COMMUNITY HEALTH NEEDS ASSESSMENT ST. VINCENT KOKOMO HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT REPORT 2016

Transcription

1 2016 COMMUNITY HEALTH NEEDS ASSESSMENT ST. VINCENT KOKOMO HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT REPORT 2016

2 COMMUNITY HEALTH NEEDS ASSESSMENT - 2 Contents EXECUTIVE SUMMARY... 4 DEMOGRAPHICS...4 IDENTIFYING COMMUNITY HEALTH NEEDS METHODOLOGY...4 Secondary Data... 4 Primary Data Community Input... 4 SIGNIFICANT COMMUNITY HEALTH NEEDS...4 PRIORITIZATION PROCESS & PRIORITY NEEDS...5 CONCLUSION...5 NOTE TO THE READER...5 INTRODUCTION... 6 ABOUT ST. VINCENT HEALTH...6 ABOUT ST. VINCENT KOKOMO HOSPITAL...6 ABOUT HEALTHY COMMUNITIES INSTITUTE...6 SERVICE AREA... 6 DEMOGRAPHICS... 6 POPULATION...7 Race/ethnicity... 7 Age... 7 ECONOMY...7 Income... 7 Poverty... 8 Unemployment... 8 EDUCATION...9 TRANSPORTATION PRECEDING CHNA EFFORTS & PROGRESS PRIORITY HEALTH TOPICS IN PRECEDING CHNA COMMUNITY FEEDBACK ON PRECEDING CHNA & IMPLEMENTATION PLAN IDENTIFYING SIGNIFICANT COMMUNITY HEALTH NEEDS: METHODOLOGY SECONDARY DATA Overview Analyzing Disparities Identifying Geographic Areas of Highest Need PRIMARY DATA: COMMUNITY INPUT SIGNIFICANT COMMUNITY HEALTH NEEDS ASSESSMENT FINDINGS GEOGRAPHICAL AREAS OF HIGHEST NEED QUALITY OF LIFE FINDINGS... 16

3 COMMUNITY HEALTH NEEDS ASSESSMENT - 3 HEALTH NEEDS FINDINGS SIGNIFICANT HEALTH NEEDS PRIORITIZATION OF TOP HEALTH NEEDS PRIORITIZATION SESSION PARTICIPANTS PRIORITIZATION PROCESS Focus Group Discussion HEALTH PRIORITIES FOR HOWARD COUNTY SUBSTANCE ABUSE ACCESS TO HEALTH SERVICES MENTAL HEALTH & MENTAL DISORDERS EXERCISE, NUTRITION, & WEIGHT DIABETES OTHER SIGNIFICANT COMMUNITY HEALTH NEEDS CONCLUSION APPENDIX A: EVALUATION OF PRECEDING CHNA PRIORITIES APPENDIX B: SECONDARY DATA ANALYSIS SCORING METHOD Comparison to a Distribution of County Values: Within State and Nation Comparison to Values: State, National, and Targets Trend Over Time Missing Values Indicator Scoring Topic Scoring DISPARITIES SCORING RESULTS DATA SOURCES APPENDIX C: COMMUNITY INPUT KEY INFORMANT INTERVIEW QUESTIONS APPENDIX D: PRIORITIZATION TOOLS APPENDIX E: AUTHORS APPENDIX F: COMMUNITY INPUT REPORT FOR HOWARD COUNTY APPENDIX G: HOWARD COUNTY RESOURCE LIST...72 For comments or questions about this report, please contact St. Vincent Community Development & Health Improvement: CommunityDevelopment@stvincent.org PRODUCED BY HEALTHY COMMUNITIES INSTITUT E, OCTOBER

4 COMMUNITY HEALTH NEEDS ASSESSMENT - 4 Executive Summary As part of St. Vincent Health s 2016 Community Benefit efforts, St. Vincent Kokomo Hospital is pleased to present the 2016 Community Health Needs Assessment (CHNA). As federally required by the Affordable Care Act, this report provides an overview of the methods and process used to identify and prioritize significant health needs in Howard County, Indiana. St. Vincent Health contracted Healthy Communities Institute (HCI) to help facilitate their system-wide CHNA work and document all efforts into the 2016 reports for each hospital. DEMOGRAPHICS According to the 2015 County Health Rankings, Howard County ranks 61 st out of 92 Indiana counties in health outcomes. Howard County demographics are slightly more homogenous than the overall Indiana state population. According to Nielsen Claritas 2015, 87.5% the county s population is White, 7.1% is Black/African American, 1.1% is Asian, 2.% is of two or more races, and 3.2% is Hispanic/Latino. The median household income is lower than the state at about $38,922 annually, and roughly 13.1% of Howard County families are living in poverty, which is slightly higher than the state. HCI s SocioNeeds Index identified the zip code of as having the greatest socioeconomic need. IDENTIFYING COMMUNITY HEALTH NEEDS METHODOLOGY SECONDARY DATA The secondary data used in this assessment was obtained and analyzed from the St. Vincent Health Community Dashboard ( which includes a comprehensive dashboard of over 100 community health and quality of life indicators covering over 20 topic areas. Indicator values for Howard County were compared to other counties in Indiana and nationwide to score health topics and compare relative areas of need. Other considerations for health areas of need included trends over time, Healthy People 2020 targets, and disparities by gender and race/ethnicity. PRIMARY DATA COMMUNITY INPUT The needs assessment was further informed by interviews with community members who have a fundamental understanding of Howard County s health needs and represent the broad interests of the community. Eight key informants provided valuable input on the county s health challenges, the sub-populations most in need, and existing resources for county residents. SIGNIFICANT COMMUNITY HEALTH NEEDS Primary and secondary data were evaluated and synthesized to identify the significant community health needs in Howard County. These needs span the following topic areas and are often inter-related: Wellness & Lifestyle Diabetes Substance Abuse Children s Health Respiratory Diseases Social Environment Transportation Exercise, Nutrition, & Weight Mental Health & Mental Disorders Access to Health Services

5 COMMUNITY HEALTH NEEDS ASSESSMENT - 5 PRIORITIZATION PROCESS & PRIORITY NEEDS Kokomo Hospital called together hospital decision makers and community leaders to prioritize the significant community health needs of Howard County considering several criteria: alignment with Ascension Health strategies of healthcare that leaves no one behind and care for the poor and vulnerable; opportunities for partnership; availability of existing programs and resources; opportunities for partnership; addressing disparities of subgroups; availability of evidence-based practices; and community input. The following five health and/or quality of life topics were selected as the top priorities: Substance Abuse Access to Health Services Mental Health & Mental Disorders Exercise, Nutrition, & Weight Diabetes CONCLUSION This report describes the process and findings of a comprehensive health needs assessment for the residents of Howard County, Indiana. The prioritization of the identified significant health needs will guide the community health improvement efforts of St. Vincent Kokomo Hospital. From this process, St. Vincent Kokomo will outline how they will address the top five prioritized health needs in their Implementation Strategy. NOTE TO THE READER Your feedback is welcomed and encouraged. Please send any feedback and/or comments about this report to: CommunityDevelopment@stvincent.org.

6 COMMUNITY HEALTH NEEDS ASSESSMENT - 6 Introduction ABOUT ST. VINCENT HEALTH St. Vincent Health has been serving their Indiana community members for over 130 years. As a member of Ascension Health, the largest Catholic health care system in the country, the St. Vincent mission is to care for the body, mind and spirit of those in need, regardless of personal means or religious affiliation. St. Vincent is dedicated to providing spiritually centered, holistic care, that sustains and furthers both individual and community health - with 22 health ministries serving 47 counties in Central and Southern Indiana. ABOUT ST. VINCENT KOKOMO HOSPITAL St. Vincent Kokomo, formerly St. Joseph Hospital, is a 138-bed acute care facility that has been serving Howard County for over 100 years. As a nonprofit hospital, and part of St. Vincent Health, Kokomo Hospital is dedicated to improving the health of Howard County residents, with special attention to the poor and vulnerable. St. Vincent Kokomo Hospital is located in Kokomo, Indiana, and serves Howard County. ABOUT HEALTHY COMMUNITIES INSTITUTE Healthy Communities Institute, now part of Midas+, a Xerox Company, was retained by St. Vincent Health to conduct the 2016 Community Health Needs Assessment (CHNA) for 11 of their service areas, and to author the subsequent CHNA reports for each service area. Based in Berkeley, California, HCI provides customizable, web-based information systems that offer a full range of tools and content to improve community health, and developed the St. Vincent Community Health Needs Assessment Platform. The organization is comprised of public health professionals and health IT experts committed to meeting clients health improvement goals. To learn more about Healthy Communities Institute please visit Service Area St. Vincent Kokomo Hospital is located in Kokomo, Indiana. St. Vincent Kokomo serves Howard County, which includes the city of Kokomo and the towns of Russiaville and Greentown. Howard County has an estimated population of 82,660 and, according to the 2015 County Health Rankings, ranks 61st out of 92 Indiana counties for overall health. Howard County is a manufacturing center, and has many workers who commute into the county from other communities. Demographics The demographics of a community significantly affect its health profile. Different race/ethnic, age and socioeconomic groups may have unique needs and require varied approaches to health improvement efforts. All estimates are sourced from the 2015 Nielsen Claritas data unless otherwise indicated.

7 COMMUNITY HEALTH NEEDS ASSESSMENT - 7 POPULATION Howard County has a population of 82,660. Figure 1 shows the population count by zip code, with St. Vincent Kokomo Hospital being located in Howard County s zip code with the highest population count (46901). Figure 1. RACE/ETHNICITY Howard County s population is slightly more homogenous than that of the statewide population, with 87.5 percent of the population being white. The remaining population primarily consists of Black/African American, those of 2 or more races, and Asian. At 3.2 percent, the Hispanic/Latino population is less than the state. St. Vincent Kokomo Figure 2. AGE 5-17 As shown in Figure 2, the age distribution of Howard County is quite similar to the rest of Indiana with the exception of some minor differences. Proportionally, there are slightly less young adults aged years old and there are more adults who are 65 and older when compared to Indiana state. The proportion of children aged 0-7 and adults aged are approximately the same between the county and state. ECONOMY INCOME The median household income of Howard County is $38,922, which is approximately $10,000 less than Indiana as a state overall. At a more granular level, there are variations in income levels among Howard County zip codes. In Figure 3, Zip Code is shown as having the lowest median household income when compared to other zip codes, the county value, and the state value. The zip code in gray has the highest income level.

8 COMMUNITY HEALTH NEEDS ASSESSMENT - 8 Figure 3. POVERTY As shown in Figure 4, the family poverty rates in Howard County are higher compared to the rest of the state. Families and families with children living below the poverty line in the county are higher by about 2 percent. Figure 4. Figure 5. UNEMPLOYMENT The overall unemployment rate in Howard County is slightly higher than Indiana, and is highest among males by a small margin. The unemployment rate in Howard County ranges from 6.5% to 11.5% among the county s zip codes, with an overall county value of 10.6%. The map in Figure 5 shows zip code as having the highest unemployment rate in the county. At 11.1%, Howard County males have a higher unemployment rate than the county overall, state, and females in both the county and state (see Figure 6).

9 Figure 6. COMMUNITY HEALTH NEEDS ASSESSMENT - 9 EDUCATION In the chart under Figure 7, high school degree attainment in the adult population among Howard County residents is about even with the state, but bachelor degree attainment is about 5 percent lower in Howard. Figure 7. Figures 8 and 9 show maps of High School Degree or Higher and Bachelor s Degree or higher by zip code for the 25 years and older population of Howard County. Zip code has the lowest high school degree attainment and lowest bachelor s degree attainment within the county. Figure 8.

10 COMMUNITY HEALTH NEEDS ASSESSMENT - 10 Figure 9. TRANSPORTATION The area covered by Zip Code has the highest percentage of households without a vehicle when compared to other Howard County zip codes. Figure 10.

11 COMMUNITY HEALTH NEEDS ASSESSMENT - 11 Preceding CHNA Efforts & Progress The CHNA process should be viewed as a three-year cycle (Figure 11). An important piece of that cycle is revisiting the progress made on priority health topics set forth in the preceding CHNA. By reviewing the actions taken to address a priority health issue and evaluating the impact those actions have made in the community, it is possible to better target your resources and efforts during your next round of the CHNA cycle. Figure Year CHNA Cycle 3-Year Cycle PRIORITY HEALTH TOPICS IN PRECEDING CHNA St. Vincent Kokomo s priority health topics for FY were: Obesity Food/Access to Food Jobs/Economic Opportunity Addiction Mental Health Teen Births/Family Disintegration A detailed table describing the strategies/action steps and indicators of success for each of the preceding priority health topics that were included in the Implementation Strategy (Obesity, Hunger, and Jobs/Economic Opportunity) can be found in Appendix A. COMMUNITY FEEDBACK ON PRECEDING CHNA & IMPLEMENTATION PLAN St. Vincent Kokomo s preceding CHNA was made available to the public via the website: stvincent.org. To collect comments or feedback on the report, a special address was created: CommunityDevelopment@stvincent.org. No comments had been received on the preceding CHNA at the time this report was being written.

12 COMMUNITY HEALTH NEEDS ASSESSMENT - 12 Identifying Significant Community Health Needs: Methodology Significant community health needs for Howard County were determined using a combination of secondary and primary data (community input). SECONDARY DATA OVERVIEW Secondary data used for this assessment were collected and analyzed with the St. Vincent Community Dashboard ( a web-based community health data platform developed by Healthy Communities Institute and sponsored by St. Vincent. The community dashboard brings non-biased data, local resources and a wealth of information to one accessible, user-friendly location. It includes a comprehensive dashboard of over 100 community indicators covering over 20 topics in the areas of health, determinants of health, and quality of life. The data are primarily derived from state and national public secondary data sources. The value for each of these indicators is compared to other communities, nationally or locally set targets, and to previous time periods. HCI s Data Scoring Tool was used to systematically summarize multiple comparisons across the Community Dashboard to rank indicators based on highest need. For each indicator, the community value was compared to a distribution of Indiana and US counties, state and national values, Healthy People 2020 and significant trends were noted. These comparison scores range from 0-3, where 0 indicates the best outcome and 3 the worst. Availability of each type of comparison varies by indicator and is dependent upon the data source, comparability with data collected for other communities, and changes in methodology over time. These indicators were grouped into topic areas for a higher level ranking of community health needs. More detailed methodology used by the Data Scoring Tool is described in Appendix B: Secondary Data Analysis. Figure 12. HCI Data Scoring Score range: Good Bad

13 COMMUNITY HEALTH NEEDS ASSESSMENT - 13 Table 1. Quality of Life and Health Topics Quality of Life Health Economy Education Environment Public Safety Social Environment Transportation Please note that the most recent period of measure was used for all secondary data presented in this report (as publicly available on January 20, 2015). ANALYZING DISPARITIES Access to Health Services Cancer Children s Health Diabetes Exercise, Nutrition, & Weight Heart Disease & Stroke Immunization & Infectious Diseases Kidney & Urinary Tract Diseases Maternal, Fetal & Infant Health Outside of topic area scoring, a separate analysis was conducted to determine if disparities exist among subpopulations within Howard County. If age, gender, or race/ethnicity specific values were available, the indicator was evaluated for the presence of substantial disparities. For details on the methods used to analyze disparities, please see Appendix B: Secondary Data Analysis. IDENTIFYING GEOGRAPHIC AREAS OF HIGHEST NEED Men s Health Mental Health & Mental Disorders Older Adults & Aging Prevention & Safety Respiratory Diseases Substance Abuse Women s Health Wellness & Lifestyle Indicators were categorized into 23 topic areas, which were further classified as a quality of life or health topic. The SocioNeeds Index developed by Healthy Communities Institute and available on the St. Vincent health data platform is a tool used to help determine which communities of Howard County are in most need of services and interventions. The Index summarizes multiple socioeconomic indicators, ranging from poverty to education, which may affect health or access to care. All zip codes in the United States are given an Index value from 0 (low need) to 100 (high need). Within Howard County, zip codes are ranked based on their Index value. These ranks are used to identify the relative level of need within the county. Figure 13. The SocioNeeds Index

14 COMMUNITY HEALTH NEEDS ASSESSMENT - 14 PRIMARY DATA: COMMUNITY INPUT To expand upon the information gathered from the secondary data, Healthy Communities Institute conducted key informant interviews to collect community input. Interviewees who were asked to participate were recognized as having expertise in public health, special knowledge of community health needs and/or represented the broad interest of the community served by the hospital, and/or could speak to the needs of medically underserved or vulnerable populations. Fourteen individuals were contacted for the service area, and eight agreed to participate and scheduled an interview. The following organizations were contacted to provide community input through key informant interviews with HCI. Those in bold were able to provide an interview: 211 of Howard County United Way 4Community of Howard County Bridges Outreach Headstart Howard County Commissioner Howard County Public Health Indiana Health Center Kokomo Economic Development Alliance Interviews were conducted during the months of February to April 2015 by telephone and ranged from minutes in length. During the interview, questions were asked to learn about the interviewee s background and organization, biggest health needs and barriers of concern in the community, as well as the impact of health issues on vulnerable populations. A list of the questions asked during the interviews can be found in Appendix C. Kokomo Police Department Kokomo Urban Outreach Project Access Rescue Mission St. Vincent Kokomo Hospital Behavioral Health Western High School Each interview included both an interviewer and a note taker from HCI, so much of the conversation was captured verbatim. Notes taken during the interviews were uploaded to a summary qualitative data analysis tool, TagCrowd.com, to create a word cloud. Word clouds help to identify the words or phrases mentioned most often in the interviews, and appear in the largest and darkest font in Figure 14 below. Figure 14. Primary Data Word Cloud

15 COMMUNITY HEALTH NEEDS ASSESSMENT - 15 The word cloud was used to get an initial sense of the major issues in the community. The interview notes were also uploaded to the web application Dedoose, a qualitative data analysis software. Using the major issues from the word cloud, themes from the interview questions (such as needs, barriers and advice), and secondary data health and quality of life topics, a code list was created. Interview notes were coded using this list, which allows for comparison and inclusion of the primary data with the secondary data throughout the report. Input from key informants is included in each relevant topic area. The code cloud below, Figure 15, was created from the key informant interview transcripts, where the size and darkness of the words reflect the relative number of times the word appeared. The figure provides an overall picture of the themes that were most prominent in the community input. Figure 15. Primary Data Code Cloud Significant Community Health Needs Assessment Findings The secondary data summary and key informant interview findings are presented together to capture a more holistic assessment of health needs in Howard County. Quality of life topics are presented first, as they are key to understanding the barriers to health in the community. Furthermore, the availability of socioeconomic data for specific sub-populations and sub-county geographies provides a framework for identifying the populations most vulnerable to the poor health outcomes identified.

16 COMMUNITY HEALTH NEEDS ASSESSMENT - 16 Figure 16. HCI SocioNeeds Index by Zip Code, Howard County Table 2. HCI SocioNeeds Index Values & Rankings by Zip Code, Zip Code Index Rank GEOGRAPHICAL AREAS OF HIGHEST NEED Social and economic factors are well known to be strong determinants of health outcomes. The HCI SocioNeeds Index summarizes multiple socioeconomic indicators, ranging from poverty to education, which may affect health or access to care. All zip codes in the United States are given an Index value from 0 (low need) to 100 (high need). Within Howard County, zip codes are ranked based on their Index value (see Table 2). These ranks are used to identify the relative level of need within the county. Geographically, there are parts of Howard County for which quality of life issues are of greater concern (Figure 16). The Index shows that zip codes and are the communities with the highest socioeconomic need within Howard County and are more likely to be affected by poor health outcomes. QUALITY OF LIFE FINDINGS Socioeconomic indicators across the quality of life topic areas point to multiple barriers to health, and the effect of these drivers was noted in both the secondary data and key informant interviews specifically around social environment, economy and transportation (Table 3). Outside of Kokomo, Howard County is rural and one key informant stated that the lowincome population is more spread out than it used to be. Public transportation has improved in Kokomo with a free trolley, but transportation is still a barrier in the county to accessing services. Table 3. Quality of Life Topics Topic Score Community Input Social Environment 1.92 Economy 1.81 Environment 1.67 Education 1.53 Transportation 1.42 Public Safety 1.29 Key Informant Total:

17 COMMUNITY HEALTH NEEDS ASSESSMENT - 17 HEALTH NEEDS FINDINGS The outcomes of the primary and secondary data analysis were combined to identify the significant community needs in Howard County. The analysis revealed that there were significant needs across the majority of the topic areas considered. Table 4 briefly summarizes the findings by topic area, where topics are sorted by secondary data summary score range; areas are identified with a high disparity score by category; and the number of times the area was identified as a top need by a key informant. Some topic areas which did not score high or did not have a score in the secondary data summary were identified as a top need by key informants, underlining the importance of considering both quantitative data and community input when assessing health issues. Table 4. Health Topics Disparities Topic Score Community Input Wellness & Lifestyle 2.03 R Diabetes 2.02 G Substance Abuse 1.88 G Children's Health 1.81 R G Respiratory Diseases 1.78 Exercise, Nutrition, & Weight 1.77 Mental Health & Mental Disorders 1.71 R G Older Adults & Aging 1.68 Heart Disease & Stroke 1.68 G Kidney & Urinary Tract Diseases 1.60 G Immunizations & Infectious Diseases 1.36 Prevention & Safety 1.29

18 COMMUNITY HEALTH NEEDS ASSESSMENT - 18 Disparity Health Topic Topic Score Community Input Women's Health 1.22 R Maternal, Fetal & Infant Health 1.22 Access to Health Services 1.08 G Cancer 0.88 Men's Health 0.63 R indicates Disparity by Race G indicates Disparity by Gender Key Informant Total: The graph in Figure 17 below provides an overall synthesis of the primary and secondary data for all quality of life and health topics available for Howard County analysis. The X-axis demonstrates the evidence of need based on secondary data scores, and the Y-axis displays evidence of need based on the percentage of key informants indicating the topic as a health concern. The size of the circles provides another level of evidence larger circles indicate more indicators were available for that secondary data topic. Figure 17. Secondary and Primary Data Synthesis High Community Input & Low Secondary Data Scoring High Community Input & High Secondary Data Scoring Low Community Input & Low Secondary Data Scoring Low Community Input & High Secondary Data Scoring

19 COMMUNITY HEALTH NEEDS ASSESSMENT - 19 Taking the information displayed in the above graph to a broader view of the health needs of Howard County based on the rigorous secondary data analysis and rich community input that was synthesized, the Venn diagram below Figure 18. Venn Diagram of Topic Areas and Data Support Strong Evidence of Need in Primary Data Transportation Access to Health Services Substance Abuse Exercise, Nutrition, & Weight Mental Health & Mental Disorders Strong Evidence of Need in Secondary Data Diabetes Social Environment Children s Health Economy Wellness & Lifestyle Respiratory Diseases Environmental & Occupational Health Older Adults & Aging Heart Disease and Stroke Kidney & Urinary Tract Infections Environment Education Weak Evidence of Need in Primary and Secondary Data: Immunizations & Infectious Diseases, Maternal, Fetal & Infant Health, Public Safety, Prevention & Safety, Women s Health, Cancer, Men s Health

20 COMMUNITY HEALTH NEEDS ASSESSMENT - 20 SIGNIFICANT HEALTH NEEDS The list of health needs in Table 5 below highlights the most significant health needs based on the analysis and synthesis of the primary and secondary data. This list represents 10 of the most pressing health and quality of life topics to be considered for the prioritization process. Table 5. Significant Health and Quality of Life Topics for Prioritization Secondary Data Primary Data Topic Score Health Topic Disparities in Data Community Input (Total N=8) Key Themes from Community Top 5 Health Needs/Concerns from Secondary Data 2.03 Wellness & Lifestyle 2.02 Diabetes African-Americans have ER Rate for diabetes and long-term diabetes complications N/a, not mentioned as a top health need/concern during community input process Diabetes frequently mentioned as an issue; lack of preventive services or programs for pre-diabetics Substance Abuse 1.81 Children s Health 1.78 Respiratory Diseases Top Quality of Life 1.92 Social Environment Men have hospitalization and ER rates due to alcohol abuse Boys have hospitalization rates for pediatric asthma Women and African-Americans have ER rates due to adult asthma Drug and alcohol abuse perceived as high; heroin and meth use on rise; smoking a big issue. Parenting issues and family stability; nutrition and food allergies; smoking in the home and childhood asthma. Concern with child asthma rates; smoking rates and smoking during pregnancy. Lifestyle and family stability; cycle of non-traditional family structure; domestic violence. Many grandparents are raising preschoolers, the parents are out of

21 COMMUNITY HEALTH NEEDS ASSESSMENT - 21 the picture for whatever reason Transportation Free trolley improved things in city, but not in county; trolley schedule/stops may not be convenient; only one cab company takes Medicaid, specialists far away. Top 3 Needs/Concerns from Community Input 1.77 Exercise, Nutrition & Weight 1.71 Mental health & Mental Disorders 1.08 Access to Health Services Obesity; unhealthy habits - overeating, lack of exercise; lack of nutrition availability and education. Lack of mental and behavioral health services, not enough therapists and psychiatrists; long wait time for appointments. Difficulties with health system navigation; lack of transportation; issues with understanding new coverage; provider retention; long wait times.

22 Prioritization of Top Health Needs COMMUNITY HEALTH NEEDS ASSESSMENT - 22 To better target community resources on Howard County s most pressing health needs, St. Vincent Kokomo participated in a group discussion facilitated by HCI to hone in on up to five health needs. Those health needs will be under consideration for the development of an implementation plan that will address some of the community s most pressing health issues. PRIORITIZATION SESSION PARTICIPANTS o o o o o o o o o o o Abbie Smith, United Way of Howard County, President Dennis Ressler, St. Vincent Kokomo, Executive Director Finances Diana H. Lowery, Clinic of Hope, Social Worker Jeana O Haver, St. Vincent Kokomo, Solutions Development Analyst John Rudy, St. Vincent Kokomo, Executive Director of Diagnostic & Treatment Services Karam Abbasi, MD, St. Vincent Kokomo, General Surgeon Kathy Peoples, St. Vincent Kokomo, VP Nursing/CNO Margie Johnson, St. Vincent Kokomo, Interim Regional President Mark D. Deckinger, St. Vincent Kokomo, Manager Pastoral Care Robert A. Lee, Township Trustee/Board, Trustee/Board Member Rolando Fuertes, St. Vincent Kokomo, Health Access Coordinator PRIORITIZATION PROCESS On July 15, 2015, the above participants convened at St. Vincent Kokomo to review and discuss the results of HCI s primary and secondary data analysis leading to the preliminary top 10 significant health needs highlighted in Table 5 above. From there, participants utilized a prioritization toolkit (Appendix D) to examine how well each of the 10 significant health needs met the criteria set forth by St. Vincent. The criteria for prioritization can be seen in Figure 19 below: Figure 19: St. Vincent System-Wide Criteria for Prioritization Alignment with Ascension Health Strategies Healthcare that Leaves No One Behind & Care for the Poor & Vulnerable Community Input Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Addresses Disparities of Sub-Groups

23 COMMUNITY HEALTH NEEDS ASSESSMENT - 23 FOCUS GROUP DISCUSSION Additional community input was presented from the Howard County Focus Group, to be taken into account during the prioritization process. Kelly Peisker, St. Vincent/St. Joseph Hospital, Ann Yeakle, Community Health Network, Lisa Holaday, Howard Community Hospital, and Whitney Albrecht, student from IUPUI, School of Public Health facilitated the focus group which was held at the Kokomo Public Library on March 25, 2015, from 11am to 2pm with key community leaders. In attendance were representatives from: Acacia Academy, Indiana University American Cancer Society Bona Vista Center Township City of Kokomo Clinic of Hope Community Foundation Early Headstart Excel Center Indiana Health Center Ivy Tech The six main topics brought up during the Focus Group were Behavioral & Mental Health, Lifestyle, Access to Healthcare, Tobacco, Unemployment/Underemployment, and Food Security. In Figure 20 below, these topics were matched up to HCI secondary data topic definitions, the poorest performing indicators for that topic from the secondary data analysis, and how the topic fared in the key informant interviews. There was overall agreement between the main issues mentioned in the focus group and the key informant interviews, though more emphasis was placed on unemployment/underemployment in the focus group than by key informants. Figure 20. Howard County Focus Group Findings Kokomo Housing Authority Kokomo Public Library Kokomo Rescue Mission Mental Health Association Project Access Samaritan Caregivers St. Vincent Kokomo Hospital UAW/Partners for a Healthier Community United Way YMC Focus Group Health Topic HCI Health Topics Warning Indicators Secondary Data Community Input Behavioral Health & Mental Health Mental Health & Mental Disorders Poor Mental Health Days Death Rate to Suicide Depression: Medicare Pop. 6 out of 8 Key Informants Lifestyle Access to Healthcare - Wellness & Lifestyle - Exercise, Nutrition & Weight Access to Health Services Adults who are Obese Adults who are Sedentary Low-Income Preschool Obesity Non-Physician Primary Care Provider Rate 7 out of 8 Key Informants 7 out of 8 Key Informants Tobacco Unemployment/ Underemployment Food Security Substance Abuse Economy Exercise, Nutrition & Weight Adults who Smoke Mothers who Smoke during Pregnancy Unemployed Workers in Civilian Labor Force Grocery Store Density Food Environment Index Food Insecurity Rate Low Income & Low Access to a Grocery Store 7 out of 8 Key Informants 2 out of 8 Key Informants 7 out of 8 Key Informants

24 COMMUNITY HEALTH NEEDS ASSESSMENT - 24 Completion of the prioritization toolkit in Appendix D allowed participants to arrive at numerical scores for each health need that correlated to how well each health need met the St. Vincent system-wide criteria for prioritization. Participants then ranked the top 10 health needs according to their topic scores, with the highest scoring health needs receiving the highest priority ranking. Participants were encouraged to use their own judgment and knowledge of their community in the event of a tie score. After completing their individual ranking of the 10 health needs, participants submitted their ranking into an online polling platform that collates the submissions and results in an aggregate ranking of the health needs. The aggregate ranking can be seen below in Figure 21. Figure 21. Group Ranking of Howard County s Most Pressing Health Needs As seen in the group ranking above, the top five health priorities for Howard County to consider for subsequent implementation planning are: Substance Abuse Access to Health Services Mental Health & Mental Disorders Exercise, Nutrition, & Weight Diabetes These five health needs will be broken down in further detail below to understand how findings in the secondary data and community input led to each issue becoming a high priority health need for Howard County.

25 Health Priorities for Howard County COMMUNITY HEALTH NEEDS ASSESSMENT - 25 SUBSTANCE ABUSE SECONDARY DATA FINDINGS Substance Abuse s Poorest Performing Indicators and Rankings Howard County ranks in the worst quartile in the US, Indiana state, and Indiana Counties for Liquor Store Density, and ranks in the worst quartile for Indiana state and counties and the Age-Adjusted Hospitalization Rate due to Alcohol Abuse. According to the CDC, excessive alcohol use, either in the form of heavy drinking (drinking more than two drinks per day on average for men or more than one drink per day on average for women), or binge drinking (drinking more than four drinks during a single occasion for men or more than three drinks during a single occasion for women), can lead to increased risk of health problems such as liver disease or unintentional injuries. Health Disparities for Substance Abuse Males have higher hospitalization and ER rates due to alcohol abuse than females. Substance Abuse was frequently cited during the key informant interviews. The secondary data analysis illustrates poor performance across indicators, with the exception of a self-reported indicator of adults who drink excessively. Table 6 below shows the Substance Abuse indicators that contributed to the topic receiving an overall topic score of The gauges illustrate how Howard County is faring compared to the following six comparisons: the Indiana State Value, Indiana County Value, US Value, US Counties Value, HP2020 if a target is available, and the time trend score. A gauge in the green received a score of 0-1 (good), yellow a score of 1-2 (fair), and red a score of 3 (poor). Table 6. Comparison Scores for Substance Abuse Indicators Substance Abuse Topic Score 1.88 Indicator: Howard County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Liquor Store c Density Death Rate due to Drug Poisoning b Age-Adjusted Hospitalization Rate due to Alcohol Abuse d

26 COMMUNITY HEALTH NEEDS ASSESSMENT - 26 Indicator: Howard County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Age-Adjusted ER Rate due to Alcohol Abuse e Health Behaviors Ranking a Alcohol- Impaired Driving Deaths 29.7% Adults who Smoke 24% Mothers who Smoked During Pregnancy 20.6% Adults who Drink Excessively a Value represents Howard County s rank out of 92 Indiana Counties b Value represents the number of deaths per 100,000 population c Value represents the number of stores per 100,000 population d Value represents the number of hospitalizations per 10,000 population ages 18+ e Value represents the number of ER visits per 10,000 population ages 18+ COMMUNITY INPUT Seven out of eight Key Informants cited Substance Abuse as a need for Howard County. Key themes from the informants indicate that drug and alcohol abuse rates are high in the community, heroin and meth use appears to be on the rise, and smoking continues to be an issue. Key informants spoke to substance abuse and the connection to mental health, and even nutrition. Infectious diseases, such as hepatitis C, related to drug use are of concern. Progress has not yet been made around tobacco use despite trying to be a smoke free city and smoking rates during pregnancy are still too high. Quotes from Key Informants Smoking is a problem there is an ordinance where you have to stand outside commercial buildings Breathe Easy Committee that was sadly declined by city government. Smoking is still ok in a lot of bars and clubs. Another health issue- drug use and infectious diseases relating from drug use. Our police department just has jurisdiction within city limits, but a lot of meth/ drug use in rural areas now. Drug and alcohol abuse is a huge issue. It s the bulk of what we see, as the chemical dependency unit in the whole regional area. Sometimes I have an all heroin day with appointments. Teen pregnancy, smoking rates during pregnancy those are also big issues.

27 COMMUNITY HEALTH NEEDS ASSESSMENT - 27 ACCESS TO HEALTH SERVICES SECONDARY DATA FINDINGS Access to Health Service s Poorest Performing Indicators and Rankings Howard County ranks in the worst quartile in the Indiana state for the Non-Physician Primary Care Provider Rate. Access to primary care providers increases the likelihood that community members will have routine checkups and screenings. Moreover, those with access to primary care are more likely to know where to go for treatment in acute situations. Since Access to Health Services made the initial shortlist for pressing health needs in Howard County due to community input evidence, the indicators available in the secondary data for this topic aren t quite as poor performing compared to some other topics that were presented for consideration. Table 7 below shows all Access to Health Services indicators that contributed to the topic receiving an overall topic score of The gauges illustrate how Howard County is faring compared to the following six comparisons: the Indiana State Value, Indiana County Value, US Value, US Counties Value, HP2020 if a target is available, and the time trend score. A gauge in the green received a score of 0-1 (good), yellow a score of 1-2 (fair), and red a score of 3 (poor). Table 7. Comparison Scores for Access to Health Services Indicators Access to Health Services Topic Score 1.08 Indicator: Howard County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Non-Physician Primary Care Provider Rate a Adults with Health Insurance 81.5% 80.1% 1.40 Clinical Care Ranking c Primary Care Provider Rate a Children with Health Insurance 92.8% 91.3% 0.98 Dentist Rate a Preventable b Hospital Stays

28 COMMUNITY HEALTH NEEDS ASSESSMENT - 28 a Rates are expressed as the number of providers per 100,000 population b Indicates the hospital discharge rate for ambulatory care-sensitive conditions (ACSC) per 1,000 Medicare enrollees c From the County Health Rankings, this value is the Howard County Ranking out of 92 total Indiana Counties COMMUNITY INPUT Seven out of eight Key Informants cited Access to Health Services as a need for Howard County. The most pressing issues in regard to access to health services, as cited by key informants were a lack of general practitioners in the community, the need for more education and outreach around navigating the healthcare system, and barriers to specialist care. Key informants also provided insight to the experiences of poor and vulnerable populations pertaining to accessing health services. The figure to the right includes some direct quotes from key informants regarding accessing health services in their community and the populations most affected. Quotes from Key Informants There s difficulty in keeping providers and long wait times for patients. Access to specialist services is difficult for Medicaid patients or those with no insurance, so wait time is again a big barrier. Lots of patients can t travel to the capital for services because it is too far. Once people are on Medicaid or HIP, they are not eligible for any kind of dental resources in the community. No one can get serious dental procedures, which can have serious medical consequences. People have issues understanding their new insurance coverage. General public doesn t even know what a health navigator is or how to deal with their insurance. I don t think it s necessarily the lowest income who are struggling most because they are covered by Medicaid. It s the groups that don t really qualify, that are working 2 or 3 part-time jobs that don t offer benefits. Or maybe they are working full time but can t afford the benefits. They aren t going to see a specialist.

29 COMMUNITY HEALTH NEEDS ASSESSMENT - 29 MENTAL HEALTH & MENTAL DISORDERS SECONDARY DATA FINDINGS Mental Health & Mental Disorder s Poorest Performing Indicators and Rankings Howard County ranks in the worst quartile for Indiana state and counties and US counties for Poor Mental Health Days Adults reported that their mental health was not good approximately 4.9 days of the past 30. Howard County ranks in the worst quartile for Indiana state and the US for the Age-Adjusted Death Rate due to Suicide. An estimated 25 attempted suicides occur per every suicide death, and those who survive suicide may have serious injuries, in addition to having depression and other mental problems. Other repercussions of suicide include the combined medical and lost work costs on the community, totaling to over $30 billion for all suicides in a year, and the emotional toll on family and friends. Men are about four times more likely than women to die of suicide, but three times more women than men report attempting suicide. Suicide occurs at a disproportionately higher rate among adults 75 years and older. Mental Health & Mental Disorders was a commonly cited issue during our key informant interviews. The topic made the initial shortlist for pressing health needs in Howard County due to community input evidence more so than the secondary data, as this topic was not as poor performing compared to some others that were presented for consideration. Table 8 below shows the poorest performing Mental Health & Mental Disorders indicators that contributed to the topic receiving an overall topic score of The gauges illustrate how Howard County is faring compared to the following six comparisons: the Indiana State Value, Indiana County Value, US Value, US Counties Value, HP2020 if a target is available, and the time trend score. A gauge in the green received a score of 0-1 (good), yellow a score of 1-2 (fair), and red a score of 3 (poor). Table 8. Comparison Scores for Mental Health & Mental Disorders Indicators Mental Health & Mental Disorders Topic Score 1.71 Indicator: Howard County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Poor Mental Health Days Age-Adjusted Death Rate due to Suicide a Depression: Medicare Population 16.3% Alzheimer s Disease or Dementia: Medicare Population 9.5%

30 COMMUNITY HEALTH NEEDS ASSESSMENT - 30 Indicator: Howard County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Age-Adjusted Death Rate due to Alzheimer s Disease a a Value represents the number of deaths per 100,000 population COMMUNITY INPUT Six out of eight Key Informants cited Mental Health & Mental Disorders as a need for Howard County. The most pressing issues in regard to mental health and mental disorders in Howard County were access to mental and behavioral healthcare. There is a lack of services and support across the board, as well as concern for children and youth. Quotes from Key Informants I think mental health issues and the lack of resources in my opinion is the #1 issue. Across the board, everyone is affected by mental health in the community. There are simply not enough therapists or psychiatrists to see in the community. There are not a lot of resources for kids with mental health issues either, which is a challenge with behaviors and mental health problems in our Headstart program. EXERCISE, NUTRITION, & WEIGHT SECONDARY DATA FINDINGS Exercise, Nutrition, & Weight s Poorest Performing Indicators and Rankings Howard County ranks in the worst quartile for Indiana and Indiana counties for Adults who are Obese Approximately 37.8% of adults are obese compared to 31.4% in Indiana. Howard County ranks in the worst quartile for Indiana and US counties for Grocery Store Density. There are strong correlations between the density of grocery stores in a neighborhood and the nutrition and diet of its residents. The availability and affordability of healthy and varied food options in the community increase the likelihood that residents will have a balanced and nutritious diet. A diet comprised of nutritious foods, in combination with an active lifestyle, can reduce the incidence of heart disease, cancer and diabetes, and is essential to maintain a healthy body weight and prevent obesity. Low-income and under-served communities often have limited access to stores that sell healthy food, especially high-quality fruits and vegetables. Moreover, rural communities often have a high number of convenience stores, where healthy and fresh foods are less available than in larger, retail food markets. Similar to both Access to Health Services and Mental Health & Mental Disorders, Exercise, Nutrition, & Weight made the initial shortlist for pressing health needs in Howard County due to community input evidence. The

31 COMMUNITY HEALTH NEEDS ASSESSMENT - 31 indicators available in the secondary data for this topic aren t quite as poor performing compared to some other topics that were presented for consideration. Table 9 below shows all Exercise, Nutrition, & Weight indicators that contributed to the topic receiving an overall topic score of The gauges illustrate how Howard County is faring compared to the following six comparisons: the Indiana State Value, Indiana County Value, US Value, US Counties Value, HP2020 if a target is available, and the time trend score. A gauge in the green received a score of 0-1 (good), yellow a score of 1-2 (fair), and red a score of 3 (poor). Table 9. Comparison Scores for Exercise, Nutrition, & Weight Indicators Exercise, Nutrition, & Weight Topic Score 1.77 Indicator: Howard County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Grocery Store a Density Adults who are Obese 37.8% Food Environment Index c Children with Low Access to a Grocery Store 7.5% 2.10 Fast Food Restaurant Density a People 65+ with Low Access to a Grocery Store 4.9% 2.10 Farmers Market Density a Low-Income Preschool Obesity Low-Income and Low Access to a Grocery Store 15.1% % 1.90 Food Insecurity Rate 15.9%

32 COMMUNITY HEALTH NEEDS ASSESSMENT - 32 Indicator: Howard County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Child Food Insecurity Rate 22.9% Health Behaviors b Ranking Adults who are Sedentary 30.7% Households with No Car and Low Access to a Grocery Store 2.2% 1.50 SNAP Certified a Stores Recreation and Fitness Facilities a Access to Exercise Opportunities 77.4% a Value expressed as the number per 1,000 population b Rankings equate to the value out of 92 Indiana counties c Index ranges from 0 (worst) to 10 (best) COMMUNITY INPUT Seven out of eight Key Informants cited Exercise, Nutrition & Weight as a need for Howard County. The most pressing issues in regard to exercise, nutrition & weight, as cited by key informants were obesity among children and adults, unhealthy habits such as overeating and lack of exercise, and the need for education on nutrition and access to healthy foods. Key informants also Quotes from Key Informants Access to healthy food is tough lots of organizations are providing food pantries, but nutrition isn t great. There is no education around what is healthy for them and how to prepare something nutritious. Overeating and lack of exercise are issues in the community. For the past several years, we ve been fighting childhood obesity. A third of our students are overweight or obese. From my perspective, people who are underinsured, low-income, ethnic groups those people are the hardest hit. It s a really tough nut to crack, whether it be obesity (we all love to eat!) or something else, education can only do so much. Smoking Those two things are wrecking our society and our economic systems in communities, families, and individually.

33 COMMUNITY HEALTH NEEDS ASSESSMENT - 33 provided insight to the experiences of poor and vulnerable populations pertaining to exercise, nutrition & weight. The figure to the right includes some direct quotes from key informants regarding the topic area of exercise, nutrition, and weight in their community and the populations most affected. DIABETES SECONDARY DATA FINDINGS Diabetes Poorest Performing Indicators and Rankings Howard County ranks in the worst quartile in the US, US counties, the state and Indiana counties for Age- Adjusted Death Date due to Diabetes Lawrence county has 32.4 deaths per 100,000 population. Diabetes can have a harmful effect on most of the organ systems in the human body; it is a frequent cause of end-stage renal disease, non-traumatic lower-extremity amputation, and a leading cause of blindness among workingage adults. Persons with diabetes are also at increased risk for ischemic heart disease, neuropathy, and stroke. In economic terms, the CDC estimates that direct medical expenditures attributable to diabetes is over $116 billion. Health Disparities for Substance Abuse African-Americans have higher ER Rate for diabetes and long-term diabetes complications. The topic of Diabetes had the highest topic score in the secondary data analysis that also was mentioned during the key informant interviews. Table 10 below shows the poorest performing Diabetes indicators that contributed to the topic receiving an overall topic score of The gauges illustrate how Howard County is faring compared to the following six comparisons: the Indiana State Value, Indiana County Value, US Value, US Counties Value, HP2020 if a target is available, and the time trend score. A gauge in the green received a score of 0-1 (good), yellow a score of 1-2 (fair), and red a score of 3 (poor). Table 11. Comparison Scores for Diabetes Indicators Diabetes Topic Score 2.02 Indicator: Howard County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Age-Adjusted Death Rate due to Diabetes a Diabetes: Medicare Population Diabetic Screening: Medicare. 30.2% %

34 COMMUNITY HEALTH NEEDS ASSESSMENT - 34 Indicator: Howard County Value Indiana State Value Indiana State Indiana Counties US Value US Counties HP2020 Benchmark Time Trend Score Total Indicator Score Age-Adjusted ER Rate due to Diabetes b Age-Adjusted Hospitalization Rate due to Uncontrolled Diabetes c Age-Adjusted Hospitalization Rate due to Short-Term Complications of Diabetes c Age-Adjusted ER Rate due to Long-Term Complications of Diabetes b Age-Adjusted ER Rate due to Uncontrolled Diabetes b Age-Adjusted Hospitalization Rate due to Diabetes c Age-Adjusted ER Rate due to Short-Term Complications of Diabetes b Age-Adjusted Hospitalization Rate due to Long-Term Complications of Diabetes c

35 COMMUNITY HEALTH NEEDS ASSESSMENT - 35 COMMUNITY INPUT Three out of eight Key Informants cited Diabetes as a need for Howard County. Key informants felt that diabetes was a major issue in the community and cited a lack of programs for prediabetics or preventive services. It was often brought up along with issues of nutrition and obesity. Quotes from Key Informants Overeating and type of eating, lack of exercise, bad daily habits for diabetes & heart disease. Lack of preventive services for diabetics the food pantries don t provide healthy enough foods for them to be compliant. They can t visit multiple food pantries to get what they need. There s no gluten- or salt-free options for people with chronic health problems who need to visit the food pantries. Not the amount of food that s the problem, it s the quality of it. OTHER SIGNIFICANT COMMUNITY HEALTH NEEDS As part of the community health needs assessment process, the primary and secondary data analysis identified additional significant community health needs (Table 11). While these health needs have not been prioritized for this CHNA cycle, St. Vincent Kokomo and other community partners will still continue to work hard to address the following issues: Children s Health Social Environment Transportation Respiratory Diseases Wellness & Lifestyle Table 11. Other Significant Community Health Needs for Howard County Health or Quality of Life Topic Insights from Secondary Data Topic Score Warning Indicators Contributing to Topic Score Score range: Good Bad Insights from Primary Data/ Community Input Number of Community Members Citing Topic as Pressing Health Concern (Total # interviewed=8) =issue cited =issue not cited Key Themes from Community Input Children s Health 1.81 Children with Low Access to a Grocery Store 2.10 Parenting issues and family stability

36 COMMUNITY HEALTH NEEDS ASSESSMENT - 36 Age-Adjusted ER Rate due to Pediatric Asthma Low-Income Preschool Obesity Poor nutrition and perceived increase in food allergies Smoking in the home and high rates of childhood asthma Social Environment 1.92 Young Children Living Below Poverty Level Children Living Below Poverty Level Single-Parent Households 2.45 Lifestyle and family stability; cycle of nontraditional family 2.35 structure; domestic violence Many grandparents are raising preschoolers, the 2.05 parents are out of the picture for whatever reason. Transportation 1.42 Workers who Drive Alone to Work Households without a Vehicle Workers Commuting by Public Transportation 2.50 Free trolley improved things in city, but not in 2.20 county; trolley schedule/stops may not be convenient Only one cab company 1.80 takes Medicaid; specialists are far away Respiratory Diseases 1.78 Asthma: Medicare Population COPD: Medicare Population Age-Adjusted ER Rate due to Pediatric Asthma 2.65 Concern with child asthma rates 2.10 High smoking rates and smoking during pregnancy 2.03 Wellness & Lifestyle 2.03 Poor Physical Health Days Self-Reported General Health Assessment: Poor or Fair 2.43 N/a, not mentioned as a top health need/concern during community input 2.23 process Life Expectancy for Females 2.15

37 COMMUNITY HEALTH NEEDS ASSESSMENT - 37 Conclusion This community health needs assessment utilized a comprehensive set of secondary data indicators measuring the health and quality of life needs of Howard County, Indiana, residents and was further informed with community input from knowledgeable persons representing the broad interests of the community. The prioritization of the identified health needs will guide the community health improvement efforts of St. Vincent Kokomo Hospital. From this process, Kokomo Hospital will outline how they plan to address their prioritized health needs of Substance Abuse, Access to Health Services, Mental Health & Mental Diseases, Exercise, Nutrition & Weight, and Diabetes into their Implementation Strategy. In addition, we hope to incorporate any feedback on this report into our next Community Health Needs Assessment process. Please send your feedback and/or comments to CommunityDevelopment@stvincent.org.

38 COMMUNITY HEALTH NEEDS ASSESSMENT - 38 Appendix A: Evaluation of Preceding CHNA Priorities Significant health need identified in previous CHNA FY14- FY15 St. Vincent Kokomo Hospital Strategy/Action Step Indicators of Success Obesity 1) Provide opportunities for physical activity Continue support for the new YMCA facility which will provide greater access to fitness activities 2) Model best practices in workplace based strategies to support physical fitness. Issue a Corporate Challenge to area businesses to promote health and wellness with their employees. This may include: Workplace exercise programs such as walking/biking programs, on site fitness equipment, or group fitness classes Promotion of healthy foods through the cafeterias and catered workplace events 3) Provide access to healthy foods Expand in school healthy snack pilot program with students at Pettit Park Elementary School and consider expansion to take home healthy snacks Continue to support the Kokomo Farmers Market and explore ability of the Farmers Market to accept WIC vouchers and SNAP benefits Note: Pettit Park Elementary school s students are disproportionately low income with over 95% who qualify for free or reduced price meals. SV Kokomo Hospital is a major financial contributor toward the construction of a new YMCA in Kokomo. Our leadership team has been involved in community fund raising efforts. A Corporate Challenge is being built into the 2014 Running the Shores event. Also, SV Kokomo. A walking trail has been established on the campus the public to use. A wellness program was established offering a variety of fitness classes on a rotating schedule. The SV Kokomo Cafeteria continually offers healthy choices and education regarding healthy food selection and preparation. SV Kokomo dietitians are available at the local Farmers Market to promote healthy eating and lifestyle. Also, SV Kokomo has supported Pettit Park Elementary school in securing a grant from the Indiana Department of Education Fresh Fruit and Vegetable Program to provide healthy snacks of fruits and vegetables to the students at Pettit Park

39 COMMUNITY HEALTH NEEDS ASSESSMENT - 39 Hunger 4) Promote healthy eating and exercise to the youth of Howard County Incorporate healthy eating into the Let s Pretend Hospital Incorporate a fun run into the annual Running the Shores 5K Partner with Pettit Park Elementary School to sponsor an annual Track and Field day for the students 1) Provide access to nutrient dense foods to school age youth Continue the Buddy Bag week-end meal program with students at Pettit Park Elementary School Expand in school healthy snack pilot program with students at Pettit Park Elementary School and consider expansion to take home snacks Note: Pettit Park Elementary school s students are disproportionately low income with over 95% who qualify for free or reduced price meals. 2) Facilitate access to community resources that connect families to food resources Continue supporting the Health Access Worker (HAW) position at St. Joseph Kokomo Ensure that the HAW is equipped with up-todate information regarding resources for families Continue to support the Kokomo Farmers Market and explore ability of the Farmers Market to accept WIC vouchers and SNAP benefits School. SV Kokomo is a financial sponsor of the local Farmers Market. The Farmers Market now accepts WIC and SNAP benefits. Let s Pretend Hospital promotes healthy lifestyles to over 1,500 kindergarten children in Howard County. The 2014 Running the Shores will offer a fun walk/run option. We have begun exploring the possibility of a Track and Field day for the students at Pettit Park. SV Kokomo sponsored 110 students in who received Buddy Bags through the Kokomo Urban Outreach Buddy Bag program. We will continue this sponsorship in We have not expanded to take home snacks. SV Kokomo continues to support our Health Access Worker, equipping him with the information and resources to assist families and individuals in receiving the health access they need. The health access worker is out in the community connecting with people where they live and in the local office located in the United Way Building. From September 2013 thru June 2014 the health access worker met with and served over 536 households with 232 initial visits and 304 follow-up visits. Services rendered by the health access worker include:

40 COMMUNITY HEALTH NEEDS ASSESSMENT Coordination of appointment to Primary Care and Specialist, help with co-pay for medication or purchase of the medications. - Help with co-pay at the PCP and Dentist, or finds a third party that would help with the cost of both medication and appointment. - Regularly visits the Domestic Violence Shelter, Open Arms Women and Children s Shelter and the Kokomo Rescue Mission to provide services. - Enrolls uninsured residents of Howard County in the Project Access, HIP, Medicaid, Hoosier Health Wise, Food Stamps, TANF and Market Place programs. SV Kokomo continues to support the Farmers Market financially and by sponsoring a booth staffed with SV Kokomo dieticians to provide cooking demonstrations and healthy eating education. The Market accepts WIC and SNAP vouchers. Jobs/Economic Development 1) Promote careers in healthcare to the residents of Howard County. Continue to provide opportunities for people of all ages to connect to careers in healthcare via hospital based workshops, shadowing experiences, internships, and clinical rotations. This would include: SV Kokomo has promoted careers in healthcare to residents of Howard County with the following: Let s Pretend Hospital introduces healthcare careers to over 1,500 Kindergarten children of Howard County.

41 COMMUNITY HEALTH NEEDS ASSESSMENT - 41 Let s Pretend Hospital program for Kindergarteners Shadowing for high school students enrolled in Kokomo Area Career Center Summer Internship Program for college students Clinical rotations for Nursing, Radiology, Emergency Medical Technician, and Respiratory Therapist students 2) Increase career and employment opportunities for residents of Howard County. Continue leadership role in the Greater Kokomo Economic Development Alliance with a focus on recruiting employers to the community and preparing residents to have the workforce skills to meet the needs of Howard County employers. This includes: Financial sponsorship Participation on the Governing Board and Executive Committee Hosting of Sister City visit Promote and expand the STAR employment program to adults in Howard County 3) Explore the development of a Nurse Practitioner program in partnership with Ivy Tech Community College. In FY 14, provided paid summer internships for 10 college students as well as clinical rotations for more than 120 students from IUK and Ivy Tech. More than 59 nursing students completing their Clinical Rotations, 24 EMTs/Paramedics, 8 Respiratory, and 10 Pharmacy students. An associate serves on the Greater Kokomo Economic Development Alliance. Two new employers have been recruited to the community: Patriot is bringing 140 jobs and Systems In Motion is bringing 240 jobs. Update: The STAR program has been discontinued by St. Vincent Health. The Nurse Practitioner Program is being developed and is currently awaiting approval by the I.U. Board of Trustees (October 2014), as well as the hiring of a FNP by SV Kokomo for a dual appointment at the hospital and to teach at IUK. *The last year of the FY14- FY16 implementation strategy will be reported and attached to the FY16 Form 990.

42 Appendix B: Secondary Data Analysis COMMUNITY HEALTH NEEDS ASSESSMENT - 42 SCORING METHOD For each indicator, the county was assigned a score based on its comparison to other communities, whether health targets have been met, and the trend of the indicator value over time. These comparison scores range from 0-3, where 0 indicates the best outcome and 3 the worst. Availability of each type of comparison varies by indicator and is dependent upon the data source, comparability with data collected for other communities, and changes in methodology over time. Indicators were categorized into 29 topic areas and each topic area receives a score. Indicators may be categorized in more than one topic area. Topic scores are determined by the comparisons of all indicators within the topic. COMPARISON TO A DISTRIBUTION OF COUNTY VALUES: WITHIN STATE AND NATION For ease of interpretation and analysis, indicator data on the St. Vincent Health Community Dashboard is visually represented as a green-yellow-red gauge showing how the community is faring against a distribution of counties in Indiana or the United States. A distribution is created by taking all county values within the state or nation, ordering them from low to high, and dividing them into three groups (green, yellow, red) based on their order. Indicators with the poorest comparisons ( in the red ) scored high, whereas indicators with good comparisons ( in the green ) scored low. HCI Platform County Distribution Gauge COMPARISON TO VALUES: STATE, NATIONAL AND TARGETS The county value is compared to the state value, the national value, and Healthy People 2020 (HP2020) target values. Healthy People 2020 goals are national objectives for improving the health of the nation set by the Department of Health and Human Services (DHHS) Healthy People Initiative. For all value comparisons, the scoring depends on whether the county value is better or worse than the comparison value, as well as how close the county value is to the target value. TREND OVER TIME The Mann-Kendall statistical test for trend was used to assess whether the county value is increasing over time or decreasing over time, and whether the trend is statistically significant. The trend comparison uses the four most recent comparable values for the county, and statistical significance is determined at the 90% confidence level. For each indicator with values available for four time periods, scoring was determined by direction of the trend and statistical significance. MISSING VALUES Indicator scores are calculated using the comparison scores, availability of which depend on the data source. If the comparison type is possible for an adequate proportion of indicators on the community dashboard, it will be included in the indicator score. After exclusion of comparison types with inadequate availability, all missing comparisons are substituted with a neutral score for the purposes of calculating the indicator s weighted average.

43 COMMUNITY HEALTH NEEDS ASSESSMENT - 43 When information is unknown due to lack of comparable data, the neutral value assumes that the missing comparison score is neither good nor bad. INDICATOR SCORING Indicator scores are calculated as a weighted average of all included comparison scores. More weight was given to comparison to US counties, comparison to Indiana counties, and trend over time. If neither of the included comparison types are possible for an indicator, then a score is not calculated and the indicator is excluded from the data scoring results. TOPIC SCORING Indicator scores are averaged by topic area to calculate topic scores. Each indicator may be included in up to three topic areas if appropriate. Resulting scores range from 0-3, where a higher score indicates a greater level of need as evidenced by the data. A topic score is only calculated if it includes at least three indicators. These scores were used to categorize the topics as red (score 1.5), yellow (1.25 score <0.1.5), or green (score <1.25). DISPARITIES To identify indicators with the largest disparities by gender or race/ethnicity, the Index of Disparity 1 measure was used to calculate the average of the absolute differences between rates for each subgroup within a sub-population category and the overall county rate, divided by the county rate. The index of disparity summarizes disparities across groups within a population that can be applied across indicators. The measure is expressed as a percentage. Across all indicators, an Index of Disparity score that ranked in the top 25% of all disparities scores in either gender or race/ethnicity category was identified as having a high disparity. The availability of sub-population data varies by source and indicator. In this example to the right, Age-Adjusted Death Rate due to Diabetes by Gender has county values for the female and male subgroups that are closer to each other and close to the overall county value when compared to the subgroup values for Age- Adjusted Death Rate due to Diabetes by Race/Ethnicity. The ±3.3 ±11.4 ±4.8 ±2.8 1 Pearcy, J. & Keppel, K. (2002). A Summary Measure of Health Disparity. Public Health Reports, 117,

44 COMMUNITY HEALTH NEEDS ASSESSMENT - 44 absolute difference between the Black or African American value and the overall value is much larger than the difference between the White value and overall value, resulting in a higher Index of Disparity score than the score calculated for the gender subgroups. SCORING RESULTS The following table lists all indicators by topic area, with the most recent value for Howard County and comparison scores (0-3 or good to bad). The county value is compared to a distribution of Indiana and US counties, state and national values, and the HP2020 target. Indicators are also compared across four time periods and are scored under the trend column. If data was not available for a comparison or disparity score, then the cell is left blank. Source: as of January 20, Indicator Period Score Access to Health Services Non-Physician Primary Care Provider Rate Topic Score: 1.08 Adults with Health Insurance Clinical Care Ranking Primary Care Provider Rate Children with Health Insurance Dentist Rate Preventable Hospital Stays Cancer Oral Cavity and Pharynx Cancer Incidence Rate Topic Score: 0.88 Lung and Bronchus Cancer Incidence Rate Age-Adjusted Death Rate due to Lung Cancer Mammography Screening: Medicare Population Age-Adjusted Death Rate due to Breast Cancer Breast Cancer Incidence Rate Cancer: Medicare Population Age-Adjusted Death Rate due to Colorectal Cancer Colorectal Cancer Incidence Rate Prostate Cancer Incidence Rate Age-Adjusted Death Rate due to Prostate Cancer Children's Health Children with Low Access to a Grocery Store Topic Score: 1.81 Age-Adjusted ER Rate due to Pediatric Asthma Low-Income Preschool Obesity Age-Adjusted Hospitalization Rate due to Pediatric Asthma Child Food Insecurity Rate Child Abuse Rate Children with Health Insurance Diabetes Age-Adjusted Death Rate due to Diabetes

45 COMMUNITY HEALTH NEEDS ASSESSMENT - 45 Topic Score: 2.02 Diabetes: Medicare Population Economy Diabetic Screening: Medicare Population Age-Adjusted ER Rate due to Diabetes Age-Adjusted Hospitalization Rate due to Uncontrolled Diabetes Age-Adjusted Hospitalization Rate due to Short- Term Complications of Diabetes Age-Adjusted ER Rate due to Long-Term Complications of Diabetes Age-Adjusted ER Rate due to Uncontrolled Diabetes Age-Adjusted Hospitalization Rate due to Diabetes Age-Adjusted ER Rate due to Short-Term Complications of Diabetes Age-Adjusted Hospitalization Rate due to Long- Term Complications of Diabetes Renters Spending 30% or More of Household Income on Rent Topic Score: 1.81 Young Children Living Below Poverty Level Children Living Below Poverty Level Homeowner Vacancy Rate Households with Cash Public Assistance Income People Living Below Poverty Level Median Household Income Low-Income Preschool Obesity People Living 200% Above Poverty Level Low-Income and Low Access to a Grocery Store Food Insecurity Rate Students Eligible for the Free Lunch Program Child Food Insecurity Rate Families Living Below Poverty Level Unemployed Workers in Civilian Labor Force Oct Social and Economic Factors Ranking Per Capita Income Severe Housing Problems Persons with Disability Living in Poverty Homeownership SNAP Certified Stores People 65+ Living Below Poverty Level Education 4th Grade Students Proficient in Math Topic Score: 1.53 High School Graduation th Grade Students Proficient in Math

46 COMMUNITY HEALTH NEEDS ASSESSMENT th Grade Students Proficient in English/Language Arts People 25+ with a Bachelor's Degree or Higher Student-to-Teacher Ratio th Grade Students Proficient in English/Language Arts People 25+ with a High School Degree or Higher Environment Liquor Store Density Topic Score: 1.67 Grocery Store Density Food Environment Index Children with Low Access to a Grocery Store Fast Food Restaurant Density People 65+ with Low Access to a Grocery Store Farmers Market Density Low-Income and Low Access to a Grocery Store Houses Built Prior to PBT Released Annual Particle Pollution Households with No Car and Low Access to a Grocery Store Severe Housing Problems Recognized Carcinogens Released into Air Physical Environment Ranking Drinking Water Violations FY SNAP Certified Stores Recreation and Fitness Facilities Access to Exercise Opportunities Exercise, Nutrition, & Weight Grocery Store Density Topic Score: 1.77 Adults who are Obese Food Environment Index Children with Low Access to a Grocery Store Fast Food Restaurant Density People 65+ with Low Access to a Grocery Store Farmers Market Density Low-Income Preschool Obesity Low-Income and Low Access to a Grocery Store Food Insecurity Rate Child Food Insecurity Rate Health Behaviors Ranking Adults who are Sedentary Households with No Car and Low Access to a Grocery Store SNAP Certified Stores

47 COMMUNITY HEALTH NEEDS ASSESSMENT - 47 Heart Disease & Stroke Recreation and Fitness Facilities Access to Exercise Opportunities Age-Adjusted Death Rate due to Coronary Heart Disease Topic Score: 1.68 Hypertension: Medicare Population Immunizations & Infectious Diseases Topic Score: 1.36 Kidney & Urinary Tract Diseases Hyperlipidemia: Medicare Population Age-Adjusted Death Rate due to Cerebrovascular Disease (Stroke) Ischemic Heart Disease: Medicare Population Atrial Fibrillation: Medicare Population Stroke: Medicare Population Heart Failure: Medicare Population Age-Adjusted Hospitalization Rate due to Heart Failure Age-Adjusted ER Rate due to Heart Failure Age-Adjusted Hospitalization Rate due to Bacterial Pneumonia Age-Adjusted Hospitalization Rate due to Hepatitis Age-Adjusted Hospitalization Rate due to Immunization-Preventable Pneumonia and Influenza Salmonella Infection Incidence Rate Age-Adjusted Death Rate due to Influenza and Pneumonia Gonorrhea Incidence Rate Age-Adjusted ER Rate due to Bacterial Pneumonia Age-Adjusted ER Rate due to Immunization- Preventable Pneumonia and Influenza Chlamydia Incidence Rate HIV Prevalence Rate Age-Adjusted ER Rate due to Urinary Tract Infections Topic Score: 1.6 Chronic Kidney Disease: Medicare Population Age-Adjusted Death Rate due to Kidney Disease Age-Adjusted Hospitalization Rate due to Urinary Tract Infections Maternal, Fetal & Infant Health Teen Birth Rate Topic Score: 1.22 Mothers who Smoked During Pregnancy Mothers who Received Early Prenatal Care Preterm Births Babies with Low Birth Weight

48 COMMUNITY HEALTH NEEDS ASSESSMENT - 48 Infant Mortality Rate Men's Health Life Expectancy for Males Topic Score: 0.63 Prostate Cancer Incidence Rate Age-Adjusted Death Rate due to Prostate Cancer Mental Health & Mental Disorders Poor Mental Health Days Topic Score: 1.71 Age-Adjusted Death Rate due to Suicide Depression: Medicare Population Alzheimer's Disease or Dementia: Medicare Population Age-Adjusted Death Rate due to Alzheimer's Disease Older Adults & Aging Asthma: Medicare Population Topic Score: 1.68 Osteoporosis: Medicare Population Diabetes: Medicare Population Hypertension: Medicare Population COPD: Medicare Population People 65+ with Low Access to a Grocery Store Diabetic Screening: Medicare Population Depression: Medicare Population Hyperlipidemia: Medicare Population Chronic Kidney Disease: Medicare Population Ischemic Heart Disease: Medicare Population Rheumatoid Arthritis or Osteoarthritis: Medicare Population Atrial Fibrillation: Medicare Population People 65+ Living Alone Alzheimer's Disease or Dementia: Medicare Population Stroke: Medicare Population Heart Failure: Medicare Population Mammography Screening: Medicare Population People 65+ Living Below Poverty Level Cancer: Medicare Population Age-Adjusted Death Rate due to Alzheimer's Disease Prevention & Safety Death Rate due to Drug Poisoning Topic Score: 1.29 Severe Housing Problems Age-Adjusted Death Rate due to Unintentional Injuries Public Safety Child Abuse Rate Topic Score: 1.29 Alcohol-Impaired Driving Deaths

49 COMMUNITY HEALTH NEEDS ASSESSMENT - 49 Age-Adjusted Death Rate due to Motor Vehicle Traffic Collisions Respiratory Diseases Asthma: Medicare Population Topic Score: 1.78 COPD: Medicare Population Age-Adjusted ER Rate due to Pediatric Asthma Age-Adjusted ER Rate due to Adult Asthma Age-Adjusted ER Rate due to Asthma Age-Adjusted Hospitalization Rate due to Asthma Age-Adjusted Hospitalization Rate due to Adult Asthma Age-Adjusted Hospitalization Rate due to Pediatric Asthma Age-Adjusted Hospitalization Rate due to Bacterial Pneumonia Age-Adjusted ER Rate due to COPD Age-Adjusted Death Rate due to Chronic Lower Respiratory Diseases Lung and Bronchus Cancer Incidence Rate Age-Adjusted Hospitalization Rate due to Immunization-Preventable Pneumonia and Influenza Age-Adjusted Death Rate due to Lung Cancer Age-Adjusted Death Rate due to Influenza and Pneumonia Age-Adjusted ER Rate due to Bacterial Pneumonia Age-Adjusted Hospitalization Rate due to COPD Age-Adjusted ER Rate due to Immunization- Preventable Pneumonia and Influenza Social Environment Young Children Living Below Poverty Level Topic Score: 1.92 Children Living Below Poverty Level Single-Parent Households Child Abuse Rate Voter Turnout Social and Economic Factors Ranking People 65+ Living Alone Substance Abuse Liquor Store Density Topic Score: 1.88 Death Rate due to Drug Poisoning Age-Adjusted Hospitalization Rate due to Alcohol Abuse Age-Adjusted ER Rate due to Alcohol Abuse Health Behaviors Ranking

50 COMMUNITY HEALTH NEEDS ASSESSMENT - 50 Alcohol-Impaired Driving Deaths Adults who Smoke Mothers who Smoked During Pregnancy Adults who Drink Excessively Transportation Workers who Drive Alone to Work Topic Score: 1.42 Households without a Vehicle Workers Commuting by Public Transportation Households with No Car and Low Access to a Grocery Store Mean Travel Time to Work Solo Drivers with a Long Commute Age-Adjusted Death Rate due to Motor Vehicle Traffic Collisions Wellness & Lifestyle Poor Physical Health Days Topic Score: 2.03 Self-Reported General Health Assessment: Poor or Fair Life Expectancy for Females Morbidity Ranking Life Expectancy for Males Women's Health Life Expectancy for Females Topic Score: 1.22 Mammography Screening: Medicare Population DATA SOURCES Age-Adjusted Death Rate due to Breast Cancer Breast Cancer Incidence Rate The St. Vincent Data Platform utilizes indicator data from the following data sources: American Community Survey American Lung Association Annie E. Casey Foundation Centers for Disease Control and Prevention Centers for Medicare and Medicaid Services County Health Rankings Feeding America Indiana Hospital Association Indiana Secretary of State Indiana State Department of Health Indiana University Center for Health Policy Institute for Health Metrics and Evaluation National Cancer Institute National Center for Education Statistics National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Nielsen Claritas Small Area Health Insurance Estimates US Bureau of Labor Statistics US Census County Business Patterns US Department of Agriculture: Food Environment Atlas US Environmental Protection Agency

51 COMMUNITY HEALTH NEEDS ASSESSMENT - 51 Appendix C: Community Input Key Informant Interview Questions Questions that were asked during the Key Informant Interviews are presented below: Q1. Could you tell me a little bit about yourself, your background, and your organization? Q2. What are the major health needs/issues you see in the community? Q3. Who in your community appears to struggle most with these issues you ve identified and how does it impact their lives? Q4. Are there any barriers to receiving care in the community? Q5. Could you tell me about some of the strengths and resources in your community that address these issues, such as groups, initiatives, services, or programs? Q6. What advice do you have for a group developing a plan to address these needs? Q7. Is there anything else you d like us to note?

52 Appendix D: Prioritization Tools Prioritization Matrix Tools Howard County COMMUNITY HEALTH NEEDS ASSESSMENT - 52 This packet will help you assess each of the 10 pressing health needs identified by HCI s data analysis, and how each of those health needs relate to the criteria set forth by St. Vincent for prioritizing health topics in your service area. Please have a quick look through the packet, and then follow the directions below to score how well each of the health topics meets the prioritization criteria. After you have completed the ranking below, please submit your results on the Poll Everywhere software. The software will collate your results with those of other participants, and will instantaneously show the group s collective ranking of the most pressing health needs in your service area. Directions 1. On the following pages, score each health need for how well it meets each criteria: 1= Low (Does Not Meet Criteria) 2= Medium (Meets Criteria) 3= High (Meets Criteria Well) 2. Add total scores for each health need and write total in Total Health Topic Score column. 3. Write the total scores for each topic in the table below. 4. Assign ranking to health needs based on total score, with highest score receiving a ranking of 1. If you have tying scores for health topics, assign rank as you see best fit. Please feel free to work in groups and ask questions of HCI staff and your colleagues! Health Topics Total Score Rank Social Environment Transportation Wellness & Lifestyle Diabetes Substance Abuse Children s Health Respiratory Diseases Exercise, Nutrition, & Weight Mental Health & Mental Disorders Access to Health Services If you feel a health topic is missing from this list, please write it here:

53 COMMUNITY HEALTH NEEDS ASSESSMENT - 53 Social Environment Topic Score Health Topic Community Input (Total N=8) Key Themes from Community Warning Indicators from Secondary Data 1.92 Social Environment Lifestyle and family stability; cycle of non-traditional family structure; domestic violence. Many grandparents are raising preschoolers; the parents are out of the picture for whatever reason. Young Children Living Below Poverty Level Children Living Below Poverty Level Single-Parent Households Prioritization Criteria Alignment w/ascension Health Strategies Leave no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Among Sub-Groups? Community Input Key Data Insights Key Themes from Community Input & Secondary Data Indicators indicate this issue affects poor & vulnerable populations Min. of 3 community organizations in Resource List who directly address this health topic. (Refer to Resource Handout) Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 200 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) No race or gender disparity data Cited by 3 out of 8 Key Informants How Well Does Health Topic Relate to Criteria 1=Low 2=Medium 3=High Total Health Topic Score

54 COMMUNITY HEALTH NEEDS ASSESSMENT - 54 Transportation Topic Score Health Topic Community Input (Total N=8) Key Themes from Community Warning Indicators from Secondary Data 1.42 Transportation Free trolley improved things in city, but not in county, trolley schedule/stops may not be convenient; only one cab company takes Medicaid, specialists far away. Workers who Drive Alone to Work Households without a Vehicle Workers Commuting by Public Transportation Prioritization Criteria Alignment w/ascension Health Strategies Leave no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Among Sub-Groups? Community Input Key Data Insights Key Themes from Community Input & Secondary Data Indicators indicate this issue affects poor & vulnerable populations 3 community organizations in Resource List who address this health topic. (Refer to Resource Handout) Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 70 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) No race or gender disparity data in HCI data analysis Cited by 5 out of 8 Key Informants How Well Does Health Topic Relate to Criteria 1=Low 2=Medium 3=High Total Health Topic Score

55 COMMUNITY HEALTH NEEDS ASSESSMENT - 55 Wellness & Lifestyle Topic Score Health Topic Community Input (Total N=8) Key Themes from Community Warning Indicators from Secondary Data 2.03 Wellness & Lifestyle N/a, not mentioned as a top health need/concern during community input process Poor Physical Health Days Self-Reported General Health Assessment: Poor or Fair Life Expectancy for Females Prioritization Criteria Alignment w/ascension Health Strategies Leave no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Among Sub-Groups? Community Input Key Data Insights Not enough data to determine in HCI data synthesis 0 community organizations in Resource List who address this health topic. (Refer to Resource Handout) Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 150 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) No race or gender disparity data in HCI data analysis Cited by 0 out of 8 Key Informants How Well Does Health Topic Relate to Criteria 1=Low 2=Medium 3=High Total Health Topic Score

56 COMMUNITY HEALTH NEEDS ASSESSMENT - 56 Diabetes Topic Score Health Topic Community Input (Total N=8) Key Themes from Community Warning Indicators from Secondary Data 2.02 Diabetes Diabetes frequently mentioned as an issue; lack of preventive services or programs for pre-diabetics. Age-Adjusted Death Rate due to Diabetes Diabetes: Medicare Population Diabetic Screening: Medicare Population Prioritization Criteria Alignment w/ascension Health Strategies Leave no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Among Sub-Groups? Community Input Key Data Insights Not enough data to determine in HCI data synthesis 2 community organizations in Resource List who address this health topic. (Refer to Resource Handout) Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 90 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) African-Americans have ER Rate for diabetes and long-term diabetes complications Cited by 3 out of 8 Key Informants How Well Does Health Topic Relate to Criteria 1=Low 2=Medium 3=High Total Health Topic Score

57 COMMUNITY HEALTH NEEDS ASSESSMENT - 57 Substance Abuse Topic Score Health Topic 1.88 Substance Abuse Community Input (Total N=8) Key Themes from Community Drug and alcohol abuse perceived as high; heroin and meth use on rise; smoking a big issue. Warning Indicators from Secondary Data Liquor Store Density Death Rate due to Drug Poisoning Age-Adjusted Hosp. Rate for Alcohol Abuse Prioritization Criteria Alignment w/ascension Health Strategies Leave no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Among Sub-Groups? Community Input Key Data Insights Not enough data to determine in HCI data synthesis 2 community organizations in Resource List who address this health topic. (Refer to Resource Handout) Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 270 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) Males have hospitalization and ER rates due to alcohol abuse Cited by 7 out of 8 Key Informants How Well Does Health Topic Relate to Criteria 1=Low 2=Medium 3=High Total Health Topic Score

58 COMMUNITY HEALTH NEEDS ASSESSMENT - 58 Children s Health Topic Score Health Topic 1.81 Children s Health Community Input (Total N=8) Key Themes from Community Parenting issues and family stability; nutrition and food allergies; smoking in the home and childhood asthma. Warning Indicators from Secondary Data Children with Low Access to a Grocery Store Age-Adjusted ER Rate due to Pediatric Asthma Low-Income Preschool Obesity Prioritization Criteria Alignment w/ascension Health Strategies Leave no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Among Sub-Groups? Community Input Key Data Insights Some key themes from Community Input & Secondary Data Indicators indicate this issue affects poor & vulnerable populations 5 community organizations in Resource List who address this health topic. (Refer to Resource Handout) Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 350 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) Boys have hospitalization rates for pediatric asthma Cited by 2 out of 8 Key Informants How Well Does Health Topic Relate to Criteria 1=Low 2=Medium 3=High Total Health Topic Score

59 COMMUNITY HEALTH NEEDS ASSESSMENT - 59 Respiratory Diseases Topic Score Health Topic 1.78 Respiratory Diseases Community Input (Total N=8) Key Themes from Community Concern with child asthma rates; smoking rates and smoking during pregnancy. Warning Indicators from Secondary Data Asthma: Medicare Population COPD: Medicare Population Age-Adjusted ER Rate due to Pediatric Asthma Prioritization Criteria Alignment w/ascension Health Strategies Leave no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Among Sub-Groups? Community Input Key Data Insights Not enough data to determine in HCI data synthesis 1 community organization in Resource List who address this health topic. (Refer to Resource Handout) Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 220 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) Women and African-Americans have ER rates due to adult asthma Cited by 1 out of 8 Key Informants How Well Does Health Topic Relate to Criteria 1=Low 2=Medium 3=High Total Health Topic Score

60 COMMUNITY HEALTH NEEDS ASSESSMENT - 60 Exercise, Nutrition, & Weight Topic Score Health Topic 1.77 Exercise, Nutrition & Weight Community Input (Total N=8) Key Themes from Community Obesity; unhealthy habits - overeating, lack of exercise; lack of nutrition availability and education Warning Indicators from Secondary Data Access to Grocery Stores Adults who are Obese Low Income Preschool Obesity Fast Food Restaurant Density Prioritization Criteria Alignment w/ascension Health Strategies Leave no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Among Sub-Groups? Community Input Key Data Insights Not enough data to determine in HCI data synthesis 8 community organizations in Resource List who address this health topic. (Refer to Resource Handout) Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx. 290 Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) No race or gender disparity data in HCI data analysis Cited by 7 out of 8 Key Informants How Well Does Health Topic Relate to Criteria 1=Low 2=Medium 3=High Total Health Topic Score

61 COMMUNITY HEALTH NEEDS ASSESSMENT - 61 Mental Health & Mental Disorders Topic Score Health Topic 1.71 Mental Health & Mental Disorders Community Input (Total N=8) Key Themes from Community Lack of mental and behavioral health services, not enough therapists and psychiatrists; long wait time for appointments; Warning Indicators from Secondary Data Poor Mental Health Days Age-Adjusted Death Rate due to Suicide Depression in Medicare Population Prioritization Criteria Alignment w/ascension Health Strategies Leave no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Among Sub-Groups? Community Input Key Data Insights Not enough data to determine in HCI data synthesis 5 community organizations in Resource List who address this health topic. (Refer to Resource Handout) Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) No race or gender disparity data in HCI data analysis Cited by 6 out of 8 Key Informants How Well Does Health Topic Relate to Criteria 1=Low 2=Medium 3=High Total Health Topic Score

62 COMMUNITY HEALTH NEEDS ASSESSMENT - 62 Access to Health Services Topic Score Health Topic 1.08 Access to Health Services Community Input (Total N=8) Key Themes from Community Difficulties with health system navigation; lack of transportation; issues with understanding new coverage; provider retainment; long wait times; Warning Indicators from Secondary Data Non-Physician Primary Care Rate Prioritization Criteria Alignment w/ascension Health Strategies Leave no one behind & care for poor & vulnerable Opportunity for Partnership Availability of Existing Resources or Programs Availability of Evidence-Based Practices Are There Disparities Among Sub-Groups? Community Input Key Data Insights Some key themes from Community Input indicate this issue affects poor & vulnerable populations 20 community organizations in Resource List who address this health topic. (Refer to Resource Handout) Not covered in HCI Data Analysis does your hospital or any community partners have current resources or programs? Approx Promising or Effective Practices on St. Vincent Data Platform Promising Practices Database (stvincent.org/chna/) No race or gender disparity data in HCI data analysis Cited by 7 out of 8 Key Informants How Well Does Health Topic Relate to Criteria 1=Low 2=Medium 3=High Total Health Topic Score

63 COMMUNITY HEALTH NEEDS ASSESSMENT - 63 Appendix E: Authors Heather Cobb, MPH HCI Public Health Consultant Project Lead Norwin Espiritu, MPH HCI Senior Researcher Lead Project Researcher Mari Rasmussen, MPH HCI Public Health Consultant Primary Data Specialist Nicolia Eldred-Skemp, MPH HCI Research Associate Project Support Claire Lindsay, MPH HCI Research Associate Project Support Yelena Meisel, MPH HCI Director of Consulting Services Project Advisor

64 COMMUNITY HEALTH NEEDS ASSESSMENT - 64 Appendix F: Community Input Report for Howard County The purpose of this work is to provide a report of the input from community members about the health needs of Howard County. It is designed to be either a stand-alone report or appendix to the Community Health Needs Assessment (CHNA) report prepared by the Healthy Communities Institute (HCI). Using results from the CHNA report, the top three system-wide health priorities were identified as: Behavioral Health Access to Health Services Exercise, Nutrition, and Weight For this reason, this report will focus on the interpretation of the sample results for these priorities. NOTE: Behavioral health consists of the health needs: mental health/mental disorders, substance abuse, and smoking/tobacco use. The decision to fold these health needs into one health priority was obtained through group consensus during sessions. Details about the methods and analysis, results, interpretation, and a conclusion comprise the report. METHODS Take the Survey Your Input Counts! survey is an online, opinion tool designed by a collaborative of 4 hospital systems to gather community input about the health needs in Indiana (n=92 counties) (CHNA Hospital Collaborative, 2014). The survey contains 25 closed questions (with optional Comment box) and collects information at the county level from October 1, 2014 to August 31, 2015 (see Supplement - Survey). Questions for this survey and those used by HCI in the CHNA prioritization session and key informant interviews were developed independently of each other. This sample s respondents were not administered the same survey given in the session and interview; however, questions assessing similar health needs were identified. Areas of apparent differences and congruency are highlighted in this report. A total of 7,102 responses were received from Indiana residents. For this report, county (county=howard) and zip codes within the county were used as inclusion criteria for this report (see Supplement Zip Codes) (Zip- Codes.com, 2015). The initial sample included 250 respondents. Exclusion criteria applied to the initial sample were records outside data collection period, zip codes outside of the county, or incomplete/incorrect zip codes (n=1). After applying both criteria, 249 respondents (0.04%) self-identified as Howard County residents. Descriptive statistics were performed using Microsoft Excel and analytic tools within Survey Monkey. RESULTS Table 1 provides demographic results for the sample s respondents. Race and ethnicity were reflective of HCI findings (Health Communities Institute, 2015). Most of the respondents self-identified as Caucasian (n=240, 96.39%). Ethnicity was 0.40% (n=1). The majority of respondents were between years old (n=79, 31.73%). The most frequently reported household income range was $50,000-74,999 (n=66, 27.85%).

65 COMMUNITY HEALTH NEEDS ASSESSMENT - 65 Table 1. Respondent Demographics Characteristics n (%) Race/Ethnicity Age Range (years) Household Income Range American Indian/Alaskan Native Asian/Pacific Islander Black/African American White/Caucasian Hispanic $0-24,999 $25,000-49,999 $50,000-74,999 $75,000-99,000 $100, ,999 $125, ,999 $150, ,999 $175, ,999 $200,000 and up 8 (3.21%) 2 (0.80%) 5 (2.10%) 240 (96.39%) 1 (0.40%) *Respondents=249 (100%) 5 (2.10%) 43 (17.27%) 35 (14.06%) 67 (26.91%) 79 (31.73%) 20 (8.03%) Respondents=249 (100%) 21 (8.86%) 41 (17.30%) 66 (27.85%) 52 (21.94%) 26 (10.97%) 13 (5.49%) 8 (3.38%) 4 (1.69%) 6 (2.53%) Respondents=237 (95%) *The survey allowed multiple selections for race/ethnicity. Respondents were asked in Question 3 to Select the top five health needs in your community (city/town/neighborhood/zip code) (CHNA Hospital Collaborative, 2014). Predetermined needs were presented to respondents who ranked the needs in order from 1 to 5 (top health need=1, descending scale to 5). The majority (n=210, 84.34%) ranked mental health as the top health need in Howard County. The remaining four identified health needs were substance abuse (n=208, 83.53%), obesity (n=180, 72.29%), access to healthcare (n=144, 57.83%), and smoking and tobacco use (n=141, 56.63%). Aggregate rankings for the other health needs are provided in Figure 1.

66 COMMUNITY HEALTH NEEDS ASSESSMENT Figure 1. Frequencies of Reported Health Needs Frequency Mental health (depression, anxiety, sadness)=210 Substance abuse (alcohol, other drugs)=208 Obesity=180 Access to healthcare=144 Smoking and tobacco use=141 Chronic disease (cancer, heart disease, etc.)=135 Dental/oral health=60 Prenatal health=38 Injury prevention=23 Hearing/vision problems=16 Infant mortality=13 Asthma=11 Question 5 of the survey asked respondents to Select the top 3 ways to improve mental health in your community (CHNA Hospital Collaborative, 2014). Response scheme was similar to Question 3. Ways to improve mental health were presented in a list format and respondents ranked each way in order from 1 to 3 (top way=1, descending scale to 3). Most respondents indicated that an increase in programming for mental health problems was the top way to improve mental health in Howard County (n=164, 65.86%). The two other ways that rose to the top were increases in awareness of mental health services (n=121, 48.59%) and the number of treatment facilities (n=116, 46.49%). Findings for the remaining ways to improve mental health are provided in Figure Figure 2. Frequencies of Reported Ways to Improve Mental Health Frequency Increase programs for mental health problems (depression, anxiety, and suicide)=164 Increase awareness of mental health services=121 Increase number of treatment facilities=1116 Increase substance abuse program and resources=111 Increase mental health screenings from doctor=74 Increase prevention programs=72 Increase mental health treatment from doctor=54 Not a problem=9 9

67 COMMUNITY HEALTH NEEDS ASSESSMENT - 67 Access to health services was assessed in Question 12 (see Figure 3). Respondents were presented a list of potential challenges to their household in receiving healthcare, then ranked them in order from 1 to 3 (top challenge=1, descending scale to 3). No problems receiving health services (n=105, 42.16%) was the most frequently reported response. About one-third indicated that the cost of co-pay and limited hours at doctor s office were challenges to getting health services (n=82, 32.29%, respectively). A small percentage of the respondents perceived transportation to be a challenge to receiving health services (n=5, 2%). Figure 3. Perceived Challenges to Receiving Health Services Question 4 collected respondents opinions about reasons why obesity was a health problem in their community. Respondents ranked perceived reasons in order from 1 to 3 (top challenge=1, descending scale to 3). Most respondents indicated that an unhealthy diet and exercise habits was the main reason for obesity in Howard County (n=235, 94.38%). The two other reasons that rose to the top were access to healthy and affordable foods (n=172, 69.08%) and not promoting healthy habits in the community, schools, and churches (n=133, 53.41%). Findings for the remaining opinions about reasons for obesity are provided in Figure 4.