Adena Pike Medical Center PIKE COUNTY 2013 COMMUNITY HEALTH NEEDS ASSESSMENT

PIKE COUNTY 2013 COMMUNITY HEALTH NEEDS ASSESSMENT

TABLE OF CONTENTS Adena Health System 02 Executive Summary 05 Introduction 12 Process 14 Data 16 Community Profile 16 County Health Rankings 22 Health System and Hospital Utilization 23 Healthcare Access 24 Death and Illness 25 Health Risk 27 Pike County Public Opinion 29 Community Leader and Stakeholder Responses 29 Survey Distribution and Responses 30 Prioritization Process 39 Conclusion 44 Attachments 45 1

ADENA HEALTH SYSTEM Since 1895, Adena Health System has remained focused on its commitment to provide patients with the best healthcare and personal service. Today, Adena Health System includes three hospitals (Chillicothe, Waverly and Greenfield) and five regional clinics, with a total of 311 beds. Adena is here to provide quality healthcare for the more than 400,000 people who call south central and southern Ohio home. With more than 2,500 employees, Adena also serves as an economic catalyst for the region. Adena offers its patients leading edge services in the areas of heart health, cancer diagnosis and treatment, women's health, children's health and orthopaedics. The skilled physicians and medical staff at Adena provide a number of specialty services that are typically found in larger medical centers. These include: open heart surgery; da Vinci robotic surgery; cardiac catheterization; cancer care; advanced orthopaedic procedures; high level MRI testing; and a Level II pediatric nursery. As the only health care provider in south central Ohio with da Vinci robotic surgery and the most advanced MRI capabilities in the region, Adena is well-positioned to provide patients with advanced care, close to home. As a non-profit hospital, founded on religious beliefs, Adena treats every patient with respect and compassion. Be assured you or your loved one will receive exceptional care at any Adena facility. 2

Adena Health System Facilities Adena Regional Medical Center: A 261-bed inpatient facility in Chillicothe, OH features an emergency department, diagnostic and treatment services, advanced surgical suites (including da Vinci Robotic Surgery), intensive/cardiac care, medical office building and the Adena Health Pavilion, which includes outpatient surgery, physician offices and the Adena Sleep Center. Adena Greenfield Medical Center: A 25-bed inpatient facility in Greenfield, OH features an emergency department, inpatient rehabilitation and medical/surgical units, diagnostic and surgical treatment services, as well as family practice and specialty physicians. : A 25-bed inpatient facility in Waverly, OH features an emergency department, medical/surgical unit, rehabilitation, endoscopy services and a same-day surgery. Adena Cancer Center: Opened in early 2012, the state-of-the-art center offers patients close-to-home access to some of the most advanced technology in cancer care. The center enables patients to be seen by their specialist and receive treatments all in one convenient location. Adena Health Centers: Adena Health Centers include physician offices offering primary care, pediatric and specialty care. Located in Chillicothe, Circleville, Jackson, Oak Hill, Washington Court House and Waverly, Adena Health Centers also offer: diagnostic and treatment services, physical, occupational and speech therapies. Urgent care services are offered in Chillicothe and Waverly. Adena Home Care and Hospice: Provides highly personalized, quality care to patients with home health, hospice, home respiratory, durable medical equipment and home infusion. Adena Rehabilitation and Wellness Center: Provides physical, occupational, massage and industrial rehabilitation, as well as orthopaedics, sports medicine, women's health, vestibular, fibromyalgia and chronic pain programs, as well as industrial and specialized hand programs. Adena Counseling Center: Provides a wide range of outpatient counseling services, including group, individual and family counseling. A variety of support groups also meet at the center. Off-Campus Physician Offices: A number of physician offices are located throughout the region served by Adena. They include offices for family physicians and a number of specialty providers as well. The Clinic at Walmart: Walk-in retail clinics located in Chillicothe and Washington Court House Walmart Stores specializing in the quick walk in appointments for colds, flu, sinus infections, immunizations, sports and school physicals. 3

Adena Health System Service Area The mission of Adena Health System is simple: to heal, to educate, to care. The System values integrity, communication, teamwork and innovation; which is the foundation of its vision To be the best healthcare system in the nation. AHS is committed to adopting the best clinical care practices that align with a patient s need to achieve a positive health outcome. These include: outreach on the benefits of preventative care; chronic disease management services; and the latest advancements in surgery and disease treatment. By staying on par with the best clinical standards, particularly for those with chronic disease, AHS envisions continuous improvement in the health outcome rankings and health factors rankings in its 12-county service region over 10 years. 4

EXECUTIVE SUMMARY As part of the Affordable Care Act, signed into law in 2010, the IRS now requires all 501(c) (3) health systems, with one or more hospitals, to complete a community health needs assessment at least once every three years for each hospital. This new requirement is intended to support the development of community health improvement strategies and planning. In addition, these assessments can provide appropriate information which policymakers, provider groups, and community advocates can base improvement efforts. Assessments can also inform funders about directing grant and other support dollars most appropriately. During 2013, the Adena Health System (AHS)/ (APMC) supported by its many Pike County partners completed its Community Health Needs Assessment (CHNA). This was accomplished by completing an initiative to collect and evaluate vital statistics, demographic and public opinion data for the region. The system also took a close look at population data for those currently served through the Regional Medical Center and countywide primary care practices, as well as the 2013 County Health Rankings published by the Robert Wood Johnson Foundation. A compilation of this data was then presented to several focus groups for evaluation. Their input on community health priorities helped identify strategies to effectively address the needs. The AHS/ARMC Community Health Department directed the project, with the support of health system data analysts who assessed in compiling and reporting the data. There were two primary data sources used in the process: the most recently-available demographic, socioeconomic, and health indicators commonly examined in needs assessments; and data collected from a community survey to help put a human face on the statistics. The community input a widely distributed online and hard-copy survey, and key informant interviews intended to solicit opinions about health needs and suggestions for improvements validated and enriched the statistical data. It should be noted that other reports of this kind may include data that is not up-to-date. This 2013 Adena Health System/ Community Health Needs Assessment provides an overview of the state of health-related needs in Pike County, and benchmarks from which to gauge progress. It also provides documentation and information for decision-making to direct funding towards the community s highest-priority health needs. 5

Key Demographics and Health Factors Data was collected from a variety of primary and secondary data sources. Secondary data on Pike County mortality rates, demographics, socioeconomic factors, disease prevalence and health factors was pulled from sources such as the Ohio Department of Health and the U.S. Census Bureau. Primary data was compiled from the public survey and key stakeholder interviews. In addition, disease prevalence of Pike County patient population served by Adena Health System was also pulled from the business platform attached to the electronic medical record system. The following are the key findings: Demographics The 2010 U.S. Census indicates the population of Pike County (28,685) has increased more than 3% since the 2000 Census. Racial and ethnic diversity in Pike County and Adena s 12 county service region is less than half of the Ohio and U.S. averages. The number of children under the age of 19 in Pike County is higher (28.3%) as compared with Ohio (26.7%) and the U.S. (27%). The number of divorced men and women in Pike County is 2-3% higher than the Ohio and U.S. averages. Socioeconomic Factors Approximately 12.6% of the population of Pike County holds a Bachelor s degree or higher which is much lower than the Ohio (24.5%) and U.S. (28%) averages. About 22% have not completed high school which is higher than the rest of the service region (18.9%), Ohio (12.2%) and U.S. (14.6%) averages. Unemployment in Pike County (10.7%) is much higher than the Ohio (6%) and the U.S. unemployment rates. Approximately 44% of the population in Pike County is not in the work force as compared with 35.4% in the rest of Ohio and the U.S. (35.2%). The per capita income in Pike County is $18,715, which is lower than the rest of its service region ($19,514), Ohio ($25,618) and the U.S. ($27,915). The number of individuals living at poverty level in Pike County is 22.5%, which is higher than the rest of its service region (20.4%), Ohio (14.8%) and the U.S. (14.3%). The number of children living in poverty in Pike County is 31%, which is higher than the rest of the service region (27.7%) and much worse than Ohio (21.7%) and the U.S. (20%). 6

Health Factors Out of Ohio s 88 counties, Pike County is ranked in the bottom 25% in the 2013 County Health Rankings at 80 for health outcomes and 86 for health factors. For every primary care provider in Pike County, there are 1,523 patients. This is a lower ratio than the rest of the service region (3,412:1) but still more than the ratio for Ohio (1,101:1). For every mental health care provider in Pike County there are 27,909 patients. This ratio is much worse than the rest of the service region (12,571:1) and Ohio (2,181:1). Heart disease, cancer and chronic lower respiratory diseases are the three leading causes of death in Pike County. Nearly 15% of the Pike County residents served by Adena Health System have been diagnosed with diabetes. More than 38% of Pike County residents served have high blood pressure and 38.9% have high cholesterol. Infant mortality rates in Pike County are 18.6 which is much worse than the service region, (10.7), Ohio (7.7) and U.S. (6.9) rates. 7

Public Opinion The tables below describe what the community has identified as the most important health related needs and challenges in Pike County. Approximately 53% of survey respondents rated their health as good while only 12% rated their health as excellent. Key stakeholders indicated that obesity and drug abuse were their top public health concerns for the county. The findings are consistent with public data needs assessments, studies, and surveys conducted by others in Pike County. ` 8

PRIORITIES AND STRATEGIES Comprehensive analysis of the demographic and health factors data, as well as the public opinion data was completed. This included summarizing the leading causes of death, top conditions and diseases reported through public health data as well as from the public survey. The following health priorities were identified: Mortality Top 4 Vital Statistics Heart Disease Cancer Chronic Lower Respiratory Diseases Accidents /Unintentional Injuries Health Factors & Public Opinion Top Community Health Needs Overweight/Obese High Blood Pressure Joint/Back Pain Mental and Behavioral Health Problems (stress, addiction and depression) Smoking 9

After identifying the health priorities, a thorough analysis was completed. Relationships between the mortality rates, health factors and public opinion were reviewed and discussed. It was noted that obesity linked to the majority of the priorities list. The team then compared the information with research from the National Institutes of Health (NIH) and Centers for Disease Control (CDC) which outlined the linkage of obesity to certain diseases and conditions. Obesity was further highlighed as the primary public health threat in Pike County. The diagram below demonstrates all of the diseases and conditions NIH and the CDC consider, through their sponsored research, strongly correlated to obesity. The diseases and conditions that appear on the Pike County s 2013 Community Health Needs Assessment are highlighted in red. Hypertension Psychosocial Issues Dyslipidemia Reproductive Challenges Diabetes Mellitus Cancer Obesity Coronary Heart Disease Sleep Apnea Congestive Heart Failure Osteoarthritis Stroke Gallstones 10

CONCLUSION Based on the strong correlation obesity has on many of the health priorities that surfaced from the 2013 Pike County Community Health Needs Assessment, it was determined that it would be the primary community health focus. Preliminary review of information on evidence based interventions that can be delivered as part of a community wide initiative indicate impact on obesity is best seen with long-term efforts and commitment. The 2013 Pike County Community Health Needs Assessment team has recommended obesity become the primary health need addressed by AHS in Pike County over the next 10 years. Other health priorities in Pike County, not directly correlated to obesity but recognized in the community as a health concern, will also be addressed in the community by in a secondary level of engagement. Strategies for addressing both the priority and secondary health needs are outlined below. 2013 Pike County Community Health Needs Assessment Community Health Focus and Priorities Focus Health Priorities Strategies Priority Obesity High Blood Pressure Regional Initiatives Joint/Back Pain Community Programming Heart Disease Employee Health Initiatives Secondary Mental/Behavioral Health Stress Depression Drug Abuse Smoking Advocacy Referral Resources Cessation Resources 11

INTRODUCTION Community Health and Needs Assessment The term health is a multi-faceted concept, particularly from a community perspective. An individual s health is measured by presence and/or severity of a life-threatening illness, whether or not they engage in behaviors that are a risk to their health, and if so, the length of time that has occurred. It can also be measured by asking the individual to report their personal perception of their overall health. The health of an entire community is measured by collecting and compiling the individual data. Commonly used measurements of population health status are morbidity (incidence and prevalence of disease) and mortality (death rates). Socioeconomic data is usually included as it relates to the environment in which individuals live. A particular population s level of health is usually determined by comparing it to other populations or by looking at health related trends over time. Everyone in a community has a stake in health. Poor health is costly to individuals trying to maintain employment and to employers who pay for sickness with high rates of absenteeism and higher health insurance costs. Entire communities can suffer economic losses when groups of citizens are ill. As a result, everyone benefits from the addressing of social, environmental, economic, and behavioral determinants of health. Health status is closely related to a number of socioeconomic characteristics. Individuals of different socioeconomic status show different levels of health and incidence of disease, and race and ethnicity matter in complex ways. Social and economic variables that have been shown to affect health include income, education, employment and even literacy, language and culture. Health literacy is a concept that links a person s level of literacy with their ability to understand and act upon health information and, ultimately, to take control of their health. Individuals with poor health literacy who tend to be poorly educated, immigrants, elderly or members of racial/ethnic minority groups are at risk for poor health outcomes when important health care information is communicated using medical jargon and unclear language that exceed their literacy skills. These individuals can have problems reading materials such as prescription bottles, educational brochures, and nutrition labels and are more likely to have higher rates of complications than people who are more literate. Conducting a comprehensive community health needs assessment can provide a better understanding about the health needs, disparities and available resources experienced by a population. The IRS now requires all 501(c) (3) health systems operating one or more hospitals to complete one every three years for each hospital. The purpose is to provide health systems with a foundation for their community health planning and provide information to policymakers, provider groups and community advocates for improvement efforts, including the best ways to direct health-related grants and appropriations. Obtaining information and views from community members themselves is one of the most important aspects of the community health needs assessment. This involves surveying a certain percentage of the community to find out which health problems are most prevalent and soliciting their ideas about strategies to address them. It also explores the factors that affect the design of programs and services to effectively address the identified health problems on a broader scope. 12

The U.S. Department of Health and Human Services established four overarching health goals for the year 2020: 1. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. 2. Achieve health equity, eliminate disparities, and improve the health of all groups. 3. Create social and physical environments that promote good health for all. 4. Promote quality of life, healthy development, and healthy behaviors acpike all life stages. To achieve these goals, a comprehensive set of objectives was established (Healthy People 2020) with 26 leading health indicators that will be used to set priorities and measure health over a ten year period. These indicators, selected on the basis of their ability to motivate action, the availability of data to measure progress, and their importance as health issues for the public, influenced the development of APMC s 2013 Pike County Community Health Needs Assessment. The Pike County Community and APMC Pike County, home of the (APMC), is located in south central Ohio in the 2nd Congressional District and is one of Ohio s 32 Appalachian Counties. It contains the population patterns and distinct economic conditions inherent of this region of the U.S and faces similar challenges in diversifying its economy to improve the lives of its 26,066 residents. U.S. Department of Health and Human Services Healthy People 2020 Leading Health Indicators Access to Health Services Clinical Preventive Services Environmental Quality Injury and Violence Maternal, Infant, and Child Health Mental Health Nutrition, Physical Activity, and Obesity Oral Health Reproductive and Sexual Health APMC is a part of Adena Health System which is based Social Determinants out of its regional medical Substance Abuse center in Ross County Ohio, just north of Chillicothe. The Tobacco system provides its leading edge services including heart, cancer, women's health, children's health and orthopedics to the 513,937 residents of a 12 county Appalachian region of southeastern, Ohio. The service region includes the neighboring counties of Fayette, Highland, Hocking, Jackson, Pickaway,Pike, and Vinton Counties. Patients from Adams, Athens, Gallia, and Scioto are also served. The Adena Health System s other Pike County locations include: Adena Family Medicine practice in Piketon Adena Health Center located in Waverly 13

PROCESS Data Acquisition The AHS/APMC 2013 Community Health Needs Assessment was completed through a comprehensive process of data collection and evaluation. Per the requirements of the IRS, the data for this report reflects Pike County only (the immediate service region of APMC) and not the entire Adena Health System service region. However, data for Pike County is compared with the rest of the service region as many patients from neighboring counties seek services at APMC. Both qualitative and quantitative data were collected from primary and secondary sources. This information was then compiled and evaluated by the project team, focus groups and committees to identify specific health related priorities. The published assessment completed as part of these efforts is intended to inform decision makers and funders about the challenges Pike County and AHS/APMC faces in improving community health, and the priority areas where support is most needed. The information is also useful for community organizations as a planning reference. Methods Quantitative and qualitative methods were used to collect information for this assessment. Quantitative data collected includes demographic data for the county s population, vital statistics such as birth and death rates, and disease prevalence for both the county as a whole and the Pike County patients served by AHS/APMC. Qualitative data for this report was collected to provide greater insight to the issues experienced by the population. Data includes opinions expressed from a widely distributed community health survey which received more than 1,600 responses, as well as community stakeholder interviews. Source Primary and secondary data sources were used as part of the needs assessment and came from both internal and external sources. Internal data came from within the health system/hospital (patient population data) and external from outside the health system/hospital (county and state). The primary data gathered includes new information to investigate and help solve a problem. An example of this would be the percentage of survey participants who ranked obesity as a top-10 health problem. Secondary data are the statistics and other data already published or reported to government agencies. An example of this would be rates of childhood obesity. Secondary Data: Publicly-Available Statistics Existing data were collected from all applicable local, state and federal agency sources particularly public health agencies (e.g., Ohio Department of Health, Ohio Department of Job and Family Services, U.S. Department of Labor, U.S. Census Bureau). These data included demographics, economic and health status indicators, and service capacity/ availability. While data at the national and state level are generally available for community health-related indicators, local data from counties and cities are less accessible and sometimes less reliable. Data from publicly-available sources also typically lags by at least two years because it takes time for reported data to be received, reviewed, approved, analyzed, and prepared for presentation. 14

Primary Data: Community Input A community survey and key stakeholder interviews were the primary methods of collecting input from the community and were used in the assessment process. The survey was conducted simultaneously in Pike and Ross counties in the month of May during 2013. Respondents were asked to provide their zip code so that Ross County and Pike county data could be clearly identified and separated. Community Questionnaire A questionnaire was developed for the general public that inquired about most-important health needs, common barriers, and habits they used to maintain their own personal health (See Attachment 1). The survey was distributed in hard copy by the Adena Health System Community Health Office and community partners to a variety of locations in Ross and Pike counties where the groups of interest would best be reached. These included local food banks, social service providers, YMCAs, churches, community health clinics and Adena physician offices. In addition, the survey was made available online through Survey Monkey. Notices about the online version with its link were posted on the Adena Health System and partner websites, published in the Chillicothe Gazette, Pike News Watchman, broadcast on local Clear Channel radio stations and emailed to all members of local business, government, civic groups, schools and universities. All of the hard-copy survey data was entered into the electronic Survey Monkey by Adena interns, then extracted into an Excel spreadsheet. Key Informant Interviews Telephone and face-to-face interviews using the community survey questions were conducted, primarily individually, with community, government and public health representatives whose perceptions and experience were intended to inform the assessment. The interviews provided an informed perspective from those working in the community with an increased awareness about agencies and services. Most offered input about gaps and possible duplications in service, and offered ideas about possible solutions and partnership opportunities. The interviews also focused the needs assessment on particular issues of concern where individuals with particular expertise could confirm or dispute patterns in the data and identify data and other studies of which the project team might not otherwise be aware. Priority-Setting Process After the assessment data were compiled and analyzed, the project team reviewed the draft assessment report and engaged the Adena Health System Strategy Division; Health & Wellness Committee; Operations Team; Clinical, Fiscal & Quality Integration Committee; and Senior Executive Committee in discussions that led to recommended system priorities. The process included determining criteria for selecting priorities; listing key hospital issues and common themes; identifying findings; addressing the challenges and barriers; and identifying opportunities for long-term efforts for improving community health in Pike County. The final data compilation and recommended priorities were then taken before the Board of Directors and the Adena Health System Board of Trustees for final approval. 15

DATA Community Profile A profile of Pike County and its residents was formulated by collecting publicly available data such as vital statistics, economic and education data. Research shows that sociological and economic factors effect health in complicated ways, so it is understood that this information must be reviewed with public opinion data to develop a clear understanding of the state of health of a particular community. Persons 35-64 years of age represent the 42.8% of Pike County s population. Residents aged 20-34 (18.7%) represent the same as Ohio (18.9%), but lower than the U.S. (20.3%). Racial/ethnic diversity is also more limited in Pike County and in the 12-county service region as compared with Ohio and the U.S. Demographic Information The total population of Pike County Ohio is 28,685. It represents 5.6% of the total population of the total Adena Health System service region. The county, as well as the remainder of the 12 county service region, has similar demographics as the state of Ohio and U.S. Over 57% of the population is between the ages of 20 and 64 and 14.5% of the population is over the age of 65. Less than 4% of the population is a race or ethnicity other than white. Population Demographics Pike Table 1: Pike County Demographics 12 County Region Ohio U.S. Total Population 28,685 514,516 11,536,504 308,745,538 Age 0-19 Years 28.3% 26.5% 26.7% 27.0% 20-34 Years 17.1% 20.0% 18.9% 20.3% 35-64 Years & Older 40.1% 39.6% 40.5% 39.7% 65+ 14.5% 13.9% 13.9% 13.0% Race & Ethnicity African American 0.7% 2.4% 12.1% 12.6% Asian 0.2% 0.6% 1.7% 4.8% Hispanic 0.8% 1.0% 3.0% 16.4% American Indian/Alaska Native 0.7% 0.2% 0.2% 0.9% Native Hawaiian/Pacific Islander 0.1% 0.0% 0.0% 0.2% White 96.8% 94.5% 83.2% 63.7% Other 80.0% 1.3% 0.0% 0.0% Gender Male 50.0% 49.9% 48.8% 49.2% Female 50.0% 50.1% 51.2% 50.8% Source: 2007-2011 American Community Survey (U.S. Census Bureau) 16

Household Information There are 10,816 households in Pike County. The average household size is 2.61 people, comparable with the rest of the 12 county service region and Ohio. The average family size is as well with 3.11 people. A little more than 50% of the population is now married which is comparable with Ohio and national averages; more than 14% of men and women are divorced which is noticeably higher than the state averages. The average household size (2.61) and the average family size (3.11) is larger in Pike County than the rest of the service region and Ohio. Table 2: Pike County Household Information 12 County Service Households Pike Region Ohio Size Total Households 10,816 191,888 4,554,007 Average Household Size 2.61 2.53 2.46 Average Family Size 3.11 3.02 3.05 Grandparents as Caregivers Grandparents who are responsible for grandchildren 37.40% 44.40% 46.80% Marital Status Never Married Males 26.4% 29.60% 32.90% Never Married Females 19.6% 22.50% 27.20% Now Married Males 53.3% 52.70% 52.10% Now Married Females 50.8% 50.90% 47.80% Separated Males 2.7% 2.10% 1.60% Separated Females 3.4% 2.20% 2.00% Widowed Males 3.3% 3.50% 2.90% Widowed Females 11.3% 11.00% 10.20% Divorced Males 14.2% 12.10% 10.50% Divorced Females 14.8% 13.30% 12.70% Source: 2007-2011 American Community Survey (U.S. Census Bureau) 17

Education Level Approximately 22% of the adults in Pike County have not graduated from high school. This percentage is higher than the averages for the region (18.9%), Ohio (12.2%) and the nation (14.6%). More than 11% of the population of Pike County is estimated to be functionally illiterate, or lacking the reading and writing skills sufficient for ordinary practical needs. Educational attainment and literacy levels are lower Pike County than in the rest of the service region, Ohio and U.S. Table 3: Pike County Educational Attainment Education Level Pike County 12 County Service Region Ohio U.S. No High School 7.60% 5.80% 3.40% 6.10% Some High School 14.40% 13.10% 8.80% 8.50% High School Graduate 43.80% 42.90% 35.40% 28.60% Some College 15.50% 17.40% 20.50% 21.00% Associate's Degree 6.20% 7.20% 7.50% 7.60% Bachelor's Degree 7.00% 5.70% 15.50% 17.70% Graduate or Professional Degree 5.60% 5.70% 9.00% 10.50% Functionally Illiterate 11.70% 11.00% 9.10% Source: 2007-2011 American Community Survey (U.S. Census Bureau) Employment Status The unemployment rate in Pike County (10.7%) is considerably higher than the regional (6.8%), state (6%) and U.S. (7.7%) averages. In addition, more than 44.5% of the population is not in the workforce. This is higher than the state (35.4%) and national averages (35.2%). Table 4: Pike County Employment Employment Status Pike County 12 County Service Region Ohio U.S. In Labor Force 55.50% 56.50% 64.60% 64.80% Civilian Labor Force 55.50% 56.50% 64.50% 64.80% Employed 44.80% 49.70% 58.50% 58.80% Unemployed 10.70% 6.80% 6.00% 7.70% Armed Forces 0.10% 10.00% 10.00% 0.50% Not In Labor Force 44.50% 43.50% 35.40% 35.20% Source: 2007-2011 American Community Survey (U.S. Census Bureau) 18

Occupation & Industry The top five employment industries in Pike County are Management/Business/Science (28.9%), Service (21.5%) Sales (23%), Production/Transportation Services (19.2%), Sales (18.2%), and Natural Resources/Construction/Maintenance. Pike County has a greater percentage of people employed in production, transportation and material moving occupations (19.2%) than the regional, state and national averages. While the highest percentage of Pike County residents (28.6%) are employed in management, business, science and arts occupations, this is less than regional, state and national averages. Education, healthcare and social service are the primary industries in Pike County. Table 5: Pike County Industry Industry & Occupation Pike Region Ohio U.S. Employment Occupations Management, business, science, and arts occupations 28.9% 28.9% 33.8% 35.70% Service occupations 21.5% 18.8% 17.4% 17.50% Sales and office occupations 18.2% 21.6% 25.0% 25.10% Natural resources, construction, and maintenance occupations 12.2% 11.4% 8.1% 9.50% Production, transportation, and material moving occupations 19.2% 19.3% 15.7% 12.20% Employment Industry Agriculture, forestry, fishing and hunting, and mining 3.8% 2.6% 1.0% 1.9% Construction 9.3% 7.5% 5.4% 6.8% Manufacturing 13.6% 14.9% 15.7% 10.8% Wholesale trade 1.9% 2.0% 2.9% 2.9% Retail trade 9.6% 11.5% 11.7% 11.5% Transportation and warehousing, and utilities 4.9% 6.7% 4.9% 5.1% Information.70% 1.7% 1.9% 2.3% Finance and insurance, and real estate and rental and leasing 4.2% 4.2% 6.5% 6.9% Professional, scientific, and management, and administrative and waste management services 6.5% 6.0% 9.1% 10.5% Educational services, and health care and social assistance 24.2% 25.1% 23.9% 22.5% Arts, entertainment, and recreation, and accommodation and food services 9.0% 8.4% 8.6% 9.0% Other services, except public administration 5.5% 4.5% 4.5% 4.9% Public administration 6.8% 4.9% 4.0% 4.9% Source: 2007-2011 American Community Survey (U.S. Census Bureau) 19

Income & Poverty The per capita, median and mean household incomes in Pike County Ohio are much lower than the state and U.S. averages. Poverty rates are also higher than regional, state and national averages. Access to employment in Pike County is also lower than other counties in the region. Table 6: Pike County Income and Poverty Rates United Pike Region Ohio Income and Poverty States Per Capita Income $ 18,715.00 $ 19,513.92 $ 25,618.00 $ 27,915.00 Median Household Income $ 39,669.00 $ 39,643.67 $ 48,071.00 $ 52,762.00 Mean Household Income $ 48,622.00 $ 50,741.83 $ 63,477.00 $ 72,555.00 Families Below Poverty Status 16.9% 15.2% 10.8% 10.5% Individuals Below Poverty Status 22.5% 20.4% 14.8% 14.3% Under 18 Years 31.0% 27.7% 21.2% 20.0% 18 to 64 Years 20.8% 19.5% 13.7% 13.1% 65 Years and Over 13.9% 11.1% 8.1% 9.4% 2007-2011 American Community Survey (US Census Bureau) Veteran Population There are 7,697 civilian veterans living in Pike County, accounting for almost 10% of the region s population. The total civilian veterans within the Adena Health System 12-county service region represent 5% of Ohio s total civilian veteran population. Table 7: Pike County Veterans Veteran Status Pike Region Ohio U.S. Civilian Veterans 7,697 42,293 914,971 22,215,303 Percentage of Total Population 9.8% 8.2% 7.9% 7.2% 2007-2011 American Community Survey (US Census Bureau) 20

Disabilities Pike County and its entire surrounding service region have a higher prevalence of disability than the rest of Ohio. Seven of the 12 counties in the service region, including Pike County, have disability prevalence rates of 16.7% - 22%. Figure 1: Service Region Disability Prevalence 2007-2011 American Community Survey (US Census Bureau) 21

County Health Rankings The economic and educational challenges experienced in Pike County and the 12 county surrounding region have been correlated to declining health throughout Adena Health System s 12 county service region. Several counties, including Pike County, are considered some of Ohio s unhealthiest. A 2013 report published by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, County Health Rankings: Mobilizing Action Toward Community Health (www.countyhelathrankings.org/ohio). In overall positive health outcomes, the State of Ohio ranked 42 nd nationally. All 88 counties in Ohio were then ranked both related to health outcomes and health factors. Rates of death from cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and those with Type II diabetes are all well above state and national averages. Nine of twelve counties within the Table 8: Service Region Health Rankings 2013 County Health Rankings 12 County Service Region Health Outcome Ranking Health Factors Ranking Adams 85 84 Athens 61 51 Fayette 77 37 Gallia 81 69 Highland 76 41 Hocking 58 61 Jackson 85 73 Pickaway 42 38 Pike 80 86 Pike 78 83 Scioto 88 88 Vinton 82 81 service region are ranked in the bottom 25% of all counties in Ohio related to health outcomes and six out of twelve were ranked in the bottom 25% for health factors. Jackson, Pike, Pike and Vinton were in the bottom 25% in both categories. 22

Health System and Hospital Utilization The utilization of health system services by the population of Pike County, and throughout the 12 county service region, provides indicators about population health. Approximately 80% of the patients served by the system reside in Pike County. Utilized Services In 2012, AHS, throughout its 12 county service region, had more than 500,000 patient encounters that included 13,600 inpatient visits, 450,000 outpatient visits, 1,110 births, and 60,000 emergency room visits. The percentage of patients diagnosed with diabetes and heart disease are higher among the patient population served in the health system than state estimates. Table 9: Service Region Disease Prevalence Illness/ Condition Patient Sample Stroke Diabetes Coronary Artery Disease Cancer COPD Asthma High Blood Pressure High Cholesterol County Total % % % % % % % % Adams 572 4.0% 15.6% 11.5% 0.7% 8.6% 9.4% 36.7% 32.7% Athens 146 1.4% 8.9% 6.2% 0.0% 19.9% 6.8% 73.3% 65.8% Fayette 1,634 1.8% 15.4% 8.3% 0.3% 7.5% 8.3% 37.9% 33.4% Gallia 665 1.7% 14.6% 10.8% 0.5% 10.4% 9.3% 37.7% 36.1% Highland 4,112 2.5% 14.1% 9.7% 0.2% 8.9% 8.9% 35.7% 31.0% Hocking 810 4.0% 15.9% 10.7% 0.1% 11.2% 10.5% 35.2% 35.9% Jackson 8,705 2.1% 12.2% 8.3% 0.2% 9.7% 8.9% 33.8% 34.5% Pickaway 2,537 3.2% 15.4% 8.4% 0.5% 7.9% 9.7% 37.1% 34.7% Pike 10,464 3.1% 14.9% 10.3% 0.3% 8.5% 11.3% 38.2% 38.1% Pike 43,908 3.7% 16.2% 11.1% 0.3% 9.5% 11.3% 40.5% 38.9% Scioto 1,349 2.2% 13.8% 5.9% 0.1% 6.1% 10.2% 32.2% 34.0% Vinton 2,737 2.5% 15.3% 11.0% 0.2% 10.0% 10.5% 37.1% 39.2% Total 77,639 2.7% 14.4% 9.3% 0.3% 9.8% 9.6% 39.6% 37.9% *2012 Patient Population Data from Adena Health System Meditech Reporting, June 2013 23

Healthcare Access Access to healthcare is determined by both the availability of healthcare providers and resources, as well as payment resources. Accessibility plays a large role in the overall health population as it can determine whether disease prevention and intervention happen in a timely manner. Healthcare Providers Pike County has a better patient-to-primary care provider ratio than the 12-county service region, and is not considered a health professional shortage area. However, access is still more limited as There are 27,909 patients for every mental health care provider in Pike County. This is significantly higher than the regional ratio (12,571:0), and Ohio (2,181:1). compared with Ohio and U.S. Mental and oral health ratios are also considerably are much worse than the regional, state and national ratios. Table 10: Pike County Health Access Health Access Pike County 12 County Service Region Ohio Primary Care Providers per patient 2,791 3,412 1,101 Mental Health Providers per patient 27,909 12,571 2,181 Oral Health Providers per patient 4,774 4,844 2,435 Health Professional Shortage Area *County Health Rankings, RWJF, 2013 Report No 2 Counties (Adam and Vinton) No Health Insurance Health insurance is a key determinant of an individual s probability of seeking healthcare services. Among those with health insurance in Pike County, more are covered with public health insurance than private. More than 14% of the population does not have health insurance. More than 14% of the population of Pike County is uninsured, which is less than the 12 county service region (15.4%) and U.S. (15.1%) averages, but still higher than the Ohio average (11.9%). The number of those with public insurance (45.1%) is significantly higher than OH (31.2%) and U.S. averages (30.5%). Table 11: Pike County Insurance Coverage Insurance Status * Pike County 12 County Service Region Ohio U.S. With Private Health Insurance 40.5% 45.1% 69.0% 65.2% With Public Health Insurance 45.1% 39.6% 31.2% 30.5% No Health Insurance 14.4% 15.4% 11.9% 15.1% * Truven Health Data, 2013 24

Death and Illness The leading causes of death, illness, and injury are indicators to the primary health challenges of a population in a particular region. They can also indicate what health risk factors are most prevalent among a population. Heart disease is the number one cause of death in Mortality Rates The top three leading Pike County. The rate of death for chronic lower causes of death in Pike County are heart respiratory diseases in Pike County (65) is higher disease, cancer and chronic lower than the regional (64) and state (50.5) rates. The respiratory diseases. The average rate of rate of death from nephritis, nephritic syndrome death for these conditions is significantly is considerably higher in Pike County (38.1) than higher than the state average. Average the rest of the region (18.3) and Ohio (13.7). rates of death for chronic lower respiratory disease are just a little higher than the state average. Table 12: Pike County Mortality Rates Pike Region Ohio Cause of Death * Number Rate Number Rate Number Rate Diseases of the Heart 217 222.1 342 250.9 81,952 209 Cancer 200 215.1 292.3 218 74,998 195.9 Chronic Lower respiratory Diseases 60 65 83.3 64 19,364 50.5 Accidents/Unintentional Injuries 46 53.7 73.8 61.2 14,644 40.6 Stroke 47 48.6 61.3 45.7 17,275 44.1 Nephritis, Nephritic Syndrome 38.0 38.1 24.2 18.3 5,318.0 13.7 * Ohio Department of Health, Center For Public health Statistics and Informatics, 2010 **Leading causes of death, number and average age adjusted death rates per 100,000 population. Cancer is the second leading cause of death in Pike County. Five types of cancer make up the majority of these deaths, with cancers of the trachea, bronchus and lung being the leading cause. Rates of death from breast and prostrate cancer in the region are significantly lower than the rest of Ohio. The rate of death for trachea, bronchus and lung cancer in Pike County (72.4) is significantly higher than the 12 county service region (69.2) and Ohio (59.7). Rates of death from breast cancer in Pike County (15) are slightly higher than the service region (13.2) but the same as Ohio (15.1). Table 13: Pike County Cancer Mortality Rates of Death From Cancer Pike Region Ohio Type of Cancer * Number Rate Number Rate Number Rate Trachea, Bronchus & Lung 72 72.4 31 69.2 7,411 59.7 Colon, Rectum & Anus 7 22.5 9.8 22.5 2,456 19.6 Pancreas 3 10.2 4.3 9.8 1,381 11.0 Breast (Female) 5 15 5.8 13.2 1889 15.1 Prostate (Male) 2 18.4 3.3 21.7 1,232 26.2 *2006-2008 Ohio Department of Health Vital Statistics **Age -adjusted death rate per 100,000 females ***Age-adjusted death rate per 100,000 males 25

Incidence of Illness and Disease The incidence of illness and disease aligns with the mortality rates in the region and are higher than the state averages. The rate of occurrence for all types of cancer in Pike County (458.8) is similar to its 12 county service region (475.4) and Ohio (470.0). Lung cancer occurrence is higher in Pike County (93.1) than in the rest of the 12 county service region (88.1) and Ohio (75). The occurrence of prostate cancer is lower in Pike County (89.1) than in the rest of the service region (120.4) and Ohio (145.5). Although breast cancer occurs more often in Pike County than any cancer, the rate of occurrence of breast cancer is lower (102.6) in Pike County than the rest of the region (106.2) and Ohio (119.9). The occurrence of cancers of the lung and bronchus in Pike County (93.1) is higher than the 12 county service region (88.1) or the rest of Ohio (75). Table 14: Pike County Cancer Prevalence Illness and Disease Pike Region Ohio Cancer Cases Rate Cases Rate Cases Rate All types 137 458.8 216.8 475.4 58,136.0 470.0 Colon and Rectum 14 48.2 24.3 53.6 6,370.0 51.1 Lung and Bronchus 28 93.1 39.3 88.1 9,295.0 75.0 Breast 16 102.6 24.8 106.2 8,073.0 119.9 Prostate 12 89.1 23.8 120.4 7,961.0 145.5 *Chronic Disease and Behavioral Epidemiology Section and the Vital Statistics Program, Ohio Department of Health, 2010. Average annual rate per 100,000, age-adjusted to the 2000 US standard population. Rate not calculated when the case count for 2003-2007 is less than five (i.e., the average annual count is less than one) 26

Health Risk Factors A risk factor is any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury. Conditions and Illnesses Common conditions and illnesses prevalent in Pike County and its surrounding community include obesity, hypertension, heart disease and diabetes. Most of the data available for the incidence of these conditions is either estimated from surveys conducted through the region and is more than 5 years old. Pike County s data aligns with the rest of the service region and Ohio with the exception of high cholesterol. Those from Pike County who indicate they have been told they are overweight is slightly higher (34.6%) than the 12 county service region (32.2) but less than the state average. Table 15: Pike County Illness and Disease Prevalence Pike Region Ohio Illness and Disease Ever told overweight* 34.6% 32.2% 35.9% Ever told obese* 25.7% 29.1% 26.3% Ever told cholesterol was high* 36.9% 51.5% 37.9% Ever told blood pressure was high* 26.6% 29.9% 27.6% Ever told had heart disease* 4.7% 5.6% 4.8% Diabetes* 8.1% 8.2% 7.9% Arthritis* 30.7% 30.6% 31.3% Asthma** 13.1% 12.8% 14.6% *2004-2007 Ohio Behavioral Risk Factor Surveillance System; Chronic Disease and Behavioral (Estimates) **2006 Asthma Local Profiles, Ohio Department of Health, Ohio Surveillance System for Asthma (OSSA) Maternal Health Maternal health refers to the health of women during pregnancy, childbirth, and the postpartum period. The health care dimensions of family planning, preconception, prenatal, and postnatal care are encompassed in order to reduce maternal morbidity and mortality. The infant mortality rate in Pike County is 18.6 which is significantly higher than the service region (10.7), Ohio (7.7) and the U.S. (6.9) Pre-term births and maternal smoking are also much higher. Table 16: Pike County Maternal Health Maternal Health Pike Region Ohio Indicators * Total Births 358 5,787 139,034 Low Birth Weight 9.2% 8.5% 8.5% Maternal Smoking 29.6% 26.4% 17.8% Teen Birth Rate 17.6% 17.7% 16.3% Preterm 16.8% 12.6% 12.5% Unmarried 52.4% 45.1% 43.7% Infant Mortality Rate ** 18.6 10.7 7.7 *From the 2010 Census * *Per 1,000 births, From the Ohio Department of Health, 2010 27

Health Risks and Behaviors Health behaviors are actions that effect the development of illness and promote health. Healthy behaviors such as regular exercise and proper nutrition have been shown to lower the risk of developing heart disease and certain cancers, while unhealthy behaviors such as smoking and lack of exercise have been known to cause them. Table 17: Pike County Health Behaviors Health Risks and Behaviors Pike Region Ohio Behaviors Adult Smoking * 23.8% 26.5% 22.0% Adult Obesity* 33.0% 32.8% 29.6% Physical Inactivity* 36.0% 32.5% Sexually Transmitted Infections ** 122 171 420 Teen Pregnancy Rate *** 13.4% 29 29 Teen Birth Rate **** 13.4% 12.6% 9.8% Fast Food Restaurants 56.0% 55.8% 55.0% *2008 Healthy Ohio Program Survey ** Ohio Department of Health Vital Statistics, 2010 Census ***County Health Rankings and Roadmaps, RWJF 2012 ****Birth rate for females ages 10-19, Ohio Department of Health Vital Statistics, 2010 Census Rate per 1,000 pregnancies, Ohio Department of Health Vital Statistics, 2010 28

PUBLIC OPINION A risk factor is any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury. By conducting a public survey to compile information related to individual health factors and behaviors insight into the broader health gaps and needs of a community can be obtained. As part of the 2013 Pike County Community Health Needs Assessment, the team collected and compiled information related to individual health status and behaviors. This was done via a survey (Attachment 1) and through key stakeholder interviews. Community Leader and Stakeholder Responses Characteristics of the Sample Five out of 9 individuals identified as key informants and contacted agreed to participate in an interview. Follow-up emails and telephone calls were made to nonrespondents to encourage their participation. Attachment 2 lists the key informants who completed an interview. The interviewees represented a broad section of Pike County health and human service community that, in addition to health care professionals and leaders from public and community-based organizations. These included policy makers, advocates, and individuals with a broad perspective about unmet health needs. While most of the interviewees spoke to the issues they knew best from their professional roles, the majority were also able to consider and describe additional health-related needs when prompted with questions to help them think about geographical, age, gender, race/ethnicity, and other factors that influence community health and access to services. Most respondents indicated that the economy, obesity, drug abuse and cancer in Pike County and the surrounding region were health issues of concern, one believing it should be a priority concern and cited specific statistics to support the opinion. I must stress the importance of jobs in the county for improving health and the importance of access to healthy foods such as fruits and vegetables Community Health Leader 29

Survey Distribution and Responses The 2013 Center Community Health Needs Survey (Attachment 1) was distributed online and in hard copy at various community locations throughout Pike and Ross Counties in an attempt to gain a wider understanding of the health needs of those who live here. Examples of sites that hosted the questionnaire which included placements intended to reach higher-risk populations local food banks, social service providers, YMCAs, churches, community health clinics and Adena physician offices. In addition, the survey was made available online through Survey Monkey. Notices about the online version with its link were posted on the Adena Health System and partner websites, published in the Chillicothe Gazette, Pike News Watchman, broadcast on local Clear Channel radio stations and emailed to all members of local business, government, civic groups, schools and universities. Surveys for both Adena Regional Medical Center and were conducted simultaneously. In total, 1,635 surveys were completed. It should be noted a total of 37 respondents did not provide their zip code and 108 provided a zip code outside of Pike and Pike Counties. These surveys were not included in the compiled data for Pike or Pike County. A total of 338 surveys were completed by respondents providing a Pike County zip code. A total of 277 of those surveys were returned in hard copy. Table 18: Pike County Survey Respondents Identifier Gender Age Employment Status Respondents Male 30.8% Female 69.2% Under 18 0.9% 18-25 6.0% 26-34 9.2% 35-45 14.9% 46-55 20.2% 56-64 14.0% 65+ 34.8% Full Time 31.6% Part Time 10.6% Unemployed 57.7% 30

Perceived Personal and Community Health Status To determine the community s perspectives about health priorities, respondents were asked to provide information related to their perception of their personal health and that of the community. Information included: rating the top 4 issues they perceived to affect the health of Pike County residents, identifying the top 3 personal health challenges they face; and providing their opinion on what they perceive to be the biggest health challenges for the community. Respondents were also asked to indicate which health topics were the most important to them and their family. More than half of Pike County respondents perceive their own health to be good. Only 12% consider their health to be excellent, while 10% believe their health to be poor. Figure 2: Overall perceived Health Rating Poor 10% Excellent 12% Fair 25% Good 53% Pike County Community Health Issues Although there is a certain amount of overlap among some of the categories, it was beneficial to segregate these items to show specificity and detail. More than 66% of respondents believed obesity to be the top health issue affecting the community. More than 48% believed stress was the next health issue followed by drug abuse at 41.9%. Almost 44% of respondents indicated that high blood pressure was one of the top health challenges they faced and 35.4% believed that it along with diabetes were the top health topics that interested them and/or their family. Out of 23 possible issues, respondents indicated that obesity, stress, drug abuse and unemployment were the top issues affecting their community. Diabetes was close as the fifth issues prioritized. 31

Figure 3: Top Community Health Issues Not Immunized 1.8% HIV/AIDS 2.4% Sexually Transmitted Diseases Homelessness Violence At-Risk Youth Literacy Lack of Mental Health Resources Dental Health Teen Pregnancy Asthma Domestic Violence Alcohol Abuse Parenting Issues Lack of Health Insurance Poor Nutrition Heart Disease Cancer Diabetes Unemployment Drug Abuse Stress 4.5% 6.0% 8.4% 8.7% 9.3% 12.9% 12.9% 13.5% 13.5% 15.9% 17.4% 20.1% 20.7% 23.4% 27.2% 30.5% 33.5% 40.1% 41.9% 48.2% Obesity 66.5% 32

Individual Health Issues Respondents were asked their opinion regarding the top 3 health challenges they face as individuals. Out of 14 possible issues, the top three indicated were high blood pressure, joint and back pain, and being overweight/obese. Approximately 24% of respondents also indicated they suffered from diabetes. Figure 4: Top Individual Health Issues Drug Addiction1.60% Stroke1.60% Lung Disease 6.20% Mental Health Issues 8.40% Cancer 10.00% Asthma 10.60% Heart Disease 11.20% Smoking Addiction 12.10% No health challenges 13.10% Depression 19.30% Diabetes 24.00% Overwieght/Obesity 35.20% Joint and Back Pain 40.50% High Blood Pressure 43.60% 33

Health Topics Respondents were also asked about their opinion regarding the top 3 health topics they felt were the most important to them and their family. Out of 24 possible issues, the top three indicated were diabetes, high blood pressure and cancer. More than 27% of respondents indicated stress management was a health topic of interest. Figure 5: Top Health Topics of Interest HIV/AIDS0.3% STD's0.6% Violence Prevention0.6% Pregnancy Health Immunizations Flu CPR First Aid Oral Health Substance Abuse Injury Prevention Men's Health Pediatric Care 1.6% 1.6% 1.9% 1.9% 3.5% 3.9% 4.5% 5.5% 7.9% Asthma Quitting Smoking Depression Cholesterol Women's Health Nutrition Heart Disease Exercise Stress Management 14.8% 15.4% 15.8% 16.1% 16.7% 16.7% 21.5% 21.9% 27.7% Cancer Blood Pressure Diabetes 34.1% 35.4% 35.4% 34

Health Habits Respondents were asked to provide information on their own health habits to provide insight on how they manage their health. Questions regarding health behaviors, as well as health care access and usage were asked. Respondents were asked to pick up to four depending on the question. Healthcare Providers Respondents were asked where they go routinely for medical care. Most indicated they seek medical care from their family doctor while the rest indicated some kind of clinic or priority care facility. Approximately 3% indicated they do not seek care from a healthcare provider. Clinics in Drug Stores, Walmart and Grocery Stores 2% I don t seek care 2% Urgent Care Center 10% Free Clinic 4% Emergency Room 4% Family Doctor 69% Specialty Care Physician 9% Figure 6: Healthcare Providers Accessed Healthcare Service Utilization Respondents were asked if they had visited a medical provider within the last year. Most indicated they had seen a family doctor within the last year. More than half indicated they had also seen a dentist and an optometrist within the last year. Figure 7: Healthcare Providers Accessed Yes No 84.8% 61.5% 62.9% 38.5% 37.1% 15.2% Visited Family Physician Within the Last Year Visited Dentist Within the Last Year Visited Optometrist Within the Last Year 35

Health Behaviors Respondents were asked to provide information regarding their own health behaviors. More than 23% indicated that they were a current smoker. When asked to pick the top four out of 12 health habits they believed Approximately 23.2% of respondents indicated they are a smoker, which aligns with the 2008 Healthy Ohio Program Survey. would contribute to their own health, respondents selected not smoking, eating fruits and vegetables, wearing a seatbelt and doing some form of exercise. Less than 28% believed limiting fast food/junk food contributed to better health. Figure 8: Health Behaviors Applying sunscreen 10.9% Limiting alcohol 16.3% Taking vitamins 26.9% Rarely eating fast or junk food 27.2% Practicing faith 33.1% Not using drugs 35.9% Sleeping 7 hours per night 36.9% Brushing teeth/flossing 38.1% Exercising 41.3% Wearing a seatbelt 42.8% Eating fruits and vegetables 47.2% Not smoking 54.7% 36

Health Information Respondents were asked how they obtain health information when it is needed. More than 76% indicated they sought information from a health professional when needed. Half of respondents indicated they look to family and friends for health information. Figure 9: Health Resource Information Sources School1.6% Church 3.5% Library 4.5% Health Department 9.2% Newspaper/Magazine/TV 17.8% Internet 45.2% Friends/Family 51.3% Doctor/Nurse/Medical Professional 76.8% Access to Health Services Respondents were asked how they access healthcare services, and to indicate any barriers experienced when they or their family needed medical/dental care. More than 87% of respondents indicated that they have some form of health insurance. Most also reported that they understand their insurance benefits. Figure 10: Insurance Coverage Figure 11: Do You Understand Your Benefits? Medicaid 15% Medicare 42% Comercial Insurance 43% 59.4% 35.2% 3.6% 1.8% Yes Somewhat No N/A 37

Healthcare Barriers More than 40% reported it was usually a problem to find affordable health care. Over 30% lack health insurance or have poor coverage which limits their access to health insurance. Transportation was also indicated as a common barrier for 23.6% of respondents. 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 40.2% 30.5% 23.6% 15.5% 14.4% 13.8% 9.2% 2.9% 38

PRIORITIZATION PROCESS Data Summary After the primary and secondary data was collected and summarized, the results were then analyzed to identify the opportunities to improve the health of Pike County. First, the top mortality rates, health factors and public needs were summarized. See figure below. Heart disease and obesity were the top needs identified. Figure 13: Needs Assessment Findings Mortality Top 4 Vital Statistics Heart Disease Cancer Chronic Lower Respiratory Diseases Accidents /Unintentional Injuries Health Factors & Public Opinion Top Community Health Needs Overweight/Obese Joint/Back Pain High Blood Pressure Mental and Behavioral Health Problems (stress, addiction and depression) Smoking 39

Relationships The relationship between these results was then analyzed to see if there was a clear priority based on the data collected. As seen in the figure below, most of the current health factors and public needs expressed in the surveys are related to the region s leading cause of death, heart disease. Figure 14: Morbidity and Mortality Relationship Heart Disease Mortality Cancer Mortality Chronic Respiratory Disease Mortality Unintentional Injury Mortality Unclear Obesity Smoking Joint Back Pain (weight related) High Blood Pressure Obesity Smoking Drug Abuse Depression Smoking Stress Stress 40

CDC and NIH Guidance With heart disease indicated as the leading cause of death in the region and obesity ranking high as a public health issue in survey data, more information from the Centers for Disease Control (CDC) and National Institutes of Health (NIH) was reviewed to determine further relevance of obesity to mortality rates. Research conducted through the NIH, supported through the CDC shows that as weight increases to reach the levels referred to as "overweight" and "obese," the risks for conditions such as heart disease, diabetes, cancer (colon, breast, endometrial and gallbladder) and stroke also increases. In addition, NIH reports its research supports a close relationship between obesity and osteoarthritis, sleep apnea, reproductive challenges and psychosocial problems. The figure below outlines the full list presented by NIH in their 1998 report, Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. Those health indicators present on the 2013 Pike County Community Health Needs Assessment are highlighted in red. Figure 15: NIH Health Risks of Obesity Hypertension Psychosocial Issues Dyslipidemia Reproductive Challenges Diabetes Mellitus Cancer Obesity Coronary Heart Disease Sleep Apnea Congestive Heart Failure Osteoarthritis Stroke Gallstones 41

Preventing Heart Disease (through system wide initiatives) Pike County Community Health Needs Assessment 2013 Mission and Capability Alignment This information was also then examined carefully by the ARMC Community Health Team using a decision grid that aligned key outcomes with health determinants, primary drivers, assessment priorities, organizational mission and capabilities. The purpose was to measure the ability of APMC to make an impact on community health. Some of the community health challenges outlined from the assessment align better with the health system s current mission and capabilities. See diagram below. Table 19: Health Risks of Overweight & Obesity Target Outcome Determinants (% of Root Cause/impact) Healthcare (20%) Primary Drivers Preventive Services Acute Care Chronic Disease End of Life Cross-Cutting Issues Community Health Priorities Joint/Back Pain High Blood Pressure Alignment with Mission High Control Central to Mission Many Capabilities Health Behaviors (30%) Tobacco Non-Use Activity Diet/Nutrition Alcohol/Drug Use Overweight/Obese Smoking Shared Control Central to Mission Shared Capabilities Socioeconomic Factors (40%) Environmental Factors (10%) Community Identified Drivers (Advocacy and Participation) Community Identified Drivers (Advocacy and Participation) Stress Drug Abuse Limited Control Aligned With Mission Limited Capabilities Figure 16: Greater Impact With A Primary Focus Obesity Broader Impact Obesity ranked as a health priority Adena could have shared control over, and one that was a foundation for not only the leading cause of death, heart disease, but also a contributor to other mortality rates. As a result of this process, obesity was determined to be the top community health need of APMC, while the remainder would be considered secondary. Preliminary discussion on the length of time and rollout of a community-wide obesity initiative were also held. It was agreed by the committee that a decade-long effort would be required to realize a broader impact of reducing regional heart disease mortality rates. 42

Input and Support The recommendations were then vetted through various internal and external groups/committees to test the results and gather opinions on the committees review and recommendation that obesity, be the Adena Health System s primary community health focus over the next 10 years. Support and approval was given by each of these groups. Figure 17: Support and Approval Process 43

CONCLUSION The APMC Community Health Team intends to ensure that the findings and recommendations from the current needs assessment are widely shared with the community and tracked so that awareness about the priorities and progress in implementing them will be high. The team believes projects based in the community have the best opportunity to make a real difference in the health of individuals and their families and those providing care. Visions for future community support in all of the priority areas will require identifying suitable leadership, raising awareness of stakeholders and determining how to involve them, and agreeing in what areas and how each group will collaborate. Engagement to address the list of community health needs will be prioritized in order to ascertain greater outreach and long-term impact. In addition, different strategies will be used with each of these health needs depending on the capability of ARMC has to address the issue. The following table outlines the 2013 Pike County Community Health Needs priorities and the strategies that will address them. 2013 Pike County Community Health Needs Assessment Community Health Focus and Priorities Focus Health Priorities Strategies Primary Obesity High Blood Pressure Joint/Back Pain Heart Disease Regional Initiatives Community Programming Employee Health Initiatives Secondary Mental/Behavioral Health Smoking Stress Depression Drug Abuse Advocacy Referral Resources Cessation Resources 44

ATTACHMENTS Attachment 1: Community Health Needs Assessment Survey 45