ROSS COUNTY 2013 COMMUNITY HEALTH NEEDS ASSESSMENT

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1 ROSS COUNTY 2013 COMMUNITY HEALTH NEEDS ASSESSMENT

2 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 Ross County Public Opinion 29 Community Leader and Stakeholder Responses 29 Survey Distribution and Responses 30 Prioritization Process 39 Conclusion 44 Attachments 45 1

3 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

4 Adena Health System Facilities : 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 treatment services, as well as family practice and specialty physicians. Adena Pike Medical Center: A 25-bed inpatient facility in Waverly, OH features an emergency department, medical/surgical unit, rehabilitation, endoscopy services and sameday 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 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, 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 specialize in quick walk-in appointments for colds, flu, sinus infections, immunizations, sports and school physicals. 3

5 Adena Health System Service Area The mission of Adena Health System (AHS) 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 outcomes. 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

6 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)/ (ARMC) supported by its many Ross 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 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 the most up-to-date. This 2013 Adena Health System/ Community Health Needs Assessment provides an overview of the state of health-related needs in Ross County, and benchmarks from which to gauge progress. It also provides documentation and information for decision-making to direct funding towards the community s highestpriority health needs. 5

7 Key Demographics and Health Factors Data was collected from a variety of primary and secondary sources. Secondary data on Ross 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. Disease prevalence of Ross County patient population served by Adena Health System was also generated from the business platform attached to Adena s electronic medical record system. The following are the key findings. Demographics The 2010 U.S. Census indicates the population of Ross County (78,143) has increased by more than 6% since the 2000 Census (73,345). Racial and ethnic diversity in Ross 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 18 in Ross County is lower (21.9%) as compared with Ohio (23.7%) and the U.S. (24%). The number of divorced men and women in Ross County is 2-3% higher than the Ohio and U.S. averages. Of the grandparents living with their grandchildren in Ross County, more than 50% are the primary caregiver for their grandchildren. This is notably higher than the Ohio (44.4%) and U.S. (46.8%) averages. Socioeconomic Factors Approximately 14% of people in Ross County hold a Bachelor s degree or higher, which is much lower than the Ohio (24.5%) and U.S. (25.3%) averages. About 16% have not completed high school which is higher than Ohio (12.2%) and U.S. (14.6%) averages, but better than the rest of the service region (18.9%) Unemployment in Ross County (7.9%) is on par with the U.S. unemployment rate (7.7%), but still higher than Ohio s 6% unemployment rate. Approximately 43% of Ross County residents are 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 Ross County is $21,423. This is higher than the rest of Adena s service region ($19,514), but lower than Ohio ($25,618) and the U.S. ($27,915). The percentage of individuals living at poverty level in Ross County is 17.5%, which is better than the service region (20.4%) but higher than Ohio (14.8%) and the U.S. (14.3%). The percentage of children living in poverty in Ross County is 24.4%, which is better than the service region (27.7%), but again higher than Ohio (21.7%) and the U.S. (20%). 6

8 Health Factors Out of Ohio s 88 counties, Ross County ranks in the bottom 25% in the 2013 County Health Rankings at 78 for health outcomes and 83 for health factors. Ross County has fewer patients (1,523) for each primary care provider than the rest of its service region (3,412) but still more than Ohio (1,101). Ross County has twice as many patients (5,075) for each mental health provider as compared to Ohio (2,181) but still less than Adena s 12-county service region (12,571). Heart disease, cancer and unintentional injuries are the three leading causes of death in Ross County. Nearly 16.2% of Ross County residents served by the have a higher incidence of diabetes in comparison to patients from the rest of the service region (14.4%). More than 40% of Ross County residents served have high blood pressure, and 38.9% have high cholesterol. These rates are higher than the rest of the service region (39.6% and 37.9% respectively). Infant mortality rates in Ross County and its service region are much higher (10.7%) than the Ohio (7.7%) and U.S. (6.9%) rates. 7

9 Public Opinion A public survey was conducted in May Interviews with key stakeholders were also conducted during that time. The tables below outline the results of the survey and interviews, and describe what the community identified as the most important health-related needs and challenges in Ross County. In addition, disease and condition prevalence among AHS patients was obtained from a patient sample extracted from Adena s electronic medical record system using a business platform attached to that system. (Note: No individual patient information was viewed or shared as part of the data extraction.) Approximately 48% of survey respondents rated their health as good while just 12% rated their health as excellent. The findings are consistent with public data needs assessments, studies, and surveys conducted by others in Ross County. When Ross County residents were asked questions about their own health and their perception of overall community health: Stress, obesity and drug abuse were ranked as the top 3 community health issues. Joint/back pain, high blood pressure, and obesity were ranked as the top 3 individual health challenges. Diabetes, blood pressure and stress management were ranked as the top 3 health topics of interest. When Ross County residents were asked questions about their own health behaviors: 32% reported being a smoker. Over 75% saw their family doctor within the last year. Not smoking and eating fruits and vegtables every day were ranked as the top 2 healthy lifestyle choices attempted by respondents. Family doctor, urgent care and the emergency room were ranked as the top 3 resources utilized for medical care. When Ross County residents were asked questions about their own healthcare access: 44% indicated they have commercial insurance to obtain medical care. Only 60% indicated they clearly understand their health benefits. Cost, no insurance/poor coverage and lack of transportation were ranked as top 3 barriers to obtaining healthcare. 8

10 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 Joint/Back Pain High Blood Pressure Mental and Behavioral Health Problems (stress, addiction and depression) Smoking 9

11 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 is linked to the majority of the priorities listed. The team then compared the information with the National Institutes of Health (NIH) and Centers for Disease Control s (CDC) research which outlines the linkage of obesity to certain diseases and conditions. Obesity was further highlighed as the primary public health threat for Ross County. The diagram below demonstrates all of the diseases and conditions NIH and the CDC consider, through their sponsored research, strongly coorelated to obesity. The diseases and conditions that appear in Ross 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

12 CONCLUSION Based on the strong correlation obesity has on many of the health priorities that surfaced in the 2013 Ross County Community Health Needs Assessment, it has been determined that obesity should 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 Ross County Community Health Needs Assessment team has recommended obesity become the primary health need addressed in Ross County over the next 10 years. Other health priorities in Ross County not directly correlated to obesity, but recognized in the community as a health concern, will also be addressed in the community by Adena Regional Medical Center through a secondary level of engagement. Strategies for addressing both the priority and secondary health needs are outlined below Ross 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

13 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 the 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 the behavior 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 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 employers pay for sickness with high rates of absenteeism and higher health insurance costs. Entire communities can suffer economic loss when groups of citizens are ill. As a result, everyone benefits from addressing 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 impact 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 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 who tend to be poorly educated, immigrants, elderly or members of racial/ethnic minority groups 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. A comprehensive community health needs assessment can provide a better understanding of a population s health needs. The IRS now requires all 501(c) (3) health systems operating one or more hospitals to complete one for each hospital every three years. 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 healthrelated grants and appropriations. Obtaining information and views from community members is one of the most important aspects of the community health needs assessment. This involves surveying a percentage of the community to determine which health problems are most prevalent and to solicit their ideas about strategies to address them. It also explores the factors that impact the design of programs and services to effectively address the identified health problems on a broader scope. 12

14 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 across all life stages. To achieve these goals, a comprehensive set of objectives were 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 ARMC s 2013 Ross County Community Health Needs Assessment. The Ross County Community and ARMC Ross County, is home to Adena Regional Medical Center, and is located in south central Ohio. It is part of two Congressional Districts (2 nd and the 15 th ) and 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 78,868 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 AHS is based out of its regional medical center in Social Determinants Ross County Ohio, just north Substance Abuse of Chillicothe. The system provides its leading edge Tobacco services including heart, cancer, women's health, children's health and orthopedics to the 514,516 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 s other Ross County locations include: Adena Cancer Center located on the ARMC campus Adena Counseling Center and Adena Rehabilitation and Wellness Center - Chillicothe Four Adena Family Medicine practices in Chillicothe, located on the ARMC campus A Residency Clinic and Pediatric Urgent Care Center, located on the ARMC campus Adena Health Center located in Chillicothe Adena Home Care - Chillicothe A walk-in clinic located within the Chillicothe Walmart store 13

15 PROCESS Data Acquisition The AHS/ARMC 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 Ross County only (the immediate service region of ARMC) and not the entire AHS/ARMC service region. However, data for Ross County is compared with the rest of the service region as many patients from neighboring counties seek services from the in Chillicothe, Ohio. 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 Ross County and AHS/ARMC 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 Ross County patients served by AHS/ARMC. 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 2 years because it takes time for reported data to be received, reviewed, approved, analyzed, and prepared for presentation. 14

16 Primary Data: Community Input A community survey and key stakeholder interviews were the primary methods of collecting input from the community were used in the assessment process. 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 Pike and Ross 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, Waverly News Watchman, broadcast on local Clear Channel stations and ed to 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, and 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 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 Ross County. The final data compilation and recommended priorities were then taken before the Adena Health System Board of Trustees for final approval. 15

17 DATA Community Profile A profile of Ross 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 years of age represent the 42.8% of Ross County s population. Residents aged (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 Ross County and in the 12-county service region as compared with Ohio and the U.S. Demographic Information The total population of Ross County Ohio is 78,868. It represents 15% of the total Adena Health System service region and is the primary place of residence for 80% of the patients it serves. 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 64% of the population is between the ages of 19 and 64 and 13% of the population is over the age of 65. The majority of the population is white with African Americans making up the majority of the region s minority population. Population Demographics Ross Table 1: Ross County Population Data 12 County Region Ohio U.S. Total Population 78, ,516 11,536, ,745,538 Age 0-19 Years 25.0% 26.5% 26.7% 27.0% Years 18.8% 20.0% 18.9% 20.3% Years & Older 42.8% 39.6% 40.5% 39.7% % 13.9% 13.9% 13.0% Race & Ethnicity African American 4.7% 2.4% 12.1% 12.6% Asian 0.4% 0.6% 1.7% 4.8% Hispanic 1.0% 1.0% 3.0% 16.3% American Indian/Alaska Native 0.2% 0.2% 0.2% 0.9% Native Hawaiian/Pacific Islander 0.0% 0.0% 0.0% 0.2% White 90.8% 94.5% 83.2% 63.7% Other 2.9% 1.3% 0.0% 0.0% Gender Male 53.0% 50.0% 49.0% 49.0% Female 47.0% 50.0% 51.0% 51.0% Source: American Community Survey (US Census Bureau) 16

18 Household Information The 28,158 households in Ross County represent 14.7% of the households in Adena Health System s 12-county service region. The average household size is 2.54 people, comparable with the rest of Ohio and the U.S. The average family size is as well with 3.05 people. Of the grandparents in Ross County, living with their grandchildren, 50% are primary caregivers. This is higher than the regional (44.4%) and Ohio (46.8%) averages. A little more than 50% of the population is now married which is comparable with Ohio and national averages; more than 14% are divorced which is noticeably higher than both the state and national averages. Households Size and Status Ross County 12 County Service Region Ohio Size Total Households 28, ,888 4,554,007 Average Household Size Average Family Size Grandparents as Caregivers Table 2: Ross County Household Information Grandparents who are responsible for grandchildren 50.80% 44.40% 46.80% Marital Status Never Married Males 31.40% 29.60% 32.90% Never Married Females 21.40% 22.50% 27.20% Now Married Males 49.00% 52.70% 52.10% Now Married Females 51.40% 50.90% 47.80% Separated Males 2.60% 2.10% 1.60% Separated Females 1.90% 2.20% 2.00% Widowed Males 3.10% 3.50% 2.90% Widowed Females 10.60% 11.00% 10.20% Divorced Males 13.90% 12.10% 10.50% Divorced Females 14.70% 13.30% 12.70% Source: American Community Survey (US Census Bureau) 17

19 Education Level More than 16% of the adults in Ross County have not graduated from high school. This percentage is higher than both the Ohio (12.2%) and national (14.6%) averages, but is lower than the average for the 12-county service region (18.9%). More than 10% of the population of Ross 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 higher in Ross County than in the rest of the service region. However, considerably lower than Ohio and U.S. averages. Education Level Ross County Table 3: Ross County Educational Attainment 12 County Service Region Ohio U.S. No High School 3.90% 5.80% 3.40% 6.10% Some High School 12.40% 13.10% 8.80% 8.50% High School Graduate 43.50% 42.90% 35.40% 28.60% Some College 18.80% 17.40% 20.50% 21.00% Associate's Degree 7.40% 7.20% 7.50% 7.60% Bachelor's Degree 8.70% 5.70% 15.50% 17.70% Graduate or Professional Degree 5.30% 5.70% 9.00% 10.50% Functionally Illiterate 10.60% 11.00% 9.10% Source: American Community Survey (US Census Bureau) Employment Status While the unemployment rate in Ross County (7.9%) is comparable to the U.S. average, it continues to be higher than both the regional (6.8%) and state (6%) averages. In addition, more than 43.4% of the population is not in the workforce. This is higher than the state (35.4%) and national averages (35.2%). Table 4: Ross County Employment Employment Status Ross County 12 County Service Region Ohio U.S. In Labor Force 56.60% 56.50% 64.60% 64.80% Civilian Labor Force 56.40% 56.50% 64.50% 64.80% Employed 48.70% 49.70% 58.50% 58.80% Unemployed 7.90% 6.80% 6.00% 7.70% Armed Forces 10.00% 10.00% 10.00% 0.50% Not In Labor Force 43.40% 43.50% 35.40% 35.20% Source: American Community Survey (US Census Bureau) 18

20 Occupation & Industry The top five employment industries in Ross County are Management/Professional Occupations (28%), Education/Healthcare Services (24.6%), Sales (23%), Production/Transportation Services (19.7%), and Service Occupations (18.9%). Ross County has a more people employed in production, transportation and material moving occupations (19.7%) than the regional, state and national averages. The county has about half as many (5.4%) professional, scientific and management services professionals as Ohio (9.1%) and the U.S. (10.5%). While the highest percentage of Ross County residents (28.6%) are employed in management, business, science and arts occupations, this is less than regional, state and national averages. Occupation & Industry Ross 12 County Service Region Table 5: Ross County Industry Ohio U.S. Occupations Management, business, science, and arts occupations 28.6% 28.9% 33.8% 35.70% Service occupations 18.9% 18.8% 17.4% 17.50% Sales and office occupations 23.1% 21.6% 25.0% 25.10% Natural resources, construction, and maintenance occupations 9.8% 11.4% 8.1% 9.50% Production, transportation, and material moving occupations 19.7% 19.3% 15.7% 12.20% Industry Agriculture, forestry, fishing and hunting, and mining 1.9% 2.6% 1.0% 1.9% Construction 6.5% 7.5% 5.4% 6.8% Manufacturing 16.5% 14.9% 15.7% 10.8% Wholesale trade 2.5% 2.0% 2.9% 2.9% Retail trade 12.2% 11.5% 11.7% 11.5% Transportation and warehousing, and utilities 6.0% 6.7% 4.9% 5.1% Information 2.0% 1.7% 1.9% 2.3% Finance and insurance, and real estate and rental and leasing 3.9% 4.2% 6.5% 6.9% Professional, scientific, and management, and administrative and waste management services 5.4% 6.0% 9.1% 10.5% Educational services, and health care and social assistance 24.6% 25.1% 23.9% 22.5% Arts, entertainment, and recreation, and accommodation and food services 8.2% 8.4% 8.6% 9.0% Other services, except public administration 3.2% 4.5% 4.5% 4.9% Public administration 7.1% 4.9% 4.0% 4.9% Source: American Community Survey (US Census Bureau) 19

21 Income & Poverty The per capita, median and mean household incomes in Ross County Ohio are much lower than the state and U.S. averages, but higher than regional average. Poverty rates are also higher than state and national averages but lower than the rest of the region. Access to employment in Ross County is higher than other counties in the region. Approximately 17.5% of individuals in Ross County live below the poverty level, as compared to 20% throughout the service region. Still the rate is higher than Ohio (14.8%) and U.S. (14.3%) averages. Income & Poverty Ross County Table 6: Ross County Income and Poverty Rates 12 County Service Region Ohio U.S. Income Per Capita Income $ 21, $ 19, $ 25, $ 27, Median Household Income $ 44, $ 39, $ 48, $ 52, Mean Household Income $ 57, $ 50, $ 63, $ 72, Poverty Families Below Poverty Status 12.9% 15.2% 10.8% 10.5% Individuals Below Poverty Status 17.5% 20.4% 14.8% 14.3% Under 18 Years 24.4% 27.7% 21.2% 20.0% 18 to 64 Years 17.0% 19.5% 13.7% 13.1% 65 Years and Over 7.9% 11.1% 8.1% 9.4% Source: American Community Survey (US Census Bureau) Veteran Population There are 7,697 civilian veterans living in Ross 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: Ross County Veterans Veteran Status Ross Region Ohio U.S. Civilian Veterans 7,697 42, ,971 22,215,303 Percentage of Total Population 9.8% 8.2% 7.9% 7.2% Source: American Community Survey (US Census Bureau) 20

22 Disabilities Ross 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 have disability prevalence rates of 16.7% - 22%. Ross County s prevalence rate is better (14.8% %) but still worse than the rest of Ohio (13.4% 14.7%). Figure 1: Service Region Disability Prevalence Source: American Community Survey (US Census Bureau) 21

23 County Health Rankings The economic and educational challenges experienced in Ross 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 Ross 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. 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 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, Ross and Vinton were in the bottom 25% in both categories. Table 8: Service Region Health Rankings 2013 County Health Rankings 12 County Service Region Health Outcome Ranking Health Factors Ranking Adams Athens Fayette Gallia Highland Hocking Jackson Pickaway Pike Ross Scioto Vinton Source: County Health Rankings, RWJF, 2013 Report, (www.countyhelathrankings.org/ohio) 22

24 Health System and Hospital Utilization The utilization of health system services by the population of Ross County and throughout the 12 county service region also provides indicators about population health. Approximately 80% of the patients served by the system reside in Ross County. Utilized Services In 2012, AHS 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 % 15.6% 11.5% 0.7% 8.6% 9.4% 36.7% 32.7% Athens % 8.9% 6.2% 0.0% 19.9% 6.8% 73.3% 65.8% Fayette 1, % 15.4% 8.3% 0.3% 7.5% 8.3% 37.9% 33.4% Gallia % 14.6% 10.8% 0.5% 10.4% 9.3% 37.7% 36.1% Highland 4, % 14.1% 9.7% 0.2% 8.9% 8.9% 35.7% 31.0% Hocking % 15.9% 10.7% 0.1% 11.2% 10.5% 35.2% 35.9% Jackson 8, % 12.2% 8.3% 0.2% 9.7% 8.9% 33.8% 34.5% Pickaway 2, % 15.4% 8.4% 0.5% 7.9% 9.7% 37.1% 34.7% Pike 10, % 14.9% 10.3% 0.3% 8.5% 11.3% 38.2% 38.1% Ross 43, % 16.2% 11.1% 0.3% 9.5% 11.3% 40.5% 38.9% Scioto 1, % 13.8% 5.9% 0.1% 6.1% 10.2% 32.2% 34.0% Vinton 2, % 15.3% 11.0% 0.2% 10.0% 10.5% 37.1% 39.2% Total 77, % 14.4% 9.3% 0.3% 9.8% 9.6% 39.6% 37.9% Source: 2012 Patient Population Data from Adena Health System Meditech Reporting, June

25 Healthcare Access Healthcare Providers Ross County has one of the highest patient-to-provider ratios within the 12-county service region, and is not considered a health professional shortage area. The patient-to-provider ratio for Ross County is 1,523:1, compared to Ohio at 1,101:1. The ratio is much better than the 12- county service region, which is 3,412:1. In Ross County, there are 1,523 patients for every primary care physician, compared to 1,101 patients per primary care physician in Ohio. Access to healthcare is determined by both the availability of 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 can happen in a timely manner. Table 10: Ross County Health Access Health Access Ross County 12 County Service Region Ohio Primary Care Providers per patient 1,523 3,412 1,101 Mental Health Providers per patient 5,075 12,571 2,181 Oral Health Providers per patient 2,581 4,844 2,435 2 Counties Health Professional Shortage Area No (Adam and Vinton) No Source: County Health Rankings, RWJF, 2013 Report, (www.countyhelathrankings.org/ohio) Health Insurance Among those with health insurance in Ross County, the majority has direct or employer-sponsored health insurance (49%). Less than 2% of Ross County children under the age of eighteen lack health insurance, which is much lower than the 12-county service region, Ohio and the U.S. More than 13% of the Ross County population 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%). Table 11: Ross County Insurance Coverage 12 County Service Insurance Status * Ross County Region Ohio U.S. With Private Health Insurance 49.0% 45.1% 69.0% 65.2% With Public Health Insurance 37.8% 39.6% 31.2% 30.5% No Health Insurance 13.2% 15.4% 11.9% 15.1% Children under 18 without insurance 1.9% 4.3% 6% 8% Source: Truven Health Data,

26 Death and Illness The leading causes of death, illness, and injury are indicators to the primary health challenges facing a population in a particular region. They can also indicate what health risk factors are most prevalent among a population. Mortality Rates The three leading causes of death in Ross County are heart disease, cancer and unintentional injuries. The average rate of death for these conditions is significantly higher than the state average. Average rates of death for chronic lower respiratory disease are just a little higher than the state average. Heart disease is the number one cause of death in the region. The rate of death for cancer in Ross County (214.7) is higher than the regional (210.23) and state (187.3) rates. Death from unintentional injuries (70.2) is significantly higher than the regional (58.63) and state (41.6) rates. Ross Region Ohio Cause of Death * Number Rate Number Rate Number Rate Diseases of the Heart Cancer Accidents/Unintentional Injuries Chronic Lower respiratory Diseases Stroke Alzheimer's Disease Source: 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 Mortality Cancer is the second leading cause of death in Ross 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 prostate cancer in the region are significantly lower than the rest of Ohio. Table 12: Ross County Mortality Rates The rate of death for trachea, bronchus and lung cancer in Ross County (76.9) is significantly higher than its 12 county service region (69.78) and Ohio (58.3). Rates of death from breast cancer in Ross County (7.7) are significantly lower than the service region (12.9) and Ohio (24.7). Table 13: Ross County Cancer Mortality Rates of Death From Cancer Ross Region Ohio Type of Cancer Number Rate Number Rate Number Rate Trachea, Bronchus & Lung , Colon, Rectum & Anus , Pancreas , Breast (Female)** , Prostate (Male)*** , Source: Ohio Department of Health Vital Statistics **Age -adjusted death rate per 100,000 females ***Age-adjusted death rate per 100,000 males 25

27 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 Ross County (472.3) is similar to other counties in Adena s 12-county service region (475.4) and Ohio (470.0). Lung cancer occurrence is higher in Ross County (91) than in the rest of the service region (88.1) and Ohio (75). The occurrence of prostate cancer is lower in Ross County (95.1) than in the rest of the service region (120.4) and Ohio (145.5). The occurrence of cancers of the lung and bronchus in Ross County (91) is significantly higher than the 12-county service region (88.1) and the rest of Ohio (75). The rate of occurrence of breast cancer is higher (114) in Ross County than the rest of the region (106.2), but lower than Ohio. Although occurrence is higher than the rest of region, rates of death (provided above) are lower than the region and Ohio. Table 14: Ross County Cancer Rates Cancer Occurrence Ross Region Ohio Cancer * Cases Rate Cases Rate Cases Rate All types , Colon and Rectum , Lung and Bronchus , Breast , Prostate , Source: Chronic Disease and Behavioral Epidemiology Section and the Vital Statistics Program, Ohio Department of Health, *Average annual rate per 100,000, age-adjusted to the 2000 US standard population. Rate not calculated when the case count for is less than five (i.e., the average annual count is less than one) 26

28 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 Ross 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, or is more than five years old. Ross County s data aligns with the rest of the service region and Ohio with the exception of high cholesterol. The percent of the population with high cholesterol is estimated to be significantly higher in the region (51.5%) than Ross County (36.9%) and Ohio (37.9%). Table 15: Ross County Conditions and Illness Prevalence Conditions and Illnesses Ross Region Ohio Respondents who indicated Ever told overweight 35.2% 32.2% 35.9% Ever told obese 26.0% 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% Diagnosed with Diabetes 8.1% 8.2% 7.9% Diagnosed with Arthritis 29.8% 30.6% 31.3% Diagnosed with Asthma 14.7% 12.8% 14.6% Source: Ohio Behavioral Risk Factor Surveillance System; Chronic Disease and Behavioral (Estimates) Source: 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 Ross County and its 12-county service region (10.7) is significantly higher than the Ohio (7.7) and U.S. averages (6.9). Pre-term births and maternal smoking are also much higher. Table 16: Ross County Maternal Health Maternal Health Ross Region Ohio Indicators * Total Births 799 5, ,034 Low Birth Weight 10.0% 8.5% 8.5% Maternal Smoking 24.3% 26.4% 17.8% Teen Birth Rate 18.0% 17.7% 16.3% Preterm 15.0% 12.6% 12.5% Unmarried 50.1% 45.1% 43.7% Infant Mortality Rate ** Source: U.S Census Bureau, 2010 Census, Ohio * *Per 1,000 births, From the Ohio Department of Health,

29 Health Risks and Behaviors Health behaviors are actions that impact 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. Health Risks and Behaviors Ross Region Ohio Behaviors Adult Smoking 24.3% 26.5% 22.0% Adult Obesity 35.0% 32.8% 29.6% Physical Inactivity 29.0% 32.5% Excessive Drinking 17.0% 7.2% Sexually Transmitted Infections Teen Pregnancy Rate * Teen Birth Rate ** 13.9% 12.6% 9.8% Fast Food Restaurants 62.0% 55.8% 55.0% Source: 2008 Healthy Ohio Program Survey Source: Ohio Department of Health Vital Statistics, 2010 Census Source: 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 Table 17: Ross County Health Risks and Behaviors 28

30 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 Ross County Community Health Needs Assessment, the team collected and compiled information related to individual health status and behaviors. This was completed via a survey (Attachment 1) and through key stakeholder interviews. Community Leader and Stakeholder Responses Characteristics of the Sample Eleven community leaders and key stakeholders were identified and encouraged to participate in the interviews through a series of s and phone calls. Two of the 11 agreed to participate in an interview. Attachment 2 lists the key informants who completed an interview. The interviewees represented a broad cross-section of Ross County At a minimum, one-third of our residents are obese or overweight, and the number of those suffering from high blood pressure, high cholesterol, heart disease and Type 2 diabetes are also increasing. Public health leader Illegal drug use is subject that has not traditionally been part of Ross County s public health arena. But in ever growing numbers, more and more of our residents are being adversely affected by drug abuse. Community leader health and human service community that, in addition to health care professionals and leaders from public and community-based organizations, 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. Both respondents indicated that drug abuse in Ross County and the surrounding region was an area of great concern, one believing it should be a priority concern, and cited specific statistics to support their opinion. These included the recently reported 7-8,000,000 doses of pain medications prescribed annually in Ross County as well as the increased man hours of city and county law enforcement resulting from addressing drug trafficking. In addition to drug addiction, the second respondent noted obesity, smoking/tobacco use, and motor vehicle safety as key concerns for public health. 29

31 Survey Distribution and Responses The Adena Community Health Needs Survey (Attachment 1) was distributed online and in hard copy in various community locations throughout Ross County 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 (link posted on 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 ed to all members of local business, government, civic groups, schools and universities. Surveys for and Adena Pike Medical Center 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 Ross and Pike Counties. These surveys were not included in the compiled data for Ross or Pike County. A total of 1,152 surveys were completed by respondents providing a Ross County zip code. A total of 848 of those surveys were returned in hard copy. Table 18: Health Risk Assessment Respondents Identifier Gender Age Employment Status Respondents Male 24.2% Female 75.8% Under % % % % % % % Full Time 28.9% Part Time 14.4% Unemployed 56.7% 30

32 Perceived Personal and Community Health Status To determine the community s perspectives about health priorities, respondents were asked to provide their perception of their own health and the health of the community. Information included rating the top 4 issues they perceived to affect the health of Ross County residents, identifying the top 3 personal health challenges they face, as well as provide their opinion on what they perceive to be the biggest health challenges for the community. Respondents were also asked to indicate that health topics were the most important to them and for their family. Poor 9% Excellent 12% Fair 31% Good 48% Figure 2: Overall Perceived Health Rating 31

33 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 52% of respondents believed stress to the top health issue affecting the community. More than 50% believed obesity was the next health priority. Almost 21% of respondents indicated that diabetes was one of the top health challenges they faced and 35% indicated it was one of the top health topics that interested them and/or their family. Out of 23 possible issues, respondents indicated that stress, obesity, drug abuse and unemployment were the top issues affecting their community. Diabetes was the fifth issue prioritized. Not Immunized 2.3% HIV/AIDS 2.8% Sexually Transmitted Diseases Literacy Violence Homelessness At-Risk Youth Teen Pregnancy Lack of Mental Health Dental Health Asthma Domestic Violence Alcohol Abuse Parenting Issues Heart Disease Cancer Poor Nutrition Lack of Health Insurance Diabetes Unemployment Drug Abuse Obesity Stress Figure 3: Top Community Health Issues 6.9% 7.6% 7.9% 8.6% 8.8% 13.2% 13.7% 13.7% 14.4% 14.8% 16.0% 17.0% 23.4% 24.8% 26.3% 28.4% 31.8% 34.9% 39.5% 50.6% 52.8% 32

34 Individual Health Issues Respondents were asked their opinion regarding the top three issues they faced as individuals. Out of 14 possible issues, the top three indicated were joint and back pain, high blood pressure and obesity. Approximately 20% of respondents also indicated they suffered from diabetes. Figure 4: Top Health Challenges Faced By Individuals Alcohol Overuse 1.20% Drug Addiction 1.70% Stroke 4.00% Lung Disease 6.40% Mental Health Issues 8.30% Cancer 9.30% Asthma 9.70% Heart Disease 11.20% Smoking Addiction 17.20% Diabetes 20.80% Depression 24.00% Overweight/Obesity 32.50% High Blood Pressure 33.90% Joint and Back Pain 39.40% 33

35 Health Topics Respondents were also asked their opinion regarding the top three health topics they felt were the most important to them and their family. Out of 24 possible issues, the top three were: diabetes, high blood pressure and stress management. Nearly 20% of respondents indicated depression was a health topic of interest. Figure 5: Top Health Topics of Interest STD's0.7% HIV/AIDS 0.8% Violence Prevention 1.3% Flu CPR First Aid Pregnancy Health Injury Prevention Immunizations Substance Abuse Oral Health Pediatric Care Men's Health 1.7% 2.2% 2.3% 2.7% 3.1% 3.4% 4.1% 7.9% 8.3% Cholesterol Quitting Smoking Women's Health Asthma Nutrition Depression Exercise Heart Disease Cancer Stress Management Blood Pressure Diabetes 15.1% 15.2% 15.5% 15.5% 19.3% 19.6% 21.6% 22.0% 26.1% 27.7% 31.2% 35.0% 34

36 Health Habits Respondents were asked to provide information on health habits to provide insight on how they manage their own health. Questions regarding health behaviors, as well as health care access and usage were asked. Respondents were asked to pick up to four responses depending on the question. Healthcare Providers Respondents were asked where they routinely go 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 6% indicated they do not seek care from a healthcare provider. Figure 6: Healthcare Providers Accessed Clinics in Drug Stores, Walmart and Grocery Stores 2% Urgent Care Center 7% I don t seek care 6% Free Clinic 6% Emergency Room 7% Specialty Care Physician 6% Family Doctor 66% 35

37 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 seen a dentist and an optometrist within the last year % 80.0% 60.0% 40.0% 20.0% 0.0% 76.7% 23.3% Visited Family Physician Within the Last Year 54.7% 45.3% Figure 7: Healthcare Utilization 60.9% 39.1% Visited Dentist Within the Last Year Visited Optometrist Within the Last Year Yes No Health Behaviors Respondents were asked to provide information about their own health behaviors. More than 32% said they were a current smoker. When asked to pick the top four Approximately 32% of respondents indicate they are a current smoker. out of 12 health habits they believed contributed to their own health, respondents selected not smoking, eating fruits and vegetables, wearing a seatbelt and doing some form of exercise. Less than 18% believed limiting alcohol or not drinking contributed to better health. Figure 8: Health Behaviors Applying sunscreen Limiting alcohol Practicing faith Taking vitamins Rarely eating fast or junk food Sleeping 7 hours per night Not using drugs Brushing teeth/flossing Exercising Wearing a seatbelt 13.0% 17.6% 23.0% 26.9% 31.1% 36.4% 37.4% 37.8% 43.6% 44.2% Eating fruits and vegetables Not smoking 54.5% 54.6% 36

38 Health Information Respondents were asked about how they obtain health information when it is needed. Approximately 64% indicated they sought information from a health professional when needed. Half of respondents also indicated they looked to family and friends for health information as well. Figure 9: Health Information Sources School 1.1% Library 3.5% Church 4.6% Health Department 11.6% Newspaper/Magazine/TV 16.3% Internet 48.2% Friends/Family 50.0% Doctor/Nurse/Medical Professional 64.1% 37

39 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 75% of respondents indicated that they have health insurance. Figure 10: Insurance Coverage Medicaid 22% Medicare 34% Comercial Insurance 44% 62.8% Figure 11: Understanding of Benefits 31.3% 4.5% 1.3% Yes Somewhat No N/A Healthcare Barriers More than 53% reported it was a problem to find affordable health care. Nearly 40% indicated lack of, or poor coverage as being a barrier. More than 20% indicated transportation was also a common barrier they faced to accessing healthcare services. Figure 12: Most Common Healthcare Barriers Specialist not located in my community for my condition 4.5% Office or clinic that is open when I am not working 9.6% No available appointment 10.9% Have the ability to take off work when I or my family is 11.0% Transportation 20.9% No Insurance/Poor Coverage Cost 39.3% 53.3% 38

40 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 Ross 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

41 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 Depression High Blood Pressure Smoking Stress Obesity Stress Smoking Drug Abuse Joint Back Pain (weight related) 40

42 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 NIH, supported by the CDC, shows that as weight increases to reach the levels referred to as "overweight" and "obesity," 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 also 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. The health indicators presented on the 2013 Ross County Community Health Needs Assessment are highlighted in red below. 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

43 Preventing Heart Disease (through system wide initiatives) Ross County Community Health Needs Assessment 2013 Mission and Capability Alignment This information was 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 ARMC to make an impact on community health. A number 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 over which Adena could have shared control; 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 has been determined to be the top community health need of ARMC, while the remainder would be considered secondary. Preliminary discussions on the length of time and rollout of a community-wide obesity initiative were also held. The committee agreed that a decade-long effort will be required to realize a broader impact of reducing regional heart disease mortality rates. 42

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