Maury Regional Medical Center. Community Health Needs Assessment

Transcription

1 Maury Regional Medical Center Community Health Needs Assessment November 2016

2 Table of Contents Executive Summary... iii Introduction... iii Summary of Findings... iii Selected Priority Areas... iii 1 Introduction Maury Regional Medical Center Definition of Community + Map Evaluation of Progress since Prior CHNA Community Feedback on Prior CHNA or Implementation Strategy Consultants Healthy Communities Institute Methods Secondary Data Sources and Analysis Race/Ethnicity Disparities Primary Data Collection and Analysis Data Considerations Prioritization Demographics Population Age Racial/Ethnic Diversity Social and Economic Determinants of Health Income Poverty Unemployment Education SocioNeeds Index Findings Prioritized Significant Health Needs Access to Health Services Exercise, Nutrition, and Weight Mental Health and Mental Disorders Substance Abuse i

3 5.2 Other Significant Health Needs Children s Health Diabetes Heart Disease & Stroke Oral Health Other Chronic Diseases Prevention and Safety Conclusion ii

4 Executive Summary Introduction Maury Regional Medical Center (MRMC) is pleased to present its 2016 Community Health Needs Assessment (CHNA). This CHNA report provides an overview of the health needs in the MRMC service area. MRMC partnered with Healthy Communities Institute to conduct the CHNA for its community. The goal of this report is to offer a meaningful understanding of the health needs in the counties of Lawrence, Lewis, Giles, Marshall, Maury, and Wayne in Tennessee, as well as to guide the hospital in their community benefit planning efforts and development of implementation strategies to address prioritized needs. Special attention has been given to identify health disparities, needs of vulnerable populations, unmet health needs or gaps in services, and input from the community. Summary of Findings The CHNA findings are drawn from an analysis of an extensive set of secondary data (over 100 indicators from national and state data sources) and in-depth primary data from community health leaders and organizations that serve vulnerable populations and/or populations with unmet health needs. Based on the analysis of the primary and secondary data, the following significant health needs emerged: Access to Health Services Children s Health Diabetes Exercise, Nutrition, & Weight Heart Disease & Stroke Mental Health & Mental Disorders Oral Health Other Chronic Diseases Prevention & Safety Substance Abuse Selected Priority Areas On September 28 th, 2016, MRMC conducted a prioritization session and selected the following priority areas for consideration in its implementation strategy: MRMC s Prioritized Significant Health Needs Access to Health Services Exercise, Nutrition, & Weight Mental Health & Mental Disorders Substance Abuse iii

5 1 Introduction 1.1 Maury Regional Medical Center Maury Regional Medical Center (MRMC) is a county owned not-for-profit acute care community medical center in Columbia, Tennessee. Columbia, located in the heart of Middle Tennessee, is approximately 45 miles south of Nashville. Founded over 60 years ago on remote farmland, MRMC provides medical care to residents in Middle Tennessee and is the largest employer in Maury County. Patients receive the health care available in metropolitan areas, but with a personal touch that has been our hallmark for over fifty years. MRMC offers a wide range of services, providing vital access to emergency and acute care as well as diagnostic and therapeutic outpatient services. MRMC s main health care service offerings are acute care, post-acute care, and wellness/prevention. Each of our main health care service offerings is important to our success and, as a community medical center, MRMC has a responsibility to provide appropriate services to meet community needs. The mechanisms used to deliver our services are inpatient (IP), outpatient (OP), emergent/urgent (ED), and community health. MRMC s stated purpose is to fulfill our mission and vision by serving our region with clinical excellence and compassionate care for every patient every day Definition of Community + Map The primary community that MRMC serves is defined by the geographic boundary of Giles, Lawrence, Lewis, Marshall, Maury, and Wayne Counties in Tennessee Evaluation of Progress since Prior CHNA In the prior CHNA cycle, MRMC prioritized obesity and associated diseases states, cancer, heart disease and stroke, and teen birth rate. Please refer to Appendix D for the evaluation of progress in these prioritized health areas Community Feedback on Prior CHNA or Implementation Strategy No written comment was received by MRMC about the prior posted CHNA. 1

6 1.2 Consultants Healthy Communities Institute Based in Berkeley, California, Healthy Communities Institute (HCI) was retained by Maury Regional Health as consultants to conduct community health needs assessments for the health system s facilities. The Institute also collaborated previously with Maury Regional Health to build capacity in implementations strategy efforts and to develop a data platform for their service area. HCI provides customizable, web-based information systems that offer a full range of tools and content to improve community health. The organization is composed of public health professionals and health IT experts committed to meeting clients health improvement goals. To learn more about HCI, please visit Report authors from Healthy Communities Institute: Therese Buendia Andrew Juhnke, MPH Rebecca Yae 2

7 2 Methods Two types of data were analyzed for this Community Health Needs Assessment: secondary data (indicators) and primary data (interviews). Each type of data was analyzed using a unique methodology, and findings were organized by health or quality of life topic areas. These findings were then synthesized for a comprehensive overview of the health needs in MRMC s Service Area. 2.1 Secondary Data Sources and Analysis Secondary data refers to data that have previously been collected. The main source for the secondary data is an internal data platform maintained by Healthy Communities Institute and spans over 100 health and health-related indicators from over 14 publicly available data sources. For further detail on the data sources included in the analysis, please see Appendix A. On July 5, 2016, data were queried and analyzed for approximately 100 or more indicators for Giles, Lawrence, Lewis, Marshall, Maury, and Wayne counties. For each indicator, there are several ways (or comparisons) by which to assess each county s status, including comparing to other Tennessee counties, all U.S. counties, the Tennessee state value, the U.S. value, the trend over time, and Healthy People 2020 targets. Each indicator is given a score based on how the county fares in these comparisons. The indicators are categorized into broader health topics, and indicator scores within each health topic are summed and averaged to produce an overall topic score. The score ranges from 0 to 3, with 0 meaning the best possible score and 3 the worst possible score, and summarizes how each county compares to the other counties in Tennessee and in the U.S., the state value and the U.S. value, Healthy People 2020 targets, and the trend over the four most recent time periods of measure. Tennessee Counties US Counties Tennessee State Score range: Good Figure 3.2.1: Secondary Data Methods US Value HP 2020 Trend Bad Indicator Score Topic Score The rankings of the health topics are collated from highest to lowest (or from worst to best possible 3

8 score) for all counties within the region. The collated data are used to assess the urgency of the health need within the community. Please see Appendix A for further details on the secondary data scoring methodology Race/Ethnicity Disparities Indicator data were included for race/ethnicity groups when available from the source. The race/ethnicity groups used in this report are defined by the data sources. The health needs disparity by race/ethnicity was quantified by calculating the Index of Disparity 1 for all indicators with at least two race/ethnic-specific values available. This index represents a standardized measure of how different each subpopulation value is compared to the overall population value. Indicators for which there is a higher Index of Disparity value are those where there is evidence of a large health disparity. 2.2 Primary Data Collection and Analysis The primary data used in this assessment consist of key informant interviews collected via by Healthy Communities Institute. Key informants are individuals recognized for their knowledge of community health in one or more health areas. Twenty key informants filled in interview questionnaires for their knowledge about community health needs, barriers, strengths, and opportunities (including the needs for vulnerable and underserved populations as required by IRS regulations). In many cases, the vulnerable populations are defined by race/ethnic groups, and this assessment will place a special emphasis on these findings. Interview topics were not restricted to the health area for which a key informant was nominated. Key Informants from: Boys and Girls Club of Maury County Centerstone Columbia Centerstone Lewisburg Department of Children s Services Hope Clinic Kings Daughters School Lawrence County Health Lawrence County Senior Citizens Lewis County Health Department Marshall County Board of Education Marshall County Health Department Marshall County Senior Citizens Center Martin Methodist College Maury County Public Schools National HealthCare Corporation Tennessee Department of Health South Central Regional Health Office The Family Center Wayne County Board of Education Youth Villages 1 Pearcy JN, Keppel KG. A summary measure of health disparity. Public Health Reports. 2002;117(3):

9 Department Excerpts from the interview transcripts were coded by relevant topic areas and other key terms using the qualitative analytic tool Dedoose. 2 The frequency with which a topic area was discussed in key informant interviews was one factor used to assess the relative urgency of that topic area s health and social needs. Please see Appendix B for a list of interview questions. 2.3 Data Considerations Several limitations of the data should be considered when reviewing the findings presented in this report. Although the topics by which data are organized cover a wide range of health and healthrelated areas, within each topic there is a varying scope and depth of secondary data indicators and primary data findings. In some topics there is a robust set of secondary data indicators, but in others there may be a limited number of indicators for which data is collected, or limited subpopulations covered by the indicators. In addition, many of the secondary data indicators included in the findings are collected by survey, and though methods are used to best represent the population at large, these measures are subject to instability especially among smaller populations. The breadth of primary data findings is dependent on who was selected to be a key informant, as well as the availability of selected key informants to be interviewed during the time period of primary data collection. The Index of Disparity is also limited by data availability: for some indicators, there is no subpopulation data, and for others, there are only values for a select number of race/ethnic groups. Despite these limitations, efforts were made to include as wide a range of secondary data indicators and key informant expertise areas as possible. 2 Dedoose Version , web application for managing, analyzing, and presenting qualitative and mixed method research data (2015). Los Angeles, CA: SocioCultural Research Consultants, LLC ( 5

10 3 Prioritization To prioritize the significant health topics and barriers for Maury Regional Medical Center s service area, key hospital staff and the Population Health Team engaged in multiple rounds of voting and discussion on September 28 th, For each round, prioritization participants were allowed a set number of votes. After each round of voting, participants discussed results and eliminated health topics with the lowest number of votes. Prior to the voting and discussion, prioritization participants were asked to consider how each significant health need fared against the criteria in Table 3.1. Table 3.1: Prioritization Criteria Criteria for Maury Regional Medical Center s Prioritization Session 1. Alignment of problem with facility s strengths/priorities/mission 2. Severity: rate/risk of morbidity and mortality associated with problem 3. Addresses disparities of subpopulations 4. Opportunity to intervene at prevention level 5. Opportunity for partnership The following health topics were identified as priorities for Maury Regional Medical Center: 1. Exercise, Nutrition, & Weight 2. Mental Health 3. Substance Abuse 4. Access to Health Services These prioritized health needs will be further considered in the implementation strategy. A plan for addressing these priority areas will be further considered in the implementation strategy report. For further information on prioritization methods and participants, see Appendix C. 6

11 4 Demographics The demographics of a community significantly impact its health profile. The following section explores the demographic profile of MRMC s service area, or the community of Giles, Lawrence, Lewis, Marshall, Maury, and Wayne Counties in Tennessee. Different age, race/ethnic, and socioeconomic groups may have unique needs and require varied approaches to health improvement efforts. All demographic estimates are sourced from the U.S. Census Bureau s American Community Survey unless otherwise indicated. 4.1 Population Age The age distribution of MRMC s service area was similar to Tennessee, as shown in Figure 4.1. Figure 4.1: Population by Age 40.0% 30.0% 28.0% 26.2% 26.7% 24.9% 20.0% 17.0% 16.9% 10.0% 6.4% 6.2% 8.1% 9.7% 9.0% 8.3% 6.5% 5.9% 0.0% < MRMC's Service Area Tennessee Racial/Ethnic Diversity The racial and ethnic makeup of the service area was more homogenous than that of the state of Tennessee. 7

12 Figure 4.2: Population by Race/Ethnicity 100.0% 90.0% 88.6% 80.0% 78.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 16.8% 10.0% 0.0% 8.0% 4.8% 3.5% 0.9% 1.5% 1.7% 1.9% White Black or African American Some other race Two or more races Hispanic or LaEno (of any race) MRMC's Service Area Tennessee A higher proportion of residents in the service area identified as White compared to the State (88.6% v. 78.0%). In addition, a smaller proportion of residents living in this region identified as Black or African American, Some Other Race, Two or More Races, or Hispanic/Latino. 4.2 Social and Economic Determinants of Health Social determinants are the conditions in which people are born, grow, work, live, and age that affect a wide range of health outcomes and risks. Resources that address the social determinants of health and improve quality of life can have a significant impact on population health outcomes. Examples of these resources include access to education, public safety, affordable housing, availability of healthy foods, and local emergency and health services Income The median household income in MRMC s service area was relatively low compared to the State

13 Figure 4.3: Median Household Income $50,000 $44,621 $41,278 $40,000 $30,000 $20,000 $10,000 $0 MRMC's Service Area Tennessee Within the service area, Maury County had the highest median household income at $46,565, which is slightly higher than the median household income for the State. The remainder of the counties in the service area had lower median household incomes compared to the State, with Wayne County the lowest in the service area. Table 4.1: Median Household Income by County Median Household Income Giles $38,739 Lawrence $37,371 Lewis $36,114 Marshall $41,822 Maury $46,565 Wayne $31, Poverty 25.0% Figure 4.4: Persons Living Below Poverty Almost one in five persons in MRMC s service area struggles with poverty (17.5%). 20.0% 15.0% 10.0% 17.5% 17.8% 5.0% 0.0% MRMC's Service Area Tennessee 9

14 Figure 4.5: Persons Living Below Poverty by Zip Code Tabulation Area Zip code tabulation areas 38456, 38471, and experienced rates of poverty over twice as high as the overall service area (Figure 4.5), with more than 36% of the residents in these zip codes living below poverty; nearly half (45.1%) of residents of zip code lived in poverty Unemployment 10.0% Figure 4.6: Unemployment Rate (as of February 2016) According to the U.S. Bureau of Labor Statistics, the unemployment rate in MRMC s service area was comparable to state of Tennessee in February % 6.0% 4.0% 2.0% 4.5% 4.5% 0.0% MRMC's Service Area Tennessee At the county level, the unemployment rates within the service area are more diverse, ranging from 3.8% in Giles County to 6.4% in Wayne County as shown in Table 4.6: 10

15 Lawrence, Lewis, and Wayne Counties had higher unemployment rates when compared to both the service area and the state value Education Table 4.2: Unemployment Rate by County 100.0% Unemployment Rate, February 2016 Giles 3.8% Lawrence 5.5% Lewis 5.8% Marshall 4.4% Maury 3.9% Wayne 6.4% U.S. Bureau of Labor Statistics Figure 4.7: Population 25+ with a High School Degree or Higher High school degree attainment is fairly similar within the region to the overall state value (Figure 4.7). 75.0% 50.0% 82.1% 84.9% 25.0% 0.0% MRMC's Service Area Tennessee Figure 4.8: Population 25+ with a Bachelor's Degree or Higher 30.0% 24.4% 25.0% 20.0% 14.8% 15.0% 10.0% 5.0% In contrast, a significantly smaller percentage of residents aged 25 and older within the service area had a Bachelor s degree or higher (14.8%) compared to the state of Tennessee (24.4%). 0.0% MRMC's Service Area Tennessee 11

16 Table 4.3: Educational Attainment by County High School Degree or Higher* Bachelor s Degree or Higher* Giles 80.4% 14.6% Lawrence 79.0% 11.9% Lewis 79.1% 12.7% Marshall 81.7% 13.2% Maury 86.4% 18.6% Wayne 75.4% 8.2% *Percentage of population 25+ Wayne County had the smallest percentages of residents aged 25 and older with high school or Bachelor s degrees while Maury County had the highest percentages of residents aged 25 and older with high school or Bachelor s degrees, as shown in Table SocioNeeds Index Healthy Communities Institute developed the SocioNeeds Index to easily compare multiple socioeconomic factors across geographies. This index incorporates estimates for six different social and economic determinants of health income, poverty, unemployment, occupation, educational attainment, and linguistic barriers that are associated with poor health outcomes including preventable hospitalizations and premature death. Within the service area, zip codes are ranked based on their index value to identify the relative levels of need, as illustrated by the map. Figure 4.9: SocioNeeds Index by Zip Code 12

17 Zip codes 38462, 38485, 38456, 38450, 38486, 38471, 38452, 38481, and 38473, as indicated by areas of the darkest shade of green in Figure 4.9, emerged as areas with the highest level of socioeconomic need. Most of these zip codes are in Wayne County. 13

18 5 Findings Together, secondary and primary data provide a breadth of information on the health needs of residents within MRMC s service area. Strong Evidence of Need in Secondary Data Strong Evidence of Need in Primary Data Heart Disease & Stroke Other Chronic Diseases Prevention & Safety Access to Health Services Children s Health Mental Health Diabetes Substance Abuse Exercise, Nutrition, Weight Oral Health The areas for which there was strong evidence of need across both data types includes Mental Health & Mental Disorders, and Substance Abuse. Several areas that scored high in secondary data scoring did not appear frequently in primary data, including Heart Disease & Stroke, Other Chronic Diseases (includes measures of osteoporosis, arthritis, and kidney diseases), and Prevention & Safety. Access to Health Services; Children s Health; Diabetes; Exercise, Nutrition & Weight; and Oral Health were frequently mentioned among key informants, but were not common pressing issues in secondary data. Findings are discussed in the report by topic area, first by prioritized health needs, then by other health needs. 14

19 The figure below illustrates the common health themes from secondary data, with Heart Disease & Stroke, Mental Health & Mental Disorders, Other Chronic Diseases, Prevention & Safety, and Substance Abuse emerging across the region as pressing common needs. 15

20 The word cloud below, created using the tool Wordle, 4 illustrates the themes that were most prominent in the primary data. Themes that were mentioned more frequently are displayed in larger font. Key informants discussed the areas of Access to Health Services; Children s Health; Diabetes; Exercise, Nutrition, & Weight; Mental Health & Mental Disorders; Oral Health; and Substance Abuse most frequently. 4 Wordle [online word cloud applet]. (2014). Retrieved from 16

21 5.1 Prioritized Significant Health Needs Access to Health Services 100% Key Informant Interviews Data Overview Secondary Data Scores for Access to Health Services Giles Lawrence Lewis Marshall Maury Wayne Key Issues Lack of health insurance among children and adults Limited providers, especially those specializing in mental health or substance abuse or serving uninsured populations Barriers include transportation, healthcare literacy and navigation, and financial resources Healthcare coverage and affordability Approximately one in five adults lacked health insurance across the region, as shown in Table 5.1. The service area also failed to meet the Healthy People 2020 target of insuring 100% of adults and children. Table 5.1: Health Insurance Rates among Children and Adults Adults with Health Insurance, 2014 Children with Health Insurance, 2014 Giles 82.6% 94.3% Lawrence 80.7% 93.5% Lewis 79.2% 93.3% Marshall 81.7% 93.9% Maury 83.4% 94.8% Wayne 81.7% 93.7% Tennessee 82.6% 94.7% U.S. 83.7% - Healthy People 2020 Target 100% 100% Small Area Health Insurance Estimates 17

22 Several key informants also cited lack of health insurance coverage as a concern within the community, corroborating the secondary data and elaborating that limited state Medicaid leaves many people in a coverage gap. According to key informant interviews, lack of health insurance leads to delayed care and use of the ER in lieu of primary care, and conditions left untreated then lead to poorer health outcomes. Even when people have health insurance, it may be inadequate or leave people with unaffordable premiums and deductibles, observed key informants. Prescription drugs, in particular, can be costly, commented key informants. In addition, health insurance coverage does not typically cover oral health, and key informants identified oral health insurance and affordable oral health care as needs within the community. Healthcare providers Table 5.2: Primary Care Providers Preventative services are not sought out and care is not given until it reaches the ER visit level. Too few physician and nonphysician primary care providers serve the region, according to secondary data. Primary Care Provider Rate, 2013* Non-Physician Primary Care Provider Rate, 2015* Giles Lawrence Lewis Marshall Maury Wayne Tennessee *providers per 100,000 population County Health Rankings Several key informants cited the need for more specialty providers and services within the community, especially in mental health and substance abuse. Two more unique service needs emerged for the region from primary data: oral health providers serving TennCare or uninsured patients, and mental health or substance abuse services serving children and adolescents. Barriers Many key informants identified transportation as the biggest barrier to care. Other barriers mentioned were language, financial [Families are forced to] prioritize basic needs such as food and shelter over medical needs. 18

23 resources, and healthcare navigation and literacy. Highly impacted populations Race/ethnic groups: Several key informants identified language barriers as a challenge within the community, though they did not specify which languages. Additionally, according to primary data, some race/ethnic groups may delay seeking services more than other groups because they feel intimidated by bureaucratic systems. 19

24 5.1.2 Exercise, Nutrition, and Weight 55% Key Informant Interviews Data Overview Secondary Data Scores for Exercise, Nutrition, and Weight Giles Lawrence Lewis Marshall Maury Wayne Key Issues Limited access to safe outdoor and indoor exercise opportunities (especially for children) Built environment is unsupportive of active lifestyle Low access and availability of affordable healthy foods, particularly for low-income families and children Obesity and its related diseases Nutrition Wayne County experienced low access to a grocery store in households without cars, lowincome, and elderly populations, as shown in Table 5.3. Several key informants commented on the lack of education on nutritious foods and how to prepare those foods. Other key informants discussed the importance of promoting healthy eating habits from a young age. Food insecurity combined with easy access to fast food leads to increased nutrition problems. Table 5.3: Low Access to a Grocery Store Percentage of given subpopulation living >1 mile (urban) or 10 miles (rural) from a grocery store, 2010 Households with 65 Years of Age and Low-Income No Car Older Giles 2.9% 5.8% 2.8% Lawrence 3.8% 2.7% 1.1% Lewis 2.5% 1.5% 0.9% Marshall 1.5% 3.0% 0.9% Maury 1.5% 4.9% 1.9% Wayne 4.4% 8.7% 2.8% U.S. 2.6% 6.2% 2.8% USDA Food Environment Atlas As mentioned by numerous key informants, hunger and a Many low-income students come to school hungry; this impacts their education. lack of proper nutrition impact all areas of life, including the ability to focus at school or work. 20

25 Exercise Opportunities Approximately half of the region s population lacks access to exercise opportunities, shown in Table 5.4. Table 5.4: Access to Exercise Opportunities All counties in the region have substantially lower access to exercise opportunities compared to the Tennessee state average. Access to Exercise Opportunities, 2016 Giles 44.2% Lawrence 56.4% Lewis 33.1% Marshall 43.9% Maury 54.4% Wayne 32.5% Tennessee 69.3% County Health Rankings Several key informants cited the built environment as a barrier to proper exercise in the region: parks are considered unsafe, walking and biking trails are limited, and the overall infrastructure promotes driving. Many key informants noted that there are no affordable recreational centers. 21

26 5.1.3 Mental Health and Mental Disorders Data Overview 55% Key Informant Interviews Secondary Data Scores for Mental Health and Mental Disorders Giles Lawrence Lewis Marshall Maury Wayne Key Issues Limited mental health providers and services, especially for youth Co-occurrence with substance abuse High rates of depression, frequent mental distress, and suicide Depression and Suicide Five of six counties in the region have a higher percentage of their Medicare population suffering from depression than the state average (Table 5.5). Depression: Medicare Population, 2014 Suicide Rate per 100,000 Population, Table 5.5: Depression and Suicide Giles Lawrence Lewis Marshall Maury Wayne Tennessee Healthy People 2020 Target 17.9% 18.3% 16.4% 18.4% 18.4% 20.3% 17.5% - Centers for Medicare and Medicaid Services Centers for Disease Control and Prevention The service area failed to meet the Healthy People 2020 Target of an age-adjusted suicide rate of 10.2 per 100,000 population, as shown in Table

27 Key informants cited lack of mental health providers and services in the area as the most pressing issue regarding mental health. Additionally, chronic mental illnesses, such as depression, are often neglected and left untreated, according to primary data. Multiple key informants observed that there is a cycle of lack of education, low paying jobs, and continuing poverty that often leads to depression. Mental health services are severely lacking for the amount of community need. Highly Impacted Populations Youth: Many key informants observed that children and youth are an extremely negatively impacted population in terms of mental health in the region. There are no Applied Behavior Analysis (ABA) services for children in rural communities, and children are often given the choice of sitting on a wait list or leaving the community in order to get the services they need, particularly if in need of a psychiatric bed. Homeless people and Non-English Speakers: These two groups are both disproportionately impacted and struggle more than others to get the care they deserve due to a lack of affordable care options. 23

28 5.1.4 Substance Abuse 65% Key Informant Interviews Data Overview Secondary Data Scores for Substance Abuse Giles Lawrence Lewis Marshall Maury Wayne Key Issues Smoking, prescription drug abuse, and other illicit drug use Lack of treatment and services options Tobacco and illicit drug use Smoking; prescription drug abuse, especially of pain medications; and drug addiction, including cocaine, heroin, marijuana, and meth emerged as needs within the region from key informant interviews. The death rate due to drug poisoning, which includes drug overdose due to painkillers, is consistently higher among the counties within the region than the national value; Marshall County experiences the highest death rate Key informant input attributed high rates of tobacco use to the culture in the area, and linking its usage to White males and populations with low-income or low educational attainment. According to key informant testimony, an increase in the number of babies born with Neonatal Abstinence Syndrome, or addicted to drugs, was observed. Table 5.6: Drug Poisoning Death Rate Drug Poisoning Death Rate, Giles 19.6 Lawrence 20.6 Lewis 19.0** Marshall 25.7 Maury 17.9 Wayne 12.6** Tennessee 18.4 U.S *deaths per 100,000 population ** County Health Rankings Tobacco use is cultural in this area. 24

29 Treatment and services Several key informants discussed inadequate adult smoking cessation programs, a lack of medical detox services available in the community, and lack of health insurance coverage to pay for inpatient medical detox as some of the barriers to accessing substance abuse treatment. Outpatient substance abuse treatment for adolescents is lacking in more rural areas. Growing number of patients seeking mental health services as an outgrowth of their use/abuse/dependency on pain medications. 25

30 5.2 Other Significant Health Needs Children s Health Data Overview 65% Key Informant Interviews Secondary Data Scores for Children's Health Giles Lawrence Lewis Marshall Maury Wayne Key Issues Mental health and psychiatric services are very limited in the community Food insecurity and obesity Low-income families lead to lack of health insurance and limited healthy opportunities for children Pediatric dental care and services are lacking Mental Health Multiple key informants described the lack of mental health services as a critical children s health issue: many patients have no access to psychiatric care, with children either having to sit on waiting lists or leave the community to access psychiatric services. They also observed that resources are inadequate for children with serious mental health diagnoses: there is a lack of psychiatric beds and tangible community resources to support those with such debilitating diagnoses. Nutrition Table 5.7: Child Food Insecurity by County Around one in four children were food insecure at some point during the year in the service area, as shown in Table 5.7. Child Food Insecurity Rate, 2014 Giles 23.2% Lawrence 26.5% Lewis 24.7% Marshall 23.0% Maury 22.7% Wayne 28.9% Tennessee 24.0% U.S. 20.9% Feeding America 26

31 Child food insecurity and childhood obesity came up frequently among key informants. One key informant noted that children from low-income families struggle with getting food, which impacts attendance at school and negatively affects a child s ability to learn while at school. Some key informants attributed the poor diets of children due to the inability to pay higher prices for healthier foods and the lack of transportation to reach places selling healthier foods, factors which disproportionately affect low-income and rural children. Other issues include a lack of healthy habits around nutrition and exercise from an early age, which leads to obesity and chronic health problems. Low-income students do not have resources to purchase nutritious foods and many come to school hungry it impacts their education. Maury County had the highest percentage of children in rural areas living greater than 10 miles from the nearest grocery store (Table 5.8). This barrier to acquiring needed and healthy foods is a detriment to children s health in the region. Children with Low Access to a Grocery Store, 2010 Table 5.8: Children with Low Access to a Grocery Store Giles Lawrence Lewis Marshall Maury Wayne 3.3% 1.6% 0.7% 1.5% 4.1% 2.6% U.S. Department of Agriculture - Food Environment Atlas Poverty Over one in five children lived below poverty level in the service area (Table 5.9). Table 5.9: Children Living Below Poverty Level Giles Lawrence Lewis Marshall Maury Wayne Tennessee U.S. Children Living Below Poverty Level, % 27.9% 22.0% 23.6% 24.4% 32.8% 25.8% 21.9% 2014 American Community Survey Key informants noted that, due to poverty, adolescents are prevented from getting the care they need to thrive in the community and become independent, with many stuck in a cycle of a lack of education, poor paying jobs, poor health behaviors, and a lack of health insurance, leading to continued poverty and overall poor health. 27

32 Oral Health Many key informants mentioned limited access to pediatric dental providers. This leads to dental needs going unmet and continuing dental issues unaddressed. 28

33 5.2.2 Diabetes 40% Key Informant Interviews Data Overview Secondary Data Scores for Diabetes Giles Lawrence Lewis Marshall Maury Wayne Secondary data scoring unavailable Key issues Lack of knowledge around preventative health behaviors Lack of proper nutrition and physical activity Disproportionate impact on low-income individuals High prevalence among the Medicare population Health behaviors and outcomes Four of the six counties in the region have a higher percentage of the Medicare population treated for diabetes than the Tennessee state average, as shown in (Table 5.10). Table 5.10: Diabetes Death Rate and Prevalence among Medicare Population Wayne and Lawrence counties have the highest death rates due to diabetes in the region. Age-Adjusted Death Rate due to Diabetes, * Diabetes: Medicare Population, 2014 Giles 23.5** 27.9% Lawrence % Lewis % Marshall % Maury % Wayne % Tennessee % *deaths per 100,000 population ** Centers for Disease Control and Prevention Centers for Medicare and Medicaid Services 29

34 Multiple key informants observed poor diet, lack of proper nutrition, and physical inactivity as the main contributors to diabetes. As mentioned by key informant input, diabetes and corresponding obesity problems are exacerbated by the generally sedentary lifestyle of the population and the lack of education surrounding healthy foods and nutrition. Barriers According to key informants, many community members do not know the importance of physical activity in preventing chronic disease. Additionally, healthy food options where community members can buy fresh fruits, vegetables, and other nutritious foods are limited. Other barriers mentioned were lack of transportation and inability to pay. Highly impacted populations Low-income/Underserved: Many individuals and families face challenges accessing healthier food options. Poor diets due to the inability to pay higher prices for healthier foods and the lack of transportation to reach places selling healthier foods are contributors disproportionately impacting the diabetes rates in low-income populations. Further, because of limited and unsafe places to engage in physical activity in low-income neighborhoods, as well as a lack of free physical activity programs, low-income populations are at risk of diabetes due to physical inactivity. Older adults: Older adults, particularly the Medicare population, are more highly impacted by diabetes in the region. As stated by one key informant, issues of nutrition, physical activity, and obesity leading to diabetes manifest themselves as people age and cause more severe issues later in life. In addition, a lack of caregiver knowledge and education about diabetes is causing more complications for older populations, especially in the most rural areas. 30

35 5.2.3 Heart Disease & Stroke Data Overview 20% Key Informant Interviews Secondary Data Scores for Heart Disease & Stroke Giles Lawrence Lewis Marshall Maury Wayne Key issues High blood pressure from stress, anxiety, and smoking Hypertension leads to residual heart and kidney defects African Americans suffers from heart disease at alarming rates High blood pressure Approximately three in five people within the Medicare population in the region suffer from hypertension, as shown in Table Table 5.11: Hypertension among Medicare Population All counties in the region have higher percentages of their Medicare population suffering from hypertension than the average U.S. county, while five of six counties are higher than the average of Tennessee counties. Hypertension: Medicare Population, 2014 Giles 64.9% Lawrence 63.6% Lewis 56.1% Marshall 59.2% Maury 58.2% Wayne 62.2% Tennessee 58.5% U.S. 55.1% Centers for Medicare & Medicaid Services According to key informants, high blood pressure in the community stems from, and is exacerbated by, smoking, stress and anxiety, and lack of opportunity for job improvement. Hypertension tends to go untreated within the community s low-income population. Key informants noted chronic high blood pressure is often put Problems [like high blood pressure] that seem chronic often times lead to devastating consequences. 31

36 on the back burner because people are struggling financially. Table 5.12: Heart Disease & Stroke Age-Adjusted Death Rate due to Stroke per 100,000 Population, Age-Adjusted Death Rate due to Coronary Heart Disease per 100,000 Population, Ischemic Heart Disease: Medicare, Giles % Lawrence % Lewis % Marshall % Maury % Wayne % Tennessee % U.S % Healthy People 2020 Target Centers for Disease Control and Prevention, 2 Centers for Medicare & Medicaid Services No counties in the region meet the Healthy People 2020 Target for either Death Rate due to Stroke or Death Rate due to Coronary Heart Disease, per Table Heart disease & stroke All counties in the region have higher death rates due to stroke and coronary heart disease than the U.S. average, while all but two have higher percentages of the population suffering from ischemic heart disease than the U.S. value. Some key informants noted that stroke, as well as blood clots and heart attacks, are common consequences of ignoring early signs of chronic issues, such as high blood pressure. Highly impacted populations Race/ethnic groups: Key informants observed a disproportionate impact of high blood pressure on the Black population; this group suffers from high blood pressure at alarming rates, and since the condition is often left undiagnosed, many are left with longer-term heart and kidney diseases. 32

37 5.2.4 Oral Health Data Overview 40% Key Informant Interviews Secondary Data Scores for Oral Health Giles Lawrence Lewis Marshall Maury Wayne Secondary data scoring unavailable Key issues Lack of insurance and need for affordable care Need for oral health providers serving those who are uninsured or have TennCare Limited pediatric dental providers The most pressing issues regarding oral health, as mentioned by multiple key informants, revolved around lack of insurance and the need for affordable care. Key informants also identified transportation and lack of financial resources as other barriers to oral health. Key informants emphasized oral health s importance due to its association with other chronic diseases and its effects on physical appearance, which may result in embarrassment and decreased efforts in seeking employment opportunities. Many key informants stated that there is a need for pediatric dental providers as well as dental providers serving underserved populations, including those who are uninsured or have TennCare. According to key informant testimony, oral health has worsened each year since the removal of fluoride from the water in Marshall County. Highly impacted populations Low-Income populations: Key informants identified low-income populations as particularly vulnerable to poor oral health outcomes, citing economic barriers as a major factor to poor dental care. We are 55 minutes from Nashville and that is usually the closest affordable dental care option but with no transportation many cannot take advantage of that. 33

38 5.2.5 Other Chronic Diseases 5% Key Informant Interviews Data Overview Secondary Data Scores for Other Chronic Diseases Giles Lawrence Lewis Marshall Maury Wayne Key issues Residents often neglect chronic illnesses due to lack of financial resources Low-income, African American, and elderly adults are most highly impacted Chronic kidney disease and arthritis pain are of high concern Prevalence Among Medicare Beneficiaries, 2014 Chronic Kidney Disease Rheumatoid Arthritis or Osteoarthritis Table 5.13: Other Chronic Diseases Among Medicare Beneficiaries Giles Lawrence Lewis Marshall Maury Wayne Tennessee 21.5% 19.9% 19.0% 18.2% 18.2% 18.7% 17.5% 32.2% 31.2% 30.7% 27.4% 29.0% 32.4% 30.9% Osteoporosis 4.9% 5.9% 3.6% 4.8% 4.8% 4.5% 5.3% Chronic diseases are a significant public health burden, as they reduce one s ability to perform activities of daily living. Key informants noted that chronic illnesses seem to disproportionately affect African Americans, as well as older adults and those with low-income. 2 of 10 people in the Medicare population in the region suffer from chronic kidney disease, while 3 of 10 suffer from arthritis (Table 5.13). Centers for Medicare & Medicaid Services Many chronic illnesses are put on a back burner when you are barely surviving financially. 34

39 5.2.6 Prevention and Safety Data Overview 5% Key Informant Interviews Secondary Data Scores for Prevention and Safety Giles Lawrence Lewis Marshall Maury Wayne Key Issues High death rates due to unintentional injuries and drug poisoning Older adults at risk for falls Injuries are the leading cause of death for Americans ages 1 to 44 according to the Centers for Disease Control and Prevention and a leading cause of disability. Older adults are at higher risk for falls, emphasized one key informant. Most counties in the region experienced higher death rates due to drug poisoning relative to the State (Table 5.14). The majority of drug poisoning, or overdose, deaths involve prescription painkillers. All counties for which data was available had high death rates due to unintentional injuries, exceeding the Healthy People 2020 target of 36.4 deaths per 100,000 population by over 50%. Table 5.14: Death Rates due to Unintentional Injuries and Drug Poisoning Age-Adjusted Death Rate due to Unintentional Injuries, Death Rate due to Drug Poisoning, Giles Lawrence Lewis Marshall Maury Wayne Tennessee U.S. Healthy People 2020 Target Centers for Disease Control and Prevention County Health Rankings 35

40 6 Conclusion This report provides an understanding of the major health and health-related needs in MRMC s service area and guidance for community benefit planning efforts and positively impacting the community. Further investigation may be necessary for determining and implementing the most effective interventions. Thank you for reading the Community Health Needs Assessment (CHNA). Your views and feedback are important to the health of our community. If you have feedback about the information in the CHNA and you would like to share, please your information to CHNAFEEDBACK@mauryregional.com or mail to: Maury Regional Medical Center Attention: Jill Gaddes CHNA Feedback 1224 Trotwood Avenue Columbia, Tennessee

41 Table of Contents Appendix A: Secondary Data... 1 A.1 Methodology... 1 Secondary Data Scoring... 1 Index of Disparity... 2 A.2 Data... 3 Appendix B: Primary Data... 4 B.1 Methodology... 4 B.2 Community Resources Cited... 5 Appendix C: Prioritization... 7 C.1 Prioritization Methodology... 7 C.2 Prioritization Participants... 7 Appendix D: Evaluation of CHNA... 7

42 Appendix A: Secondary Data A.1 Methodology Secondary Data Scoring Each indicator was assessed for each county using up to six comparisons as possible. Each one is scored from 0-3 depending on how the county value compares to the relevant benchmarks as described below. Comparison to Other Tennessee Counties Values for all 95 Tennessee counties are ranked from best to worst and the score is determined by where each county (Giles, Lawrence, Lewis, Marshall, Maury, and Wayne) falls in the ranking. Comparison to Distribution of U.S. County Values A distribution is created by taking all county values, ordering them from low to high, and dividing them into four equally sized groups based on their order. The comparison score is determined by which of these four groups (quartiles) the county falls in. Comparison to Tennessee value and U.S. value For the comparisons to a single value, the scoring depends on whether the county has a better or worse value, and the percent difference between the two values. The same method is used to score the comparison to the value for the State of Tennessee and for the comparison to the U.S. value. Comparison to Healthy People 2020 Target For a comparison to a Healthy People 2020 target, the scoring depends on whether the target is met or unmet, and the percent difference between the indicator value and the target value. 1

43 Comparison to Trend The Mann-Kendall statistical test for trend is used to assess whether the indicator 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 depends on the data source. All missing comparisons are substituted with a neutral score for the purposes of calculating the indicator s weighted average. Indicator and Topic Scores Indicator scores are calculated by averaging all comparison scores. Topic scores are calculated as an average of all relevant indicator scores, and indicators may be included in multiple topics as appropriate. Index of Disparity 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 subpopulation 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. ±3.3 ±4.8 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 ±11.4 ±2.8 1 Pearcy, J. & Keppel, K. (2002). A Summary Measure of Health Disparity. Public Health Reports, 117,

44 to the overall county value when compared to the subgroup values for Age-Adjusted Death Rate due to Diabetes by Race/Ethnicity. The 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. A.2 Data The following tables present the data used in the secondary data analysis. The first table on the next page presents the common health themes across the region, followed by a list of secondary data sources used. The remaining tables are organized by county, and go through the counties that make up MRMC s service area alphabetically. Each county s data section first begins with a table that presents topic scores, with higher scores indicating higher need. The tables following the topic scoring contain a comprehensive list of the indicators that comprise each topic. For individual indicators, values for specific race/ethnic groups are presented if they were poorer than the overall indicator value, and if the indicator had a high index of disparity. 3