seek to create and sustain a united approach to improving health and wellness in our community and surrounding area; Seek collaboration towards solutions with multiple stakeholders (e.g. schools, work sites, medical centers, public health) to improve engagement and commitment focused on improving community health; and Seek to prioritize evidence-based efforts around the greatest community good that can be achieved through our available resources. The goals of the 2016 Community Health Needs Assessment were to: 1. Assess the health needs, disparities, assets and forces of change in Essentia Health St. Mary s service area. 2. Prioritize health needs based on community input and feedback. 3. Design an implementation strategy to reflect the optimal usage of resources in our community. 4. Engage our community partners and stakeholders in all aspects of the Community Health Needs Assessment process. Description of Community Served by Essentia Health St. Mary s The community served by EH St. Mary s-detroit Lakes includes Becker, Otter Tail and Hubbard counties. Discharge information shows that these are the home locations for more than 80 percent of patients discharged (See Appendix A). A primary barrier to care in the region is high poverty levels, particularly in Becker County. The region s rates of unemployment also are higher than the state. There is an aging population. Diversity, based on the American Indian population, is noted in both Becker and Hubbard counties. Poverty, education, age and race are all factors contributing to the inequitable health outcomes in this community. According to the Minnesota Department of Health s White Paper on Income and Health, Poverty in Minnesota is not evenly distributed across racial/ethnic groups, ages or educational levels. Poverty is concentrated among populations of color, children, people with less education, female headed households and rural Minnesotans. 1 People in Minnesota with lower incomes are more likely to: 1 Minnesota Department of Health, White Paper on Income and Health, March 3, 2014 http://www.health.state.mn.us/divs/opa/2014incomeandhealth.pdf 6

Have an infant die in the first year of life Report that their health is fair or poor Report having diabetes Report having seriously considered attempting suicide 2 2016 Community Health Needs Assessment Essentia Health St. Mary s With a section of the White Earth Indian Reservation in Becker County, the health needs of the American Indian population are an important aspect of this assessment. As reported by the Indian Health Service, The American Indian and Alaska Native people have long experienced lower health status when compared with other Americans. Lower life expectancy and the disproportionate disease burden exist perhaps because of inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences. These are broad quality of life issues rooted in economic adversity and poor social conditions. Diseases of the heart, malignant neoplasm, unintentional injuries, and diabetes are leading causes of American Indian and Alaska Native deaths (2007-2009). American Indians and Alaska Natives born today have a life expectancy that is 4.4 years less than the U.S. all races population (73.7 years to 78.1 years, respectively). American Indians and Alaska Natives continue to die at higher rates than other Americans in many categories, including chronic liver disease and cirrhosis, diabetes mellitus, unintentional injuries, assault/homicide, intentional self-harm/suicide, and chronic lower respiratory diseases. 3 2 Minnesota Department of Health, White Paper on Income and Health, March 3, 2014 http://www.health.state.mn.us/divs/opa/2014incomeandhealth.pdf 3 U.S. Department of Health and Human Services, Indian Health Service, Indian Health Disparities https://www.ihs.gov/newsroom/factsheets/disparities/ 7

2016 Community Health Needs Assessment Essentia Health St. Mary s Becker Hubbard Otter Tail Minn. Est. July 2015 Population 33,386 20,655 57,716 5,489,594 Diversity White Black American Indian Asian Hispanic or Latino 87.7 % 0.6 % 7.9 % 0.5 % 1.8 % 94.8 % 0.4 % 2.5 % 0.4 % 0.4 % 96.2 % 1.1 % 0.7 % 0.6 % 0.6 % 85.7 % 5.9 % 1.3 % 4.7 % 5.1 % Unemployment 6.4 % 6.8 % 6.2 % 3.7 % Median household Income in 2014 dollars, 2010-2014 $51,470 $46,412 $50,914 $60,828 Persons in poverty 14.6 % 12.2 % 11.2 % 11.5 % High School graduate or higher Bachelor s degree or higher 90.5 % 92.2 % 90.7 % 92.3 % 21.6 % 24.3 % 23.6 % 33.2 % Persons under age 5 6.3 % 5.7 % 5.8 % 6.4 % Persons under age 18 24.6 % 21 % 21.4 % 23.5 % Persons age 65 and over 19.3 % 23.6 % 22.5 % 14.3 % Data from US Census Bureau: http://quickfacts.census.gov/qfd/states/27000.html Unemployment from MN Department of Employment and Economic Development (March, 2016 not seasonally adjusted): http://mn.gov/deed/data/current-econ-highlights/county-unemployment.jsp 8

2016 Community Health Needs Assessment Essentia Health St. Mary s Health disparities were also identified by responses to the survey: (Full survey results in Appendix B) Becker, Clay, Otter Tail, Wilkin responses 2015 Overweight or obese 66.7 % Identify they are in good, very good or excellent health 91.6 % Indicate no physical activity in the past month 15.1 % Indicate they ate five or more servings of fruit and vegetables 34.9 % yesterday Diabetes 8.9 % Informed by a healthcare professional they have high blood 33.6 % pressure Smoke (Minnesota average is 14.4%) 13.0 % Any binge drinking 31.7 % Informed they have depression 20.6 % Informed they have anxiety 17.2 % Becker,Clay,Otter Tail, Wilkin survey frequencies (Appendix) Process Overview Essentia Health s Community Health Committee developed a shared plan for the 15 hospitals within the system to conduct their 2016 Community Health Needs Assessments (CHNA). This plan was based on best practices from the Catholic Health Association and lessons learned from the completion of Essentia s first CHNAs in 2013. This process was designed to: Incorporate community surveys and existing public data. Directly engage community stakeholders. Collaborate with local public health and other healthcare providers. From there, each of Essentia s three regions was responsible for adapting and carrying out the plan within their communities and hospital service areas. EH St. Mary s-detroit Lakes collaborated with Partnership 4 Health to have the Minnesota Department of Health conduct a survey of Becker, Clay, Otter Tail and Wilkin counties. Survey questions included the Behavior Risk Factor Surveillance System (BRFSS) survey from the Minnesota Department of Health Center. The vendor for the survey was Survey Systems, Inc. of New Brighton, Minnesota. The initial survey was sent to 1,600 households per county. A reminder postcard followed 10 days later. Becker County had a 22.9 percent response rate and Otter Tail County had a 27.3 percent response (methodology and survey response Appendix B). Survey Systems returned the responses in November. EH St. Mary s-detroit Lakes and Partnership 4 Health convened three successive stakeholder groups that included the hospital, Partnership 4 Health, Mahube-Otwa Community Action Partnership, Becker County Chamber of Commerce, Aging Services, Boys and Girls Club and others. (See attendance and results, Appendix C). The American Indian population was represented by Becker County Public Health and Mahube-Otwa. The White Earth Indian Reservation public health nurse attended one meeting and 9

2016 Community Health Needs Assessment Essentia Health St. Mary s agreed to work with the group going forward. This group represents strong, engaged community resources to assist in driving improvement in community health. EH St. Mary s-detroit Lakes planning was conducted in four stages: assessment, prioritization, design and finalization. The process began in August 2015 and was completed in May 2016 with the final presentation of the Community Health Needs Assessment to leadership and the Board of Directors on May 9, 2016 and the West Region Board of Directors on May 17, 2016. The following describes the assessment steps and timeline. 10

2016 Community Health Needs Assessment Essentia Health St. Mary s ASSESS (April - October 2015) Define Service Area Service Area Demographics Analyze Secondary Data Gather Community Input Conduct Asset Mapping of Available Community Resources Evaluate Progress on 2013 CHNA Priorities PRIORITIZE (December 2015 - April 2016) Set Criteria for Prioritized Needs Choose Prioritization Method Choose Needs to Address DESIGN (March - April 2016) Goal Setting Identify the "team" for each strategy Determine strategy options Choose Strategies/Progra ms Set SMART Objectives Design Implementation Plan and Evaluation Framework FINALIZE (May 2016) Review with key stakeholders for final feedback Present to EH-St. Mary's Board for Approval May 9th, 2016 Present to West Region Board May 17,2016 11

2016 Community Health Needs Assessment Essentia Health St. Mary s Assessment Process Phase 1: Assessment EH St. Mary s-detroit Lakes collaborated with Partnership 4 Health to conduct a survey of Becker, Clay, Otter Tail and Wilkin Counties. White Earth Indian Reservation conducted a separate survey but was unable to share results at the time of this report. That information will be incorporated into the implementation strategy where possible. As discussed in the overview, EH St. Mary s-detroit Lakes engaged a broad group of community representatives that included Becker, Hubbard and Otter Tail counties. White Earth Public Health was at one meeting and has agreed to represent the American Indian population. Public Health, Mahube-Otwa, the Boys and Girls Clubs, and Aging Services all work with diverse and underserved populations and represented those interests at the meetings. The stakeholder groups reviewed the survey results, previous community health initiatives and assessed progress and opportunities for the future. One limitation of the community survey was that Hubbard County was not included. However, stakeholders who can represent Hubbard County were at the meetings. No comments were received from the 2013 Community Health Needs Assessment. Any comments received would have been reviewed, evaluated and taken into consideration when preparing the 2016 Community Health Needs Assessment. Phase 2: Prioritization Needs identified by the survey were identified and placed on the Prioritization Worksheet. Criteria to identify the priority problems were discussed including cost, availability of solutions, impact of the problem, availability of resources, urgency and size. The criteria to identify interventions included expertise, return on investment, effectiveness of the solution, ease of implementation and maintenance, potential negative consequences, legal consideration, impact on systems of health, and feasibility of intervention. The results of the meeting were brought to the first stakeholder group on February 25 to discuss findings and priorities. Meetings on March 10 and March 22 identified the top three priorities. A broader stakeholder group was convened on May 13 to begin the full three-year implementation plan that will be completed by November 1, 2016. The three priorities are: 1. Improve nutrition and increase activity across the lifespan (Healthy Choices). 2. Improve collaboration between partners in providing mental health services (Mental Fitness). 12

2016 Community Health Needs Assessment Essentia Health St. Mary s 3. Improve coalition partnerships that include underserved and minorities (Community Connections). Categorize health needs into goal areas (Healthy Choices, Mental Fitness, Workplace Wellness and Community Connections). The hospital will partner with community partners but not take the lead or devote resources in those areas that are not within our expertise. For example, we support increasing the number of insured, the availability of affordable housing, the cost of public transportation, and air quality but don t have the resources or expertise to specifically drive these areas. We work with programs to improve dental access but don t provide dental services at Essentia Health St. Mary s. Phase 3: Design of Strategy and Implementation Plan SUMMARY OF COMMUNITY DEFINED PRIORITIES/STRATEGIES: The full three-year implementation plan will be completed by November 1, 2016. The stakeholder group has determined priorities and goals with strategies as listed below. These will be further developed over the next five months. Several partners have been identified for each priority and include public health and other representatives for the underserved and the American Indian population. Additional partners will continue to be added as the planning unfolds. PRIORITY AREA Healthier Choices GOALS 1. Improve nutrition and increase activity across the lifespan. STRATEGIES FOR EACH PRIORITY Priority: Healthier Choices Goal: National Diabetes Prevention Program Strategy 1: Increase both class numbers and locations. Goal: Infant Health Strategy 2: Increase access to healthy foods. Partners: Mahube/Otwa, Land of the Dancing Sky Measure: BMI and physical activity from classes Measure: Number of community gardens, number of people participating in WIC Measure: Survey perception of wellness, number of fruits and vegetables, percent of residents with no physical activity annually. PRIORITY AREA Mental Fitness GOALS 1. Improve collaboration between partners in providing mental health services 13

2016 Community Health Needs Assessment Essentia Health St. Mary s STRATEGIES FOR EACH PRIORITY Priority: Mental Fitness Goal: Improve crisis intervention Strategy 1: Provide public education about services Strategy 2: Increase collaboration between Emergency Department, Emergency Medical Services, hospitalists, sheriff s departments, police, and social services. Strategy 3: Continue Stomp the Stigma team PRIORITY AREA Community Connections Partners: Sheriff s Department, local police and fire department, Wellness in the Woods, Becker County Mental Health, White Earth Mental Health, Willow Tree Crisis Bed, Stellher Human Services, Solutions Inc., Lakeland Mental Health, MNState, Detroit Lakes Schools, Lake Park/Audubon Schools, City of Detroit Lakes officials. Measure: Increase number of people trained in Question, Persuade and Refer (suicide awareness training) and mental health first aid 1. Reduce number of mental health emergency holds in the Emergency Department 1. Number of participants in event 2. Increase funding for local mental health initiatives GOALS 1. Improve coalition partnerships that include underserved and minorities STRATEGIES FOR EACH PRIORITY Priority: Community Connections Goal: Improve coalition partnerships that include underserved and minorities Strategy 1: Collaborate on one event to improve health for an underserved population. Partners: Partnership 4 Health, White Earth Public Health, Aging Services, Mahube/OTWA CAP, Chamber of Commerce Measure: 1. Host event with MN Flyers to focus on addressing barriers for special needs children 14

2016 Community Health Needs Assessment Essentia Health St. Mary s Conclusion As part of a nonprofit health system, EH St. Mary s-detroit Lakes is called to make a healthy difference in people s lives. This needs assessment and implementation plan illustrates the importance of collaboration between our hospital and its community partners. By working collaboratively, we can have a positive impact on the identified health needs of our community during Fiscal Years 2017-2019. There are other ways in which EH St. Mary s-detroit Lakes will indirectly address local health needs, including the provision of charity care, the support of Medicare and Medicaid programs, discounts to the uninsured and others. Over the next three years, we will continue to work with the community to ensure that this implementation plan is relevant and effective and to make modifications as needed. 15

2016 Community Health Needs Assessment Essentia Health St. Mary s Appendix A: Essentia Health St. Mary s Detroit Lakes- Top 80 percent of 2015 discharges by ZIP code Zip Code City County Discharges Percentage Cumulative Percentage 56501 Detroit Lakes Becker 2,974 38.2% 38.2% Becker 56544 Frazee Becker 711 9.1% 47.4% Becker 56470 Park Rapids Hubbard 383 4.9% 52.3% Hubbard 56557 Mahnomen Mahnomen 331 4.3% 56.5% Mahnomen 56572 Pelican Rapids Otter Tail 321 4.1% 60.7% 56589 Waubun Mahnomen 321 4.1% 64.8% Mahnomen 56554 Lake Park Becker 299 3.8% 68.6% Becker 56569 Ogema Becker 278 3.6% 72.2% Becker 56464 Menahga Wadena 241 3.1% 75.3% Wadena 56511 Audubon Becker 206 2.6% 78.0% Becker 56575 Ponsford Becker 181 2.3% 80.3% Becker 16

Survey Methodology Survey Instrument Staff from the public health agencies of Becker, Clay, Otter Tail and Wilkin counties in Minnesota developed the questions for the survey instrument with technical assistance from the Minnesota Department of Health Center for Health Statistics. Existing items from the Behavior Risk Factor Surveillance System (BRFSS) survey and from recent county-level surveys in Minnesota were used to design some of the items on the survey instrument. The survey was formatted by the survey vendor, Survey Systems, Inc. of New Brighton, MN, as a scannable, selfadministered English-language questionnaire. Sample A two-stage sampling strategy was used for obtaining probability samples of adults living in each of the five counties. A separate sample was drawn for each county. For the first stage of sampling, a random sample of county residential addresses was purchased from a national sampling vendor (Marketing Systems Group of Horsham, PA). Address-based sampling was used so that all households would have an equal chance of being sampled for the survey. Marketing Systems Group obtained the list of addresses from the U.S. Postal Service. For the second stage of sampling, the most recent birthday method of within-household respondent selection was used to specify one adult from each selected household to complete the survey. Survey Administration An initial survey packet that included a cover letter, the survey instrument, and a postage-paid return envelope was mailed August 19-20, 2015, to 1600 sampled households in each of the five counties. About 10 days after the first survey packets were mailed (September 1), a reminder postcard was sent to all sampled households, reminding those who had not yet returned a survey to do so, and thanking those who had already responded. Two weeks after the reminder postcards were mailed (September 11 and 14), another full survey packet was sent to all households that still had not returned the survey. The remaining completed surveys were received over the next six weeks, with the final date for the receipt of surveys being October 21, 2015. Completed Surveys and Response Rate Completed surveys were received from 1920 adult residents of the five counties; thus, the overall response rate was 24.0% (1920/8000). County-specific response rates can be found on the next page. Data Entry and Weighting The responses from the completed surveys were scanned into an electronic file by Survey Systems, Inc. To ensure that the survey results are representative of the adult population of each of the five counties, the data were weighted when analyzed. The weighting accounts for the sample design by adjusting for the number of adults living in each sampled household. The weighting also includes a post-stratification adjustment so that the gender and age distribution of the survey respondents mirrors the gender and age distribution of the adult populations of the five counties, according to U.S. Census Bureau 2010 estimates.

Response County Rate BECKER, MN 22.9% CLAY, MN 21.6% OTTER TAIL, MN 27.3% WILKIN, MN 26.3% RICHLAND, ND 21.9%

2015 CHS Assessment Summary of Survey Findings Conducted in partnership with Essentia Hospital- Detroit Lakes, Lake Region Healthcare-Fergus Falls, Perham Health- Perham, St. Francis Hospital-Breckenridge P4H CHB worked with Minnesota Department of Health (MDH) Center for Health Statistics to conduct a mailing to a random sample of households in Becker, Clay, Otter, Tail, Wilkin counties in MN and Richland county in North Dakota. Each hospital paid $4,000 toward the cost of the assessment. Funding from the State Health Improvement Program (SHIP) paid for the costs incurred by the counties. The survey instrument was created in Clay County in partnership with Sanford Health, Essentia, and Cass County PH in North Dakota. The survey was then modified with the assistance of MDH to capture the required questions to comply with SHIP funding requirements. A total of 1600 households per county received the initial mailing. A total of 1,920 surveys were received for an overall response rate of 24.0%. To ensure that the survey results are representative of the adult population of each of the five counties, the data were weighted when analyzed. The weighting accounts for the sample design by adjusting for the number of adults living in each sampled household. The weighting also includes a poststratification adjustment so that the gender and age distribution of the survey respondents mirrors the gender and age distribution of the adult populations of the five counties, according to U.S. Census Bureau 2010 estimates. County BECKER, MN CLAY, MN OTTER TAIL, MN WILKIN, MN RICHLAND, ND Response Rate 22.9% 21.6% 27.3% 26.3% 21.9% Gender Age groups 50-50 10.6%- 19.8% 49-51 7.6%- 40.1% 50-50 12.9%- 21.0% 50-50 10.7%- 22.9% 48-52 8.9%- 30.2% Race Nonwhite Education <HS Grad Income <$40,000 Unemployed or Disabled 3.9 % 2.2% 30.9% 1%-5% 3.2% 3.4% 28.8% 2.6%-4.7% 1.4% 5.7% 28.5% 0.8%-5.2% 1.2% 2.2% 28.9% 4.9%-5.5% 1.8% 3.4% 19.7% 2.0%-3.1% Self-reported Chronic Health Conditions 40% 35% 30% 25% 20% 15% 10% 5% 0% % reporting

Self-reported Mental Health Status Mental Health 60% 40% 20% 0% Mental Health not good Little interest in doing things Feeling down, depressed, hopeless Self-reported Healthy Behaviors Healthy Behaviors 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Priorities in our 2015-2019 Community Health Improvement Plan related to survey results 1. Healthy Lifestyle Behaviors 2. Mental Health Priorities in our 2015-2019 Community Health Improvement Plan related to Health Statistics results 1. Adverse Childhood Experiences

Becker, Clay, Otter Tail, Wilkin CHB (n=1539) General health status Percent Poor 1.8 Fair 6.6 Good 35.2 Very good 42.7 Excellent 13.6 High blood pressure or pre-hypertension Percent No 66.4 Yes 33.6 Diabetes Percent No 91.1 Yes 8.9 Cancer Percent No 91.8 Yes 8.2 Chronic lung disease

Percent No 94.4 Yes 5.6 Heart trouble or angina Percent No 91.0 Yes 9.0 Stroke or stroke-related health problems Percent No 97.6 Yes 2.4 PAD or claudication Percent No 97.4 Yes 2.6 High cholesterol or triglycerides Percent No 69.3 Yes 30.7 Asthma

Percent No 89.9 Yes 10.1 Arthritis Percent No 79.2 Yes 20.8 Depression Percent No 79.4 Yes 20.6 Anxiety Percent No 82.8 Yes 17.2 Panic attacks Percent No 90.9 Yes 9.1 Alzheimer's disease

Percent No 99.3 Yes.7 Other mental health problems Percent No 95.6 Yes 4.4 Last routine checkup Percent Within the past year 75.0 Within the past 2 years 13.6 Within the past 5 years 4.8 5 or more years ago 6.5 Never.1 Personal doctor Percent Yes, only one person 60.1 Yes, more than one person 23.3 No 16.6 Usual place for care: Physician's office Percent Not checked 27.9 Checked 72.1

Usual place for care: Public health department or clinic Percent Not checked 92.5 Checked 7.5 Usual place for care: Some other free or discounted clinic Percent Not checked 99.0 Checked 1.0 Usual place for care: Hospital emergency room Percent Not checked 98.2 Checked 1.8 Usual place for care: Urgent care clinic Percent Not checked 91.4 Checked 8.6 Usual place for care: No usual place Percent Not checked 93.7 Checked 6.3

Usual place for care: Other place Percent Not checked 94.8 Checked 5.2 Dental exam or cleaning Percent Within the past year 77.8 Within the past 2 years 8.5 Within the past 5 years 5.0 5 or more years ago 8.6 Never.1 Where get most health-related information: Government websites Percent Not checked 84.8 Checked 15.2 Where get most health-related information: Non-government websites Percent Not checked 64.3 Checked 35.7 Where get most health-related information: Television Percent Not checked 87.5 Checked 12.5 Where get most health-related information: Magazine, newspapers, books

Percent Not checked 81.2 Checked 18.8 Where get most health-related information: Doctor or other healthcare professional Percent Not checked 19.2 Checked 80.8 Where get most health-related information: Fanily or friends Percent Not checked 61.7 Checked 38.3 Where get most health-related information: Telephone helpline Percent Not checked 95.3 Checked 4.7 Where get most health-related information: Other Percent Not checked 94.8 Checked 5.2 Best way to access technology for health information: Personal conputer or tablet Percent Not checked 25.1 Checked 74.9 Best way to access technology for health information: Public computer Percent

Not checked 96.4 Checked 3.6 Best way to access technology for health information: Smart phone Percent Not checked 60.6 Checked 39.4 Best way to access technology for health information: Other Percent Not checked 95.9 Checked 4.1 Best way to access technology for health information: None Percent Not checked 91.9 Checked 8.1 Calculated variable: Current insurance status Percent Currently uninsured 3.0 Currently insured 97.0 Dental or oral health insurance Percent Yes 60.0 No 36.4 Don't know 3.6 Days mental health not good

Percent 0 days 56.5 1-9 days 32.4 10-19 days 7.3 20-29 days 2.1 All 30 days 1.7 Little interest or pleasure in doing things past 2 weeks Percent Not at all 78.9 Several days 17.4 More than half the days 1.9 Nearly every day 1.8 Feeling down, depressed, hopeless past 2 weeks Percent Not at all 80.0 Several days 17.4 More than half the days 1.5 Nearly every day 1.0 Number of vegetables yesterday Percent 0 servings 11.7 1-2 servings 61.0 3-4 servings 20.7 5 or more servings 6.7 Number of solid fruits yesterday

Percent 0 servings 19.5 1-2 servings 58.7 3-4 servings 17.8 5 or more servings 4.0 Number of fruit juice servings yesterday Percent 0 servings 61.3 1-2 servings 34.5 3-4 servings 2.5 5 or more servings 1.6 Calculated variable: Number of fruits and vegetables yesterday Percent 0 servings 4.6 1-2 servings 24.5 3-4 servings 29.5 5-9 servings 34.9 10 or more servings 6.5 Past month participate in any physical activities or exercise Percent Yes 84.9 No 15.1 Moderate excercise 5+ days per week Percent 0-4 days per week 69.2

5-7 days per week 30.8 Vigorous excercise 3+ days per week Percent 0-2 days per week 71.0 3-7 days 29.0 Blood pressure screening past 12 months Percent Yes 81.9 No 18.1 Blood sugar screening past 12 months Percent Yes 58.2 No 41.8 Bone density test past 12 months Percent Yes 10.8 No 89.2 Cardiovascular screening past 12 months

Percent Yes 24.6 No 75.4 Cholesterol screening past 12 months Percent Yes 60.4 No 39.6 Dental screening and X-rays past 12 months Percent Yes 72.6 No 27.4 Flu shot past 12 months Percent Yes 55.9 No 44.1 Glaucoma test past 12 months Percent Yes 40.5 No 59.5

Hearing screening past 12 months Percent Yes 19.4 No 80.6 Immunizations past 12 months Percent Yes 26.0 No 74.0 STD screening past 12 months Percent Yes 7.7 No 92.3 Vascular screening past 12 months Percent Yes 9.2 No 90.8 Colorectal cancer screening past 12 months Percent

Yes 16.9 No 83.1 Skin cancer screening past 12 months Percent Yes 17.3 No 82.7 Pelvic exam past 12 months (female only) Percent Yes 58.9 No 41.1 Breast cancer screening past 12 months (female only) Percent Yes 58.2 No 41.8 Cervical cancer screening past 12 months (female only) Percent Yes 46.0 No 54.0

Prostate cancer screening past 12 months (male only) Percent Yes 29.1 No 70.9 Calculated variable: Smoking status Percent Current smoker 13.0 Former smoker 28.1 Never smoked 58.9 Calculated variable: Smokeless status Percent Non-user 96.6 Current user 3.4 Among those who currently smoke or use smokeless tobacco: Where would go first for help to quit tobacco: Telephone quitline Percent Not checked 92.6 Checked 7.4 Where would go first for help to quit tobacco: Doctor or other healthcare professional Percent Not checked 66.7

Checked 33.3 Where would go first for help to quit tobacco: Pharmacy Percent Not checked 95.0 Checked 5.0 Where would go first for help to quit tobacco: Private counselor/therapist Percent Not checked 100.0 Where would go first for help to quit tobacco: Public health department or clinic Percent Not checked 94.2 Checked 5.8 Where would go first for help to quit tobacco: Don't know Percent Not checked 80.3 Checked 19.7 Where would go first for help to quit tobacco: I don't want to quit Percent Not checked 81.8 Checked 18.2

Where would go first for help to quit tobacco: Other Percent Not checked 89.1 Checked 10.9 Any alcohol drinking in past 30 days Percent No drinking 25.9 Any drinking 74.1 Calculated variable: Heavy drinking Percent No drinking or not heavy 88.1 Heavy drinking 11.9 Calculated variable: Binge drinking Percent No drinking or no binge 68.3 Any binge drinking 31.7 Ever had a problem with alcohol use Percent Yes 8.3 No 91.7

Ever had a problem with Rx or non-rx drug use Percent Yes 1.8 No 98.2 Has alcohol had harmful effects in past 2 years Percent Yes 15.7 No 84.3 Has drug abuse had harmful effects past 2 years Percent Yes 6.6 No 93.4 Calculated variable: Weight status according to BMI Percent Not overweight 33.3 Overweight but not obese 38.8 Obese 27.8 Unknown weight and/or height Number of children under 18 living in household Percent

None 60.2 1 to 2 29.2 3 to 5 10.3 6 or more.3

Availabilty of affordable housing Percent Not at all concerned 33.9 Not very concerned 22.1 Somewhat concerned 32.1

Very concerned 11.8 Homelessness Percent Not at all concerned 34.6 Not very concerned 25.8 Somewhat concerned 29.7 Very concerned 9.9 Hunger Percent Not at all concerned 29.7 Not very concerned 24.9 Somewhat concerned 32.8 Very concerned 12.5 Availability of public transportation Percent Not at all concerned 42.9 Not very concerned 28.8 Somewhat concerned 20.6 Very concerned 7.6 Cost of public transportation Percent Not at all concerned 44.2 Not very concerned 30.2 Somewhat concerned 18.8 Very concerned 6.8

Driving habits Percent Not at all concerned 27.8 Not very concerned 29.9 Somewhat concerned 31.1 Very concerned 11.2 Availability of good walking or biking options Percent Not at all concerned 37.3 Not very concerned 26.9 Somewhat concerned 23.9 Very concerned 11.9 Water quality Percent Not at all concerned 33.2 Not very concerned 26.0 Somewhat concerned 23.7 Very concerned 17.2 Air quality Percent Not at all concerned 38.7 Not very concerned 28.8 Somewhat concerned 17.9 Very concerned 14.6

Home septic s Percent Not at all concerned 43.4 Not very concerned 31.4 Somewhat concerned 17.5 Very concerned 7.7 Hazardous waste Percent Not at all concerned 38.3 Not very concerned 30.5 Somewhat concerned 19.2 Very concerned 12.0 Availability of services for at-risk youth Percent Not at all concerned 22.8 Not very concerned 31.2 Somewhat concerned 34.3 Very concerned 11.8 Cost of services for at-risk youth Percent Not at all concerned 25.4 Not very concerned 32.0 Somewhat concerned 32.4 Very concerned 10.2 Youth crime

Percent Not at all concerned 16.3 Not very concerned 30.7 Somewhat concerned 36.6 Very concerned 16.4 School dropout rates Percent Not at all concerned 23.7 Not very concerned 36.9 Somewhat concerned 27.2 Very concerned 12.2 School absenteeism Percent Not at all concerned 25.0 Not very concerned 38.5 Somewhat concerned 26.3 Very concerned 10.1 Teen pregnancy Percent Not at all concerned 21.3 Not very concerned 32.1 Somewhat concerned 33.0 Very concerned 13.6 Bullying Percent

Not at all concerned 17.7 Not very concerned 21.2 Somewhat concerned 34.0 Very concerned 27.2 Availbility of activities for children and youth Percent Not at all concerned 23.1 Not very concerned 28.6 Somewhat concerned 33.5 Very concerned 14.8 Cost of activities for children and youth Percent Not at all concerned 20.6 Not very concerned 27.3 Somewhat concerned 32.3 Very concerned 19.7 Availability of quality child care Percent Not at all concerned 25.4 Not very concerned 26.2 Somewhat concerned 26.4 Very concerned 22.0 Cost of quality child care Percent Not at all concerned 22.4 Not very concerned 22.3

Somewhat concerned 29.5 Very concerned 25.8 Availability of quality infant care Percent Not at all concerned 26.4 Not very concerned 24.1 Somewhat concerned 26.3 Very concerned 23.2 Cost of quality infant care Percent Not at all concerned 24.6 Not very concerned 23.7 Somewhat concerned 26.4 Very concerned 25.3 Availability of activities for seniors Percent Not at all concerned 27.4 Not very concerned 34.1 Somewhat concerned 29.7 Very concerned 8.8 Cost of activities for seniors Percent Not at all concerned 28.1 Not very concerned 33.4 Somewhat concerned 26.4 Very concerned 12.1

Availability of resources to help the elderly stay safe in their homes Percent Not at all concerned 21.8 Not very concerned 30.4 Somewhat concerned 30.8 Very concerned 17.0 Availability of resources for family/friends caring for and making decisions for elders Percent Not at all concerned 22.9 Not very concerned 28.7 Somewhat concerned 33.4 Very concerned 15.0 Availability of resources for grandparents caring for grandchildren Percent Not at all concerned 27.3 Not very concerned 33.4 Somewhat concerned 28.7 Very concerned 10.6 Availability of long term care Percent Not at all concerned 23.8 Not very concerned 25.6 Somewhat concerned 31.0 Very concerned 19.6

Cost of long term care Percent Not at all concerned 18.6 Not very concerned 14.2 Somewhat concerned 30.3 Very concerned 37.0 Availability of memory care Percent Not at all concerned 23.6 Not very concerned 23.5 Somewhat concerned 31.5 Very concerned 21.4 Child abuse and neglect Percent Not at all concerned 16.0 Not very concerned 24.7 Somewhat concerned 34.3 Very concerned 24.9 Elder abuse Percent Not at all concerned 22.6 Not very concerned 32.1 Somewhat concerned 27.0 Very concerned 18.3

Domestic violence Percent Not at all concerned 17.8 Not very concerned 24.3 Somewhat concerned 34.9 Very concerned 22.9 Presence of street drugs, Rx drugs and alcohol in the community Percent Not at all concerned 14.0 Not very concerned 18.1 Somewhat concerned 33.5 Very concerned 34.3 Presence of drug dealers in the community Percent Not at all concerned 15.3 Not very concerned 23.0 Somewhat concerned 30.4 Very concerned 31.3 Presence of gang activity Percent Not at all concerned 24.2 Not very concerned 29.5 Somewhat concerned 24.3 Very concerned 22.0 Crime

Percent Not at all concerned 14.8 Not very concerned 25.4 Somewhat concerned 33.5 Very concerned 26.3 Sex trafficking Percent Not at all concerned 29.7 Not very concerned 30.9 Somewhat concerned 20.7 Very concerned 18.6 Access to affordable health care Percent Not at all concerned 15.5 Not very concerned 17.8 Somewhat concerned 33.8 Very concerned 32.9 Access to affordable Rx drugs Percent Not at all concerned 16.3 Not very concerned 20.0 Somewhat concerned 33.4 Very concerned 30.2 Access to affordable health insurance Percent

Not at all concerned 14.1 Not very concerned 16.2 Somewhat concerned 31.0 Very concerned 38.7 Cost of affordable vision insurance Percent Not at all concerned 16.8 Not very concerned 22.3 Somewhat concerned 30.6 Very concerned 30.3 Cost of affordable dental insurance coverage Percent Not at all concerned 15.8 Not very concerned 19.1 Somewhat concerned 32.9 Very concerned 32.2 Distance to health care services Percent Not at all concerned 31.3 Not very concerned 35.8 Somewhat concerned 22.0 Very concerned 11.0 Providers not taking new patients Percent Not at all concerned 27.1 Not very concerned 29.4

Somewhat concerned 25.2 Very concerned 18.3 Coordination of care between providers and services Percent Not at all concerned 26.8 Not very concerned 29.7 Somewhat concerned 29.2 Very concerned 14.3 Availability of non-traditional hours Percent Not at all concerned 22.0 Not very concerned 41.2 Somewhat concerned 25.7 Very concerned 11.0 Availability of transportation Percent Not at all concerned 34.4 Not very concerned 40.4 Somewhat concerned 18.0 Very concerned 7.2 Use of emergency room services for primary health care Percent Not at all concerned 24.3 Not very concerned 29.9 Somewhat concerned 25.0 Very concerned 20.9

Timely access to vision care providers Percent Not at all concerned 35.1 Not very concerned 42.3 Somewhat concerned 17.1 Very concerned 5.5 Timely access to dental care providers Percent Not at all concerned 31.5 Not very concerned 37.7 Somewhat concerned 21.1 Very concerned 9.7 Timely access to prevention programs and services Percent Not at all concerned 34.9 Not very concerned 40.1 Somewhat concerned 17.5 Very concerned 7.5 Timely access to bilingual providers and/or translators Percent Not at all concerned 52.3 Not very concerned 32.1 Somewhat concerned 11.0 Very concerned 4.6