NEVADA REGIONAL MEDICAL CENTER NEVADA, MISSOURI

Transcription

1 NEVADA REGIONAL MEDICAL CENTER NEVADA, MISSOURI 2013 COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION PLAN ADOPTED BY BOARD RESOLUTION JUNE 25, Respnse t Schedule H (Frm 990) Part V B 2 and sectin 501(r)1

2 Dear Cmmunity Resident: Nevada Reginal Medical Center (NRMC) welcmes yu t review this dcument as we strive t meet the health and medical needs in ur cmmunity. All nt-fr-prfit hspitals are required t develp this reprt in cmpliance with the Affrdable Care Act. The 2013 identifies lcal health and medical needs and prvides a plan t indicate hw NRMC will respnd t such needs. This dcument suggests areas where ther lcal rganizatins and agencies might wrk with us t achieve desired imprvements and illustrates ne way we, NRMC, are meeting ur bligatins t efficiently deliver medical services. NRMC will cnduct this effrt at least nce every three years. As yu review this plan, please see if, in yur pinin, we have identified the primary needs and if ur intended respnse shuld make apprpriate needed imprvements. We d nt have adequate resurces t slve all the prblems identified. Sme issues are beynd the missin f the hspital and actin is best suited fr a respnse by thers. Sme imprvements will require persnal actins by individuals rather than the respnse f an rganizatin. We view this as a plan fr hw we, alng with ther rganizatins and agencies, can cllabrate t bring the best each has t ffer t address the mre pressing, identified needs. The reprt is a respnse t a federal requirement f nt-fr-prfit hspital s t identify the cmmunity benefit it prvides in respnding t dcumented cmmunity need. Ftntes are prvided t answer specific tax frm questins; fr mst purpses, they may be ignred. Of greater imprtance, hwever, is the ptential fr this reprt t guide ur actins and the effrts f thers t make needed health and medical imprvements. Please think abut hw t help us imprve the health and medical services ur area needs. I invite yur respnse t this reprt. We all live and wrk in this cmmunity tgether and ur cllective effrts can make living here mre enjyable and healthier. Thank Yu

3 Nevada, Missuri Cmmunity Health Need Assessment Page i Table f Cntents Executive Summary... 1 Prject Objectives... 2 Brief Overview f... 2 Apprach... 4 Findings... 9 Definitin f Area Served by the Hspital Facility Demgraphic f the Cmmunity Leading Causes f Death Primary and Chrnic Disease Needs and Health Issues f Uninsured Persns, Lw-Incme Persns, and Minrity Grups Findings Cnclusins frm Public Input t Summary f Observatins frm Nevada Cunty Cmpared t All Other Missuri Cunties and Independent City, in Terms f Cmmunity Health Needs Summary f Observatins frm Vernn Cunty Peer Cmparisns Cnclusins frm the Demgraphic Analysis Cmparing Vernn Cunty t Natinal Averages 22 Key Cnclusins frm Cnsideratin f the Other Statistical Data Examinatins Existing Health Care Facilities, Resurces and Implementatin Plan Significant Needs Other Needs Identified During the CHNA Prcess Overall Cmmunity Need Statement and Pririty Ranking Scre: Appendices Appendix A Lcal Expert Advisr Opinin Abut Significant Needs Appendix B Prcess t Identify and Priritize Cmmunity Need Appendix C Illustrative Schedule H (Frm 990) Part V B Ptential Respnse... 60

4 Nevada, Missuri Page 1 EXECUTIVE SUMMARY

5 Nevada, Missuri Page 2 Executive Summary Nevada Reginal Medical Center ("NRMC" r the "Hspital") is rganized as a nt-fr-prfit hspital. A (CHNA) is part f the required hspital dcumentatin f Cmmunity Benefit under the Affrdable Care Act (ACA), required f all ntfr-prfit hspitals as a cnditin f retaining tax-exempt status. A CHNA assures NRMC identifies and respnds t the primary health needs f its residents. This study is designed t cmply with standards required f a nt-fr-prfit hspital 2. Tax reprting citatins in this reprt are superseded by the mst recent 990 H filings made by the hspital. In additin t cmpleting a CHNA, and funding necessary imprvements, a nt-fr-prfit hspital must dcument the fllwing: Financial assistance plicy and plicies relating t emergency medical care; Billing and cllectins; and Charges fr medical care. Further explanatin and specific regulatins are available frm Health and Human Services (HHS), the Internal Revenue Service (IRS), and the U.S. Department f the Treasury 3. Prject Objectives NRMC partnered with Qurum Health Resurces (QHR) fr the fllwing 4 : Cmplete a CHNA reprt, cmpliant with Treasury IRS; Prvide the Hspital with infrmatin required t cmplete the IRS 990h schedule; and Prduce the infrmatin necessary fr the Hspital t issue an assessment f cmmunity health needs and dcument its intended respnse. Brief Overview f Typically, nn-prfit hspitals qualify fr tax-exempt status as a Charitable Organizatin, described in Sectin 501(c) 3 f the Internal Revenue Cde; hwever, the term 'Charitable Organizatin' is undefined. Prir t the passage f Medicare, charity was generally recgnized as care prvided t the less frtunate withut means t pay. With the intrductin f Medicare, the gvernment met the burden f prviding cmpensatin fr such care. 2 Part 3 Treasury/IRS Ntice Requirements and 3 As f the date f this reprt Ntice f prpsed rulemaking was published 6/26/2012 and available at 4 Part 3 Treasury/IRS Sectin 3.03 (2) third party disclsure ntice

6 Nevada, Missuri Page 3 In respnse, IRS Revenue ruling eliminated the Charitable Organizatin standard and established the Cmmunity Benefit Standard as the basis fr tax-exemptin. Cmmunity Benefit determines if hspitals prmte the health f a brad class f individuals in the cmmunity, based n factrs including: Emergency rm pen t all, regardless f ability t pay; Surplus funds used t imprve patient care, expand facilities, train, etc.; Cntrlled by independent civic leaders; and All available and qualified physicians are privileged. Specifically, the IRS requires: Effective n tax years beginning after March 23, 2012, each 501(c) (3) hspital facility is required t cnduct a CHNA at least nce every three taxable years and adpt an implementatin strategy t meet the cmmunity needs identified thrugh such assessment; The assessment may be based n current infrmatin cllected by a public health agency r nn-prfit rganizatin and may be cnducted tgether with ne r mre ther rganizatins, including related rganizatins; The assessment prcess must take int accunt input frm persns wh represent the brad interests f the cmmunity served by the hspital facility, including thse with special knwledge r expertise f public health issues; The hspital must disclse in its annual infrmatin reprt t the IRS (Frm 990 and related schedules) hw it is addressing the needs identified in the assessment and, if all identified needs are nt addressed, the reasns why (e.g., lack f financial r human resurces); Each hspital facility is required t make the assessment widely available and ideally dwnladable frm the hspital web site; Failure t cmplete a CHNA in any applicable three-year perid results in a penalty t the rganizatin f $50,000. Fr example, if a facility des nt cmplete a CHNA in taxable years ne, tw, r three, it is subject t the penalty in year three. If it then fails t cmplete a CHNA in year fur, it is subject t anther penalty in year fur (fr failing t satisfy the requirement during the three-year perid beginning with taxable year tw and ending with taxable year fur); and An rganizatin that fails t disclse hw it is meeting needs identified in the assessment is subject t existing incmplete return penalties. 5 This reprt was develped under the guidance f IRS/Treasury as mdified by the Draft Federal Regulatins published in the April 5, 2013 Federal Register. 5 Sectin 6652

7 Nevada, Missuri Page 4 APPROACH

8 Nevada, Missuri Page 5 T cmplete a CHNA, the hspital must: Apprach Describe the prcesses and methds used t cnduct the assessment; Surces f data and dates retrieved; Analytical methds applied; Infrmatin gaps impacting ability t assess the needs; and Identificatin f with whm the Hspital cllabrated. The prpsed regulatins prvide that a hspital facility s CHNA reprt will be cnsidered t describe hw the hspital facility tk int accunt input if the CHNA reprt: (1) Summarizes, in general terms, the input prvided and hw and ver what time perid such input was prvided; (2) Prvides the names f rganizatins prviding input and summarizes the nature and extent f the rganizatin s input; and (3) Describes the medically underserved, lw incme, r minrity ppulatins being represented by rganizatins r individuals prviding input. Describe the prcess and criteria used in priritizing health needs; Describe existing resurces available t meet the cmmunity health needs; and Identify the prgrams and resurces the hspital facility plans t cmmit t meeting each identified need and the anticipated impact f thse prgrams and resurces n the health need. QHR takes a cmprehensive apprach t assess cmmunity health needs. We perfrm several independent data analyses based n secndary surce data, augment this with lcal survey data, and reslve any data incnsistency r discrepancies frm the cmbined pinins frmed frm lcal experts. We rely n secndary surce data - and mst secndary surces use the cunty as the smallest unit f analysis. We asked ur lcal expert area residents, t nte if they perceived the prblems, r needs, identified by secndary surces t exist in their prtin f the cunty. 6 Mst data used in the analysis is available frm public internet surces. Critical data needed t address specific regulatins r develped by the individuals cperating with us in this study is displayed in the reprt fr the appendix. Data surces include: 7 6 Respnse t Schedule H (Frm 990) Part V B 1 i 7 Respnse t Schedule H (Frm 990) Part V B 1 d

9 Nevada, Missuri Page 6 Web Site r Data Surce Data Element Date Accessed Data Date Truven (frmerly knwn as Thmsn) Market Planner and and iweb.nhpc.rg Assessment f health needs f Vernn Cunty cmpared t all Missuri cunties Assessment f health needs f Vernn Cunty cmpared t its natinal set f peer cunties Assess characteristics f the hspital s primary service area, at a zip cde level, based n classifying the ppulatin int varius sci-ecnmic grups, determining the health and medical tendencies f each grup and creating an aggregate cmpsitin f the service area accrding t the cntributin each grup makes t the entire area; and, t access ppulatin size, trends and sci-ecnmic characteristics; T identify the availability f Palliative Care prgrams and services in the area T identify the availability f hspice prgrams in the cunty February 15, t 2010 February 15, t 2009 February 15, February 15, February 15, T examine the prevalence f diabetic cnditins and change in life expectancy February 15, thrugh T determine availability f specific health resurces February 15, T examine area trends fr heart disease and strke T identify ptential needs amng a variety f resurce and health need metrics T identify applicable manpwer shrtage designatins February 15, t 2009 February 15, t 2010 February 15,

10 Nevada, Missuri Page 7 Web Site r Data Surce Data Element Date Accessed Data Date T determine relative imprtance amng 15 tp causes f death February 15, published 11/29/12 In additin, we deplyed a CHNA Rund 1 survey t ur Lcal Expert Advisrs t gain lcal input as t lcal health needs and the needs f pririty ppulatins. Lcal Expert Advisrs were lcal individuals selected t cnfrm t the input required by the Federal guidelines and regulatins; 8 We received cmmunity input frm 21 Lcal Expert Advisrs. Survey respnses started Mnday March 11, 2013 at 9:15 a.m. and ended with the last respnse n Tuesday, March 19, 2013 at 4:05 p.m.; and Infrmatin analysis augmented by lcal pinins shwed hw Vernn Cunty relates t its peers in terms f primary and chrnic needs and ther issues f uninsured persns, lwincme persns, and minrity grups; respndents cmmented n if they believe certain ppulatin grups (r peple with certain situatins) need help t imprve their cnditin, and if s, wh needs t d what 9. When the analysis was cmplete, we put the infrmatin and summary cnclusins befre ur lcal grup f experts 10 wh were asked t agree r disagree with the summary cnclusins. They were free t augment ptential cnclusins with additinal cmments f need; and new needs did emerge frm this exchange. 11 Cnsultatin with 18 lcal experts ccurred again via an internet-based survey (explained belw) during the perid beginning Wednesday, April 10, :18 a.m. and ending Wednesday April 17, :38 a.m. With the prir steps identifying ptential cmmunity needs, the lcal experts participated in a structured cmmunicatin technique called a Delphi methd, riginally develped as a systematic, interactive frecasting methd which relies n a panel f experts. Experts answer questinnaires in a series f runds. We cntemplated and implemented ne rund as referenced during the abve dates. After each rund, we prvide an annymus summary f the experts frecasts frm the previus rund, as well as reasns prvided fr their judgments. The prcess encurages experts t revise their earlier answers in light f the replies f ther members f their panel. Typically, this prcess decreases the range f answers and mves the expert pinins tward a cnsensus "crrect" answer. The prcess stps when we identify the mst pressing, highest pririty cmmunity needs. In the NRMC prcess, each lcal expert allcated 100 pints amng all identified needs, having the pprtunity t intrduce needs previusly unidentified and challenge cnclusins develped frm 8 Respnse t Schedule H (Frm 990) Part V B 1 h; cmplies with 501(r)(3)(B)(i) 9 Respnse t Schedule H (Frm 990) Part V B 1 f 10 Part respnse t Schedule H (Frm 990) Part V B 3 11 Respnse t Schedule H (Frm 990) Part V B 1 e

11 Nevada, Missuri Page 8 the data analysis. A rank rder f pririties emerged, with sme needs receiving nne r virtually n supprt and ther needs receiving identical pint allcatins. We dichtmized the rank rder int tw grups: high pririty needs and lw pririty needs. The determinatin f the break pint - high as ppsed t lw - was a qualitative interpretatin by QHR and the NRMC executive team where a reasnable break pint in rank ccurred, indicated by the weight amunt f pints each ptential need received and the number f lcal experts allcating any pints t the need. When presented t the NRMC executive team, the dichtmized need rank rder identified which needs the Hspital cnsidered high respnsibility t respnd vs. lw respnsibility t respnd. The result prvided a matrix f needs and guided the Hspital in develping its implementatin respnse 12. The prpsed regulatins prvide that in rder t assess the health needs f the cmmunity it serves, a hspital facility must identify significant health needs f the cmmunity, priritize thse health needs, and identify ptential measures and resurces (such as prgrams, rganizatins, and facilities in the cmmunity) available t address the health needs 13. The prpsed regulatins clarify a CHNA need nly identify significant health needs and need nly priritize, and therwise assess, thse significant health needs identified. A hspital facility may determine whether a health need is significant based n all f the facts and circumstances present in the cmmunity it serves 14. By definitin, the high pririty needs are deemed Significant needs as defined by the regulatins. 12 Respnse t Schedule H (Frm 990) Part V Sectin B 6 g, h and Part V B 1 g 13 Draft regulatins page Draft regulatins page 32

12 Nevada, Missuri Page 9 FINDINGS

13 Nevada, Missuri Page 10 Findings Definitin f Area Served by the Hspital Facility 15 Bates Cunty St. Clair Cunty Kansas Cedar Cunty Bartn Cunty NRMC, in cnjunctin with QHR, defines its service area as Nevada Cunty in Missuri, which includes the fllwing ZIP cdes: Brnaugh Deerfield Harwd Mil Mundville Nevada Richards Schell City Sheldn Walker In 2011, the Hspital received 76.9% f its patients frm this area Respnds t IRS Frm 990 (h) Part V B 1 a 16 Truven MEDPAR patient rigin data fr the hspital; Respnds t IRS Frm 990 (h) Part V B 1 a

14 Nevada, Missuri Page 11 Demgraphic f the Cmmunity 17 The 2012 ppulatin fr Nevada Cunty is estimated t be 20, and expected t increase at a rate f 2.1%. This is in cntrast t the 3.9% natinal rate f grwth and the Missuri grwth rate f 3.3%. Nevada Cunty in 2017 anticipates a ppulatin f 20,616. Accrding t the ppulatin estimates utilized by Truven, prvided by The Nielsen Cmpany, the 2012 median age fr the cunty is 38.8 years, which is lder than the Missuri median age (37.5 years) and the natinal median age (36.8 years). The 2012 Median Husehld Incme fr the area is $33,548 which is lwer than the Missuri median incme f $44,605 and the natinal median incme f $49,559. Median Husehld Wealth and Medial Hme values fllw the same pattern, being belw Missuri and Natinal values. Vernn s unemplyment rate as f March 2013 was 5.4% 19, which is better than the 6.7% Missuri statewide and the cnsiderably better than the natinal civilian unemplyment rate f 7.6%. The prtin f the ppulatin in the cunty ver 65 is 16.5%, well abve the Missuri average f 13.7%. The prtin f the ppulatin f wmen f childbearing age is 18.2%, cnsiderably belw the Missuri 19.9% value and natinal average f 20.1%. 95.2% f the ppulatin is White nn- Hispanic. All thers cnstitute the largest minrity at 2%. The Hispanic ppulatin cmprises 1.7% f the ttal. DEMOGRAPHIC CHARACTERISTICS 2000 Ttal Ppulatin 2012 Ttal Ppulatin 2017 Ttal Ppulatin % Change Average Husehld Incme $42,864 $67,315 POPULATION DISTRIBUTION Demgraphics Expert Demgraphic Snapsht Area: Vernn CO Level f Gegraphy: ZIP Cde Selected Area USA % Change 19, ,421,906 Ttal Male Ppulatin 9,802 10, % 20, ,095,504 Ttal Female Ppulatin 10,394 10, % 20, ,256,835 Females, Child Bearing Age (15-44) 3,668 3, % 2.1% 3.9% HOUSEHOLD INCOME DISTRIBUTION Age Distributin Incme Distributin Age Grup 2012 % f Ttal 2017 % f Ttal USA 2012 % f Ttal 2012 Husehld Incme HH Cunt % f Ttal USA % f Ttal , % 4, % 20.2% <$15K 1, % 13.0% % % 4.3% $15-25K 1, % 10.8% , % 1, % 9.7% $25-50K 2, % 26.7% , % 2, % 13.5% $50-75K 1, % 19.5% , % 4, % 28.1% $75-100K % 11.9% , % 2, % 11.4% Over $100K % 18.2% 65+ 3, % 3, % 12.9% Ttal 20, % 20, % 100.0% Ttal 8, % 100.0% EDUCATION LEVEL RACE/ETHNICITY Educatin Level Distributin Race/Ethnicity Distributin USA USA 2012 Adult Educatin Level Pp Age 25+ % f Ttal % f Ttal Race/Ethnicity 2012 Pp % f Ttal % f Ttal Less than High Schl % 6.3% White Nn-Hispanic 19, % 62.8% Sme High Schl 1, % 8.6% Black Nn-Hispanic % 12.3% High Schl Degree 6, % 28.7% Hispanic % 17.0% Sme Cllege/Assc. Degree 3, % 28.5% Asian & Pacific Is. Nn-Hispanic % 5.0% Bachelr's Degree r Greater 1, % 27.8% All Others % 2.9% Ttal 13, % 100.0% Ttal 20, % 100.0% 2012 The Nielsen Cmpany, 2013 Truven Health Analytics Inc. 17 Respnds t IRS Frm 990 (h) Part V B 1 b 18 All ppulatin infrmatin, unless therwise cited, surced frm Truven (frmally Thmsn) Market Planner 19

15 Nevada, Missuri Page Demgraphic Snapsht Charts Ppulatin Distributin by Age Grup Current Husehlds by Incme Grup 2,411 3,335 5,197 4, ,788 2, ,347 2,584 1,604 1,446 <$15K $15-25K $25-50K $50-75K $75-100K Over $100K Ppulatin Age 25+ by Educatin Level Ppulatin Distributin by Race/Ethnicity 1,794 3, ,236 6,146 Less than High Schl Sme High Schl High Schl Degree Sme Cllege/Assc. Degree Bachelr's Degree r Greater ,219 White Nn- Hispanic Black Nn- Hispanic Hispanic Asian & Pacific Is. Nn-Hispanic All Others 2012 Benchmarks Area: Vernn CO Level f Gegraphy: ZIP Cde Ppulatin 65+ Females Median Median Median % Ppulatin Median % f Ttal % Change % f Ttal % Change Husehld Husehld Hme Area Change Age Ppulatin Ppulatin Incme Wealth Value USA 3.9% % 15.5% 20.1% -0.9% $49,559 $54,682 $167,021 Missuri 3.3% % 14.1% 19.9% -0.5% $44,605 $55,513 $127,011 Selected Area 2.1% % 10.2% 18.2% -0.5% $33,548 $41,178 $88,313 Demgraphics Expert 2.7 DEMO0003.SQP 2012 The Nielsen Cmpany, 2013 Truven Health Analytics Inc. The ppulatin als was examined accrding t characteristics presented in the Claritas Prizm custmer segmentatin data. This system segments the ppulatin int 66 demgraphically and behavirally distinct grups. Each grup, based n annual survey data, is dcumented as exhibiting specific health behavirs. The makeup f the service area, accrding t the mix f Prizm segments and its characteristics, is cntrasted t the natinal ppulatin averages t discern the fllwing table f prbable lifestyle and medical cnditins present in the ppulatin. Items with red text are viewed as statistically imprtant adverse ptential findings. Items with blue text are viewed as statistically imprtant ptential beneficial findings. Items with black text are viewed as either nt statistically different frm the natinal nrmal situatin r nt being a favrable nr an unfavrable cnsideratin in ur use f the infrmatin.

16 Nevada, Missuri Page 13 Health Service Tpic Weight / Lifestyle Demand as % f Natinal % f Ppulatin Affected Health Service Tpic Demand as % f Natinal % f Ppulatin Affected BMI: Mrbid/Obese 109.0% 27.8% Rutine Screen: Cardiac Stress 2yr 89.6% 14.0% Vigrus Exercise 95.9% 48.8% Chrnic High Chlesterl 99.6% 22.3% Chrnic Diabetes 128.4% 13.3% Rutine Chlesterl Screening 85.9% 43.7% Healthy Eating Habits 86.9% 25.7% Chrnic High Bld Pressure 118.2% 31.1% Very Unhealthy Eating Habits 149.5% 4.1% Chrnic Heart Disease 129.8% 10.9% Behavir I Will Travel t Obtain Medical Care 97.3% 28.9% FP/GP: 1+ Visit 103.1% 91.1% I Fllw Treatment Recmmendatins 82.1% 33.2% Used Midlevel in last 6 Mnths 105.5% 43.9% I am Respnsible fr My Health 90.9% 59.6% OB/Gyn 1+ Visit 88.7% 41.0% Pulmnary Chrnic COPD 121.9% 5.7% Ambulatry Surgery last 12 Mnths 98.6% 19.0% Tbacc Use: Cigarettes 123.8% 32.1% Use Internet t Talk t MD 74.3% 10.8% Chrnic Allergies 111.1% 24.8% Facebk Opinins 80.3% 8.3% Cancer Mammgraphy in Past Yr 94.9% 43.1% Lked fr Prvider Rating 84.7% 12.3% Cancer Screen: Clrectal 2 yr 89.8% 22.1% Charitable Cntrib: Hsp/Hsp Sys 87.1% 20.8% Cancer Screen: Pap/Cerv Test 2 yr 81.3% 49.1% Charitable Cntrib: Other Health Org 81.4% 31.7% Rutine Screen: Prstate 2 yr 87.1% 27.8% HSA/FSA: Emplyer Offers 96.3% 50.2% Orthpedic Chrnic Lwer Back Pain 127.4% 28.7% Emergency Rm Use 112.8% 38.3% Chrnic Osteprsis 125.7% 12.2% Urgent Care Use 99.7% 23.6% Heart Rutine Services Internet Usage Misc Emergency Service

17 Nevada, Missuri Page 14 Leading Causes f Death Cause f Death Rank amng all cunties in MO Rate f Death per 100,000 age adjusted MO Rank Vernn C. Rank Cnditin (#1 rank = wrst in state) MO Vernn C. Observatin 1 1 Heart Disease 28 f Higher than expected 2,10,12,16,24,27, 29,30,31,32,34, 35,36,42 2 Cancer 27 f Higher than expected 15,21,22 3 Accidents 22 f Higher than expected 4 4 Strke 80 f As expected 3 5 Lung 70 f As expected 7 6 Diabetes 3 f Higher than expected 8 7 Kidney 35 f Higher than expected 5 8 Alzheimer's 59 f As expected 9 9 Flu - Pneumnia 71 f As expected Suicide 41 f Higher than expected Bld Pisning 101 f Lwer than expected Hypertensin 60 f Lwer than expected Liver 97 f Lwer than expected Parkinsn's 90 f Lwer than expected Hmicide 95 f Lwer than expected

18 Nevada, Missuri Page 15 Primary and Chrnic Disease Needs and Health Issues f Uninsured Persns, Lw- Incme Persns, and Minrity Grups Sme infrmatin is available t describe the size and cmpsitin f varius uninsured persns, lw incme persns, minrity grups, and ther vulnerable ppulatin segments. Specific studies identifying needs f such grups, distinct frm the general ppulatin at a cunty unit f analysis, are nt readily available frm secndary surces. The Natinal Healthcare Disparities Reprt results frm a Cngressinal directive t the Agency fr Healthcare Research and Quality (AHRQ). This prductin is an annual reprt t track disparities related t "racial factrs and sciecnmic factrs in pririty ppulatins." The emphasis is n disparities related t race, ethnicity, and sciecnmic status. The directive includes a charge t examine disparities in "pririty ppulatins," which are grups with unique health care needs r issues that require special attentin. 20 Natinally, this reprt bserves the fllwing trends: Measures fr which Blacks were wrse than Whites and are getting better: Diabetes Hspital admissins fr shrt-term cmplicatins f diabetes per 100,000 ppulatin; HIV and AIDS New AIDS cases per 100,000 ppulatin age 13 and ver; and Functinal Status Preservatin and Rehabilitatin Female Medicare beneficiaries age 65 and ver wh reprted ever being screened fr steprsis with a bne mass r bne density measurement. Measures fr which Blacks were wrse than Whites and staying the same: Cancer Breast cancer diagnsed at advanced stage per 100,000 wmen age 40 and ver ; breast cancer deaths per 100,000 female ppulatin per year; adults age 50 and ver wh ever received clrectal cancer screening; clrectal cancer diagnsed at advanced stage per 100,000 ppulatin age 50 and ver; clrectal cancer deaths per 100,000 ppulatin per year; Diabetes Hspital admissins fr lwer extremity amputatins per 1,000 ppulatin age 18 and ver with diabetes; Maternal and Child Health Children ages 2-17 wh had a dental visit in the calendar year; Children ages mnths wh received all recmmended vaccines; Mental Health and Substance Abuse Adults with a majr depressive episde in the last 12 mnths wh received treatment fr depressin in the last 12 mnths; peple age 12 and ver treated fr substance abuse wh cmpleted treatment curse;

19 Nevada, Missuri Page 16 Respiratry Diseases Adults age 65 and ver wh ever received pneumcccal vaccinatin; hspital patients with pneumnia wh received recmmended hspital care; Supprtive and Palliative Care High-risk lng-stay nursing hme residents with pressure sres; shrt-stay nursing hme residents with pressure sres; adult hme health care patients wh were admitted t the hspital; hspice patients wh received the right amunt f medicine fr pain; Timeliness Adults wh needed care right away fr an illness, injury, r cnditin in the last 12 mnths wh gt care as sn as wanted; emergency department visits where patients left withut being seen; and Access Peple with a usual primary care prvider; peple with a specific surce f nging care. Measures fr which Asians were wrse than Whites and getting better: Cancer Adults age 50 and ver wh ever received clrectal cancer screening; and Patient Safety Adult surgery patients wh received apprpriate timing f antibitics. Measures fr which Asians were wrse than Whites and staying the same: Respiratry Diseases Adults age 65 and ver wh ever received pneumcccal vaccinatin; hspital patients with pneumnia wh received recmmended hspital care; and Access Peple with a usual primary care prvider. Measures fr which American Indians and Alaska Natives were wrse than Whites fr mst recent year and staying the same: Heart Disease Hspital patients with heart failure wh received recmmended hspital care; HIV and AIDS New AIDS cases per 100,000 ppulatin age 13 and ver; Respiratry Diseases Hspital patients with pneumnia wh received recmmended hspital care; Functinal Status Preservatin and Rehabilitatin Female Medicare beneficiaries age 65 and ver wh reprted ever being screened fr steprsis with a bne mass r bne density measurement; Supprtive and Palliative Care Hspice patients wh received the right amunt f medicine fr pain; high-risk, lng-stay nursing hme residents with pressure sres; adult hme health care patients wh were admitted t the hspital; and Access Peple under age 65 with health insurance.

20 Nevada, Missuri Page 17 Measures fr which American Indians and Alaska Natives were wrse than Whites fr mst recent year and getting wrse: Cancer Adults age 50 and ver wh ever received clrectal cancer screening; and Patient safety Adult surgery patients wh received apprpriate timing f antibitics. Measures fr which Hispanics were wrse than nn-hispanic Whites fr mst recent year and getting better: Maternal and Child Health Children ages 2-17 wh had a dental visit in the calendar year; Lifestyle Mdificatin Adult current smkers with a checkup in the last 12 mnths wh received advice t quit smking; adults with besity wh ever received advice frm a health prvider abut healthy eating; and Functinal Status Preservatin and Rehabilitatin Female Medicare beneficiaries age 65 and ver wh reprted ever being screened fr steprsis with a bne mass r bne density measurement. Measures fr which Hispanics were wrse than nn-hispanic Whites fr mst recent year and staying the same: Cancer Wmen age 40 and ver wh received a mammgram in the last 2 years; adults age 50 and ver wh ever received clrectal cancer screening; Diabetes Adults age 40 and ver with diagnsed diabetes wh received all three recmmended services fr diabetes in the calendar year; Heart Disease Hspital patients with heart attack and left ventricular systlic dysfunctin wh were prescribed angitensin-cnverting enzyme inhibitr r angitensin receptr blcker at discharge; hspital patients with heart failure wh received recmmended hspital care; HIV and AIDS New AIDS cases per 100,000 ppulatin age 13 and ver; Mental Health and Substance Abuse Adults with a majr depressive episde in the last 12 mnths wh received treatment fr depressin in the last 12 mnths; Respiratry Disease Adults age 65 and ver wh ever received pneumcccal vaccinatin; hspital patients with pneumnia wh received recmmended hspital care; Lifestyle Mdificatin Adults with besity wh ever received advice frm a health prvider t exercise mre; Supprtive and Palliative Care Lng-stay nursing hme residents with physical restraints; high-risk, lng-stay nursing hme residents with pressure sres; shrt-stay

21 Nevada, Missuri Page 18 nursing hme residents with pressure sres; adult hme health care patients wh were admitted t the hspital; hspice patients wh received the right amunt f medicine fr pain; Patient Safety Adult surgery patients wh received apprpriate timing f antibitics; Timeliness Adults wh needed care right away fr an illness, injury, r cnditin in the last 12 mnths wh gt care as sn as wanted; Patient Centeredness Adults with ambulatry visits wh reprted pr cmmunicatin with health prviders; children with ambulatry visits wh reprted pr cmmunicatin with health prviders; and Access Peple under age 65 with health insurance; peple under age 65 wh were uninsured all year; peple with a specific surce f nging care; peple with a usual primary care prvider; peple unable t get r delayed in getting needed care due t financial r insurance reasns. Measures fr which Hispanics were wrse than nn-hispanic Whites fr mst recent year and getting wrse: Maternal and Child Health Children ages 3-6 wh ever had their visin checked by a health prvider. We asked a specific questin t ur Lcal Expert Advisrs abut unique needs f pririty ppulatins. We reviewed their respnse t identify if any f the abve trends were bvius in the service area. Accrdingly, we place great reliance n the cmmentary received t identify unique ppulatin needs t which we shuld respnd. Specific pinins frm the Lcal Expert Advisrs are summarized as fllws 21 : Lack f health care insurance, Medicaid acceptance, r the affrdability f care; Obesity related prblems; and Disease educatin needs. Statistical infrmatin abut special ppulatins fllws: 21 All cmments and the analytical framewrk behind develping this summary appear in Appendix A.

22 Nevada, Missuri Page 19

23 Nevada, Missuri Page 20 Findings Upn cmpletin f the CHNA, QHR identified several issues within the NRMC cmmunity: Cnclusins frm Public Input t Our grup f 21 Lcal Expert Advisrs participated in an n-line survey t ffer pinins abut their perceptins f cmmunity health needs and ptential needs f unique ppulatins. Respnses were first btained t the questin: What d yu believe t be the mst imprtant health r medical issue cnfrnting the residents f yur Cunty? In summary, we receive the fllwing cmmentary regarding the mre imprtant health r medical issues: Prblems relating t being able t access affrdable care Lack f Medicaid prviders with reference t dentist shrtage in particular Obesity Mental health issues Respnses were then btained t the questin: D yu perceive there are any primary and/r chrnic disease needs, as well as ptential health issues, f uninsured persns, lw-incme persns, minrity grups and/r ther ppulatin grups (i.e. peple with certain situatins) which need help r assistance in rder t imprve? If yu believe any situatin as described exists, please als indicate wh yu think needs t d what? In summary, we received the fllwing cmmentary regarding the mre imprtant health r medical issues: Lack f health care insurance, Medicaid acceptance, r the affrdability f care Obesity related prblems Disease educatin needs Summary f Observatins frm Nevada Cunty Cmpared t All Other Missuri Cunties and Independent City, in Terms f Cmmunity Health Needs In general, Vernn Cunty residents are smewhat wrse than average cmpared t the healthiest in Missuri. In a health status classificatin termed "Health Outcmes", Vernn ranks number 82 amng the 115 Missuri ranked cunties and independent city (best being #1). Typifying the prblem, Premature Death (deaths prir t age 75) is significantly higher than average fr Missuri, and the natinal average. The Vernn rate has been stable during the last 20 years but values fr Missuri and the natin have been declining (a desirable trend). Mst Mrbidity values are at MO avg, except lw birth weight which is better than MO avg., achieving the natinal gal. In anther health status classificatin "Health Factrs", Vernn Cunty ranks marginally wrse, ranking number 85 amng the 115 Missuri cunties and independent city. Smking, besity, physical inactivity and teen birth rate are at the MO avg. but abve natinal gals. The Mtr

24 Nevada, Missuri Page 21 vehicle death rate is significantly abve (wrse than) the MO avg. and Natinal gal. Sexually transmitted disease rate is cnsiderable belw (better than) the MO avg. but it is still duble the natinal gal. Uninsured rate is significantly abve the MO avg. and the Natinal gal. Dentist per ppulatin is adverse as it has twice as many peple per dentist as the MO avg. and is almst three times natinal gal. Physician per ppulatin als is adverse as Vernn has 57% mre peple per dctr than the MO avg. and is mre than duble the natinal gal. Mammgraphy and diabetic screening rates have achieved the natinal gal. Preventable hspital stays hwever is significantly abve the MO avg. and natinal gal. Educatinal metric rates trend belw their MO averages. Unemplyment is better than the MO avg. but exceeds the natinal gal. Children in pverty is significantly abve (adverse t) the MO avg. and the natinal gal. Vilent crime appears better than the MO avg. but it is 6 times the natinal gal. Physical envirnmental factrs are generally psitive, excepting drinking water safety where 45% f Vernn Cunty ppulatin drinking water vilated safety standards cmpared t MO average f 5%. Summary f Observatins frm Vernn Cunty Peer Cmparisns The federal gvernment administers a prcess t allcate all cunties int "Peer" grups. Cunty "Peer" grups have similar scial, ecnmic and demgraphic characteristics. Health and wellness bservatins when Vernn Cunty is cmpared t its natinal set f Peer Cunties and cmpared t natinal rates make the fllwing bservatins: UNFAVORABLE bservatins ccurring at rates wrse than natinal AND wrse than amng Peers (Please nte this list f adverse indicatrs is cnsiderably lnger than typically bserved): White nn-hispanic Infant Mrtality Crnary Heart Disease Lung Cancer Suicide Infant Mrtality Nenatal Infant Mrtality Pst Nenatal Infant Mrtality Unintentinal Injury Stke

25 Nevada, Missuri Page 22 SOMEWHAT A CONCERN bservatins because ccurrence is wrse than natinal average BUT better than the Peer grup average, OR, better than natinal average BUT wrse than Peer grup average: Births t Wmen Under 18 Births t Unmarried Wmen Breast Cancer (female) Cln Cancer Mtr Vehicle Injuries BETTER perfrmance than Peers and Natinal rates: Lw Birth Weight (less than 2,500g) Very Lw Birth Weight (less than 1,500g) Premature Births N Care in First Trimester Births t Wmen Age 40 t 54 Cnclusins frm the Demgraphic Analysis Cmparing Vernn Cunty t Natinal Averages Vernn Cunty in 2012 cmprises 20,196 residents. Since 2000 it has experienced ppulatin increase and anticipates cntinued slwer than average grwth thrugh the next five years t achieve 20,616 residents. The ppulatin is 95.2% nn-hispanic White. Asian & Pacific Island nn- Hispanics cnstitute 0.6% f the ppulatin. Hispanics cmprise 1.7% f the ppulatin and are the largest minrity ppulatin. Black nn-hispanics cnstitute 0.5% f the ppulatin. 16.5% f the ppulatin is age 65 r lder. This is a cnsiderably larger ppulatin segment than the elderly cmprise n average in Missuri r in cmparisn t the natinal average. 18.2% f the wmen are in the childbirth ppulatin segment. This segment is cnsiderably smaller than as elsewhere in Missuri r in cmparisn t the natinal average. The median incme, husehld wealth and Median Hme value are belw the Missuri and natinal averages. The fllwing areas were identified frm a cmparisn f the cunty t natinal averages: Metrics impacting mre than 25% f the ppulatin and statistically significantly different frm the natinal average include the fllwing. All are cnsidered adverse findings unless therwise nted: I am respnsible fr my health 9% belw average impacting 60% f the ppulatin Obtained a Pap/Cervix test in last 2 years 19% belw average impacting 49% f the ppulatin Obtained rutine chlesterl screening 14% belw average impacting 44% f the ppulatin

26 Nevada, Missuri Page 23 Mammgram in last 2 years is 5% belw average impacting 43% f the ppulatin Had an OB/GYN visit in last year is 11% belw average impacting 41% f the ppulatin Emergency rm use is 13% abve average impacting 38% f the ppulatin I fllw treatment recmmendatins 18% belw average impacting 33% f the ppulatin Use tbacc/cigarettes 24% abve average impacting 32% f the ppulatin Chrnic high bld pressure 18% abve average impacting 31% f the ppulatin Chrnic lw back pain 27% abve average impacting 29% f the ppulatin Mrbid bese 9% abve average impacting 28% f the ppulatin Rutine prstate screening 13% belw average impacting 28% f the ppulatin Healthy eating habits 13% belw average impacting 26% f the ppulatin Chrnic allergies 11% abve average impacting 25% f ppulatin Situatins and Cnditins statistically significantly different frm the natinal average but impacting less than 25% f the ppulatin include the fllwing. All are cnsidered adverse findings unless therwise nted: Obtain clrectal screening in last 2 years 10% belw average impacting 22% f the ppulatin Obtain rutine cardiac stress test in last 2 years 10% belw average impacting 14% f ppulatin Chrnic diabetes 28% abve average impacting 13% f the ppulatin Chrnic steprsis 26% abve average impacting 12% f ppulatin Chrnic heart disease 30% abve average impacting 11% f the ppulatin Chrnic COPD 22% abve average impacting 6% f the ppulatin Very unhealthy eating habits 50% abve average impacting 4% f the ppulatin Key Cnclusins frm Cnsideratin f the Other Statistical Data Examinatins Additinal bservatins f Vernn Cunty fund: Palliative Care (prgrams t relieve disease symptms pain and stress frm serius illness) exist in the CO. Hspice Care (prgrams t prvide cmfrt care during terminal disease) exist in the CO; Vernn CO has a significantly lwer death rate in 5 f the 15 leading causes f death and a significantly higher death rate in 6 f the 15 leading causes f death. In descending rder, Vernn CO leading causes f death are:

27 Nevada, Missuri Page Heart Disease (rate per 100,000) Cunty ranks #28 f 115 cunties and independent city in MO (#1 rank = wrst in MO), abve MO avg. 2. Cancer 220 significantly higher than expected, rank #27, abve MO avg. 3. Accidents 73.8 significantly higher, rank #22, abve MO avg., amng age leading cause f death in MO 4. Strke 48.5 at expected death rate, rank #80, but abve MO avg. 5. Lung 47.7 at expected death rate, rank #70, belw MO avg. 6. Diabetes 44.1 significantly higher, rank #3, cnsiderably abve MO avg. 7. Kidney 21.2 significantly higher, rank #35, abve MO avg. 8. Alzheimer s 20.2 at expected death rate, rank #59, belw MO avg. 9. Flu/Pneumnia 19.6 at expected death rate, rank #71, slightly abve MO avg. 10. Suicide 15.8 significantly higher than expected, rank #41, abve MO avg., 7th cause f death amng men, 28rd cause f death amng wmen, #3 cause f death amng age males Heart Disease Mrtality during 2007 thrugh 2009 is in the secnd highest natinal classificatin (445.9 cmpared t natinal avg.). Racial ppulatin statistics are nt available due t the small number f minrities in the Cunty; Strke deaths during 2007 thrugh 2009 (83.9 in Vernn C) is in the same statistical classificatin as the natinal average (78.6); Life expectancy fr bth Men and Wmen has increased, hwever, males imprved slightly better than females. Male life expectancy in 2009 (73.6 years) was 8 years behind the tp 10 best internatinal cuntry rates. Life expectancy fr Wmen (79.4 years) is 6.4 years behind the 10 best internatinal cuntry rates. The age f death fr bth males and females are behind the MO avg; Vernn is designated as a Health Prfessinal Shrtage Area fr primary care, dental and mental health based n access prblems fr lw incme residents. Three areas in Vernn Cunty, Bacn Service Area, Drywd Service Area and Washingtn Service Area als qualify as a Medically Underserved Area, making it eligible fr sme federal physician recruitment assistance; and 21.2% f Vernn Cunty residents live in pverty (MO avg. 14%). 46.3% f Vernn Cunty residents live belw 200% f the pverty level (MO avg. 33.4%). 50.4% f children eligible fr free/reduced price lunch (MO avg. 44.3%). The fast fd restaurants per ppulatin are belw MO and natinal rates (desirable trend). Hwever, the number f grcery stres per capita is abut half the MO and natinal average (undesirable trend). Resulting in the

28 Nevada, Missuri Page 25 percentage f residents living in fd deserts (16.9%) is abve average (MO avg. 13.4% natinal avg. 9.1%). The percent f the ppulatin withut any regular dctr (18%) is at the MO average but slightly belw the natinal average. The percent f the ppulatin nt visiting a dentist in the last year (48.9%) is cnsiderably abve the MO average (37.1%) and natinal average (30.1%). The primary care prvider per ppulatin rate (42.5/100,000) is abut half f the MO and natinal rates (undesirable).

29 Nevada, Missuri Page 26 EXISTING HEALTH CARE FACILITIES, RESOURCES AND IMPLEMENTATION PLAN

30 Nevada, Missuri Page 27 Significant Health Needs We used the pririty ranking f area health needs by the Lcal Expert Advisrs t rganize the search fr lcally available resurces as well as the respnse t the needs by NRMC. 22 The fllwing list: Identifies the rank rder f each identified Significant Need; Presents the factrs cnsidered in develping the ranking; Establishes a Prblem Statement t specify the prblem indicated by use f the Significant Need term; Identifies NRMC current effrts respnding t the need; Establishes the Implementatin Plan prgrams and resurces NRMC will devte t attempt t achieve imprvements; Dcuments the Leading Indicatrs NRMC will use t measure prgress; Presents the Lagging Indicatrs NRMC believes the Leading Indicatrs will influence in a psitive fashin, and; Presents the lcally available resurces nted during the develpment f this reprt as believed t be currently available t respnd t this need. In general, Nevada Reginal Medical Center, Inc. is the majr hspital in the service area. Nevada Reginal Medical Center is a 41 bed, acute care medical facility with a psychiatric specialty unit lcated in Nevada, MO. The next clsest facilities are utside the service area and include: Bartn Cunty Memrial Hspital a 25 bed critical access hspital in Lamar, MO; 26.9 miles frm Nevada, MO (26 minutes); Cedar Cunty Memrial Hspital a 25 bed critical access hspital in El Drad Springs, MO; 20.4 miles frm Nevada, MO (25 minutes); Ellett Memrial Hspital a 25 bed critical access hspital in Appletn City, MO; 47.8 miles frm Nevada, MO (49 minutes); Bates Cunty Memrial Hspital a 49 bed hspital in Butler, MO; 31.4 miles frm Nevada, MO (32 minutes); and Mercy Hspital a 61 bed hspital in Frt Sctt, KS; 22.2 miles frm Nevada, MO (29 minutes). All data items analyzed t determine significant needs are Lagging Indicatrs, measures presenting results after a perid f time, characterizing histrical perfrmance. Lagging Indicatrs tell yu 22 Respnse t IRS Frm 990 h Part V B 1 c

31 Nevada, Missuri Page 28 nthing abut hw the utcmes were achieved. In cntrast the NRMC Implementatin Plan utilizes Leading Indicatrs. Leading Indicatrs anticipate change in the Lagging Indicatr. Leading Indicatrs fcus n shrt-term perfrmance, and if accurately selected, anticipate the brader achievement f desired change in the Lagging Indicatr. In the QHR applicatin Leading Indicatrs als must be within the ability f the hspital t influence and measure. Significant Needs 1. Affrdability Lack f Medicaid prviders, especially dentist a leading Lcal Expert cncern; access prblems t affrdable care a leading Lcal Expert cncern; uninsured rate significantly abve MO avg. and US gal. Opprtunity Statement: Lcal residents shuld nt be denied access t care because f limited payment ability NRMC SERVICES AVAILABLE TO RESPOND TO THIS NEED INCLUDE: NRMC Emergency Services; NRMC Nw Clinic and Rural Family Health Clinics; NRMC free screenings at Annual Cmmunity Health Fair; NRMH peridic free cmmunity screenings; NRMC lunch and learn sessins (mnthly); NRMC financial cunseling and registratin fr Medicaid eligibility; NRMC financial assistance plicy; NRMC Cmplex care prgram. NRMC IMPLEMENTATION PLAN PROGRAMMATIC INITIATIVES: 23 Expand scpe f practice fr nurse practitiners, i.e., expand the types f services nurse practitiners may prvide and the settings where they may practice; Crdinate with cmmunity rganizatins; Expand use f cmmunity health wrkers by imprving rle definitin and educatin curricula and increasing funding; Crdinating effrts with the rganizatins listed belw which ffer resurces respnding t this need by identifying hw NRMC services can benefit their initiatives. NRMC will initiate effrts by cntacting each rganizatin t establish a frum fr effrt cllabratin; Cntinue t Require prvider training in cultural cmpetency; 23 This sectin in each need fr which the hspital plans an implementatin strategy respnds t Schedule H (frm 990) Part V Sectin B 6. a. and 6. b.

32 Nevada, Missuri Page 29 Increase use f telemedicine as a way fr patients t access qualified health and mental health prfessinals; and Encurage enrllment in existing prgrams such as Medicaid via utreach/educatin and expedited enrllment. ANTICIPATED RESULTS FROM NRMC IMPLEMENTATION PLAN NRMC effrts can help address the symptms f and results frm prblems f affrdability and access but it can d little t impact the underlying causes f this prblem which stem frm unemplyment, limited educatin, adverse lifestyle chices and ther factrs. LEADING INDICATOR NRMC WILL USE TO MEASURE PROGRESS: Vlume f patient financial assistance effrts shuld increase frm 2012 vlumes Medicaid applicatins = patients assisted by NRMC financial assistance plicies = 219 LAGGING INDICATOR NRMC WILL USE TO IDENTIFY IMPROVEMENT Number f Cunty residents enrlled in Medicaid prgram; and Percent f Cunty ppulatin belw Federal pverty guideline. Other Lcal Resurces identified during the CHNA prcess which are believed available t respnd t this need include the fllwing: Vernn Cunty Health Dept. 301 N Washingtn St. Nevada, MO Nevada Medical Clinic 900 S Adams St., Nevada, MO Nevada Urgent Care Clinic 111 N. Elm St., Nevada, MO Legal Aid f Western MO 1125 Grand Bulevard, #1900, Kansas City, MO Obesity/Overweight Mrbid bese 9% abve avg. impacts 28% f pp.; besity a leading Lcal Expert cncern; fast fd restaurants per capita belw MO and US rates (desirable); grcery stres per capita half the MO and US avg. (undesirable); residents living in fd deserts abve MO and US avg.; very unhealthy eating habits 50% abve avg. impacts 4% f pp.; healthy eating habits 13% belw avg. impacts 26% f pp.; besity at MO avg. but abve US gal; physical inactivity at MO avg. but abve US gal. Opprtunity Statement: Reduce besity thrugh educatin and incentives NRMC SERVICES AVAILABLE TO RESPOND TO THIS NEED INCLUDE: NRMC Lunch and Learn;

33 Nevada, Missuri Page 30 NRMC invlvement with Healthy Nevada initiative; NRMC emplyee wellness prgram and benefits; NRMC Staff dietitian available fr cmmunity cnsultatins; and NRMC Annual Cmmunity Health Fair. NRMC IMPLEMENTATION PLAN PROGRAMMATIC INITIATIVES: NRMC will establish an integrated apprach t besity by crdinating its effrts with diabetic reductin effrts frmulating a multi-cmpnent besity preventin interventin initiative; 24 NRMC will lead by example by fstering emplyee invlvement in a wrksite preventin interventin and prvide incentives t use nsite resurces; NRMC will develp health chices in the cafeteria and vending machines; In cafeteria Label fds t shw serving size and nutritinal cntent: availability and awareness f nutritinal infrmatin cntent may decrease calrie cnsumptin; Make water available and prmte cnsumptin f water in place f sweetened beverages; Use cmpetitive pricing, e.g., higher prices fr nn-nutritius fds than fr nutritius fds; Prvide pint-f-decisin prmpts fr use f stairs: mtivatinal signs placed n r near stairwells, elevatrs, and escalatrs encurage individuals t use stairs; Increase access t fitness centers and athletic facilities: access can be increased in a number f ways, including physical access/lcatin accessibility and reduced csts r sliding scale fees t imprve ecnmic access; Institute wrkplace incentives fr physical activity; Reduce health insurance premiums fr wellness prgram members; Implement breastfeeding prgrams t increase breastfeeding initiatin, exclusive breastfeeding, and duratin f breastfeeding; and Implement multi-cmpnent interventins that target bth diet and physical activity: multicmpnent interventins include cmbinatins f activities and supprt such as nutritin educatin, prescriptins fr aerbic/strength training, training in behaviral techniques, selfhelp materials, specific dietary prescriptins, grup r supervised exercise sessins, and pedmeters. 24