Community Health Needs Assessment - Tri

 Community Health Needs Assessment 2012‐2015 1 2 Table of Contents
Executive Summary……………………………………………………………………..………………………………………………………………...……6 About Tri‐County Health Care………………………………………………………………………………………………………………………………8 Introduction and Community Description…………………………………………………………………………………………………………….9 Methods: Primary and Secondary Data……………………………………………………………………………………………………………..11 Community Needs Assessment Overview of Key Findings…………………………………………………….…………………………...12 MAPP Process Overview……………………………………………………………………………………………………………………….……………14 Visioning Sessions..…………………………………………………………………………………………………………………………………………….15 Focus Groups ………………………………………………………………………………………………………………………………………………….…16 Community Health Survey…………………………………………………………………………………………………………………….……………20 Chronic Disease……………………………………………………………………………………………………………………………………..21 High Blood Pressure Diagnoses ……………………………..…………………………………………………………………21 Diabetes diagnoses…………………………………………………………………………………………………………………..21 High Cholesterol Diagnoses………………………………………………………………………………………………………21 Level of Stress ………………………………………………………………………………………………………………………….22 Feelings of Sadness and Depression………………………………………………………………………………………….22 Depression or Anxiety Diagnoses………………………………………………………………………………………………22 Health Behavior…………………………………………………………………………………………………………………………………….23 Smoking Status………………………………………………………………………………………………………………………….23 Percentage that Live with Smokers…………………………………………………………………………………………..23 Days of Moderate Physical Activity a Week……………………………………………………………………………….23 Servings of Fruits and Vegetables Eaten Yesterday……………………………………………………………………23 Sugar Drink Consumption…………………………………………………………………………………………………………24 Calculated Body Mass Index of Survey Recipient………………………………………………………………………24 Health Care………………………………………………………………..………………………………………………………………………….24 Date of Last Checkup…………………………………………………………………………………………………………………24 Delayed Medical Care……………………………………………………………………………………………………………….24 Reasons for Delayed Medical Care…………………………………………………………………………………………….25 Needed Mental Health Care but didn’t get it…………………………………………………………………………….25 Reasons for Delaying Mental Health Care…………………………………………………………………………………25 Where do you get Health Care Information………………………………………………………………………………26 Community Issues Marked as Moderate or Serious Problems………………….…………………………………………..27 Secondary Data Collection: Community Profile………………………………………………………………………………………………………………………………….………...28 Population Pyramid……………………………………………………………………………………………………………………………...29 Race/Ethnicity Statistics ……………………………………………………………………………………………………………………….30 Labor Market Data………………………………………………………………………………………………………………………………..31 3 Unemployment Data………………………………………………………………………………………………………………..31 Per Capita Income…………………………………………………………………………………………………………………….32 Average Weekly Wages…………………………………………………………………………………………………………….32 Poverty………………………………………………………………………………………………………………………………………………….33 All Ages Living In Poverty…………………………………………………………………………………………………………..33 People Under 18 Living in Poverty……………………………………………………………………….……………………33 Food Stamp Utilization……………………………………….........................................................................33 Housing………………………………………………………………………………………………………………………………………………….34 Housing Affordability by Occupation, MN………………………………………………………………………………...34 Proportion of Households Paying 30%+ for Housing, MN……………………………………………………..…..34 Proportion of Households Paying 30%+ for Housing, Otter Tail…..…………………………………………….35 Proportion of Households Paying 30%+ for Housing, Todd…..…………………………………..………………35 Proportion of Households Paying 30%+ for Housing, Wadena…………………………………..………………35 Household Income for Renters and Owners………………………………………………………….………………….35 Homelessness………………………………………………………………………………………………………………………………………..36 Crime Statistics……………………………………………………………………………………………………………………………………..37 Education………………………………………………………………………………………………………………………………………………38 K‐12 Public School Enrollment…………………………………………………………………………………………………..38 K‐12 Students Enrolled in Special Education……………………………………………………………………………..38 High School Graduation Rate…………………………………………………………………………………………………….38 Students Receiving Free and Reduced Lunch…………………………………………………………………………….38 Birth Statistics…………………………………………………………………………………………………………………………………………………….39 Natality Statistics…………………………………………………………………………………………………………………………………..39 Prenatal Care…………………………………………………………………………………………………………………………………………39 Preterm Births and Low Birth Weight…………………………………………………………………………………………………….39 Birth Outcomes/Sociodemographic Factors…………………………………………………………………………………………..40 Teen Pregnancy Rates 15‐19 Year Olds………………………………………………………………………………………………….40 Number of Infant Deaths……………………………………………………………………………………………………………………….40 Children and Youth…………………………………………………………………………………………………………………………………………….41 Annual Cost for Licensed Family‐Based Child Care…………………………………………………………………………………41 Monthly Enrollment for Medical Assistance 0‐17 Year Olds…………………………………………………………………..41 Monthly Enrollment for MinnesotaCare 0‐17 Year Olds………………………………………………………………………..41 Childhood Immunization Coverage of Vaccine Series…………………………………………………………………………….41 Determined Abuse and Neglect Cases for 2010……………………………………………………………………………………..42 Mothers and Children Receiving WIC…………………………………………………………………………………………………….42 Households with Children Receiving Food Support………………………………………………………………………………..42 Percentage of Students Receiving Free and Reduced Lunches………………………………………………………………42 Percent of Students who Feel Safe at School…………………………………………………………………………………………43 Had Suicidal Thoughts in the Past Year………………………………………………………………………………………………….43 Used Alcohol One or More Times in the Past Year…………………………………………………………………………………43 Smoked Cigarettes During the Previous 30 Days……………………………………………………………………………………44 Physically Active for 30min or More 5 of 7 Days…………………………………………………………………………………….44 Have Had Sexual Intercourse…………………………………………………………………………………………………………………44 Adult Health……………………………………………………………………………………………………………………………………………………….45 Adult Smoking Prevalence……………………………………………………………………………………………………………………..45 Adult Obesity Prevalence………………………………………………………………………………………………………………………45 Adult Physical Inactivity……………………………………………….............................................................................46 Disease Data and Preventative Practices……………………………………………………………………………………………………………47 4 Diagnosed with Diabetes……………………………………………………………………………………………………………………….47 Diabetic Screening…………………………………………………………………………………………………………………………………47 Mammography Screening……………………………………………………………………………………………………………………..48 Sexually Transmitted Infections…………………………………………………………………………………………………………….48 Incidence Rates of Asthma Hospitalizations, Cancer, COPD, MI……………...................................................49 MN Injury Hospital Data………………………………………………………………………………………………………………………..50 Leading Causes of Hospitalization for all Ages……………………………………………………………………………………….50 Mental Health…………………………………………………………………………………………………………………………………………………….51 Children………………………………………………………………………………………………………………………………………………..51 Adults……………………………………………………………………………………………………………………………………………………51 Mortality……………………………………………………………………………………………………………………………………………………………52 Top 15 Causes of Mortality……………………………………………………………………………………………………………………52 Premature Death…………………………………………………………………………………………………………………………………..52 Top Causes of Death …………………………………………………………………………………………………………………………….52 Wadena County Public Health Issues 2008………………………………………………..………………………………………………………53 Todd County Public Health Issues 2007………………………………………………………………………………………………………………54 Otter Tail County Public Health: Health Priorities 2012‐2014……………………………………………………………………………..55 Forces of Change in Service Area with Barriers and Opportunities……………………………………………………………………..56 Key Stakeholder Input and Vision…………………………………………………………...…………………………………………………………57 Concerns and Strategic Issues………………….…………………………………..……………………………………………………….57 Clinical Advisory Focus Group Nov 2013…………………………………………………………………………………………………………….58 Health Needs Based on Key Issues……………….…………………………………………………………………………………………………….59 Current Tri‐County Health Care Initiatives…………………………………………………………………………………………………………63 Health Care Resources in the Primary Service Area……………………………………………………………………………………………64 Opportunities for Health Improvements…………………………………………………………………………………………………………….65 Research Study Proposal……………………………………………………………………………………………………………………………………66 Strategic Plan Strategies and Objectives……………………………………………………………………………………………………………69 Implementation Plan…………………………………………………………………………………………………………………………………………71 References…………………………………………………………………………………………………………………………………………………………74 Appendix……………………………………………………………………………………………………………………………………………………………76 5 Executive Summary
Who we are: Tri‐County Health Care (TCHC) began operating in 1925 in the Wadena community as Wesley Hospital and has grown into a health care organization with 429 employees. It is now a private, not‐for‐profit health care corporation providing service through Tri‐County Hospital (Wadena) and clinics located in Bertha, Henning, Ottertail, Sebeka, and Wadena. TCHC is one of the few independent health care systems in Minnesota and is known for its innovation and expertise. TCHC’s mission is to improve the health of the communities they serve and deliver services with the highest standard of care on a continuous basis. Our Community: The Tri‐County Health Care community is located in west, central Minnesota and includes eastern/central Otter Tail, Todd, and northern Wadena counties. The total population of all three counties is estimated at 96,225; the primary service area population of TCHC is estimated at 26,278 because it more specifically focuses on the cities of Wadena, Sebeka, New York Mills, Bertha, Deer Creek, Hewitt, Aldrich, Verndale, Blufton, Henning, Menahga, and Ottertail. The community is primarily of Caucasian descent (93.9%) followed by Hispanic (3.2 percent), Black (0.8 percent), and American Indian/Alaskan Native (0.5 percent)). Community Needs Assessment: Tri‐County Health Care conducted the following Community Health Needs Assessment (CHNA) with the collaboration of a sub‐committee from Todd Wadena Healthy Connections and CentraCare in 2013 to ensure the most comprehensive assessment of the service area community. The MAPP Process (Mobilizing for Action through Planning and Partnerships, page 14) was used as a “community‐driven strategic planning process for improving community health” and provided the framework for data collection and prioritizing public health needs (NACCHO). Data was collected from a variety of sources including group administered questionnaires (visioning sessions), focus groups (Hispanic perspective and nursing students), a community health survey, and quantitative statistics from local, county, and state public health sources. The data gathered was then used to identify specific issues and prioritize them according to need. This prioritized issues list was used to develop strategies for implementation of interventions. This report summarizes and highlights key findings and opportunities for implementation. Findings: After conducting the assessments discussed above, the CHNA collaborative group identified the following eleven topics as concerns within the TCHC service area. In no particular order: mental health (depression, anxiety, suicide), obesity, chronic diseases (diabetes, heart disease, stroke, etc), cancer, unhealthy behaviors (exercise, diet, smoking, etc.), parenting (injury prevention, immunizations, etc.), access to care, poverty, aging demographic, unintended injury, and social determinants of health (employment, environment, transportation, housing, etc.). 6 Priorities: To prioritize the issues identified in the data collection assessment and analysis, the TCHC clinic advisory group considered the community health survey opinion topics that respondents labeled moderate or serious. Advisory group members were split into groups to discuss and decide an area of focus. “Unhealthy behaviors” was chosen by all but one group as priority #1 because of its potential to affect other issues (obesity, diabetes, heart disease, mental health, etc). The graphic below highlights the opinion topics that were considered. The priorities and implementation plan are discussed in greater detail on page 71. 7 About Tri‐County Health Care
Tri‐County Health Care (TCHC), formerly known as Wesley Hospital, began operating in 1925 and has become a 25‐bed critical access health care organization with 429 employees. TCHC owns and operates five clinics, located in the communities of Wadena, Bertha, Sebeka, Henning and Ottertail, which exemplify the rich history of caring for patients in the area. As a private, non‐profit, primary health care organization, TCHC serves a population of approximately 25,000 from Wadena, Todd and Otter Tail Counties in west central Minnesota. TCHC is proud of its commitment to quality patient care. The medical staff is comprised of 12 board certified, family practice physicians, three obstetrician/gynecologists, one psychiatrist, two general surgeons, one radiologist, eight physician assistants and seven family nurse practitioners. Specialty services offered have been enhanced by the addition of consulting physicians in the areas of pathology, oncology, cardiology, orthopedics, ophthalmology, urology, psychology, dermatology, spine, wound management and pulmonology. Professional and support staff dedicated to excellence provides services in areas of surgery, obstetrics, nursery, pediatrics, intensive and coronary care, 24‐hour emergency room coverage, Medicare skilled nursing, respite and transitional care. Outpatient surgeries include laparoscopy, arthroscopy, colonoscopy, endoscopy and cataract eye surgery. Cardiac and pulmonary rehab, ambulatory care, physical therapy and occupational health are all part of outpatient services available at TCHC. Ancillary services include the diagnostic imaging department, with in‐house general X‐ray, fluoroscopy, mammography, ultrasound, bone densitometry, 16‐slice CT scanning and nuclear medicine. Mobile services include MRI. A 24‐hour laboratory is offered as well. Pharmacy, respiratory therapy, social service, dietary and nutritional counseling, speech and occupational therapy, nursing home consultations, diabetes education and various support groups, complete the listings of services. The hospital takes pride in continually upgrading its technology. The purchase of equipment and advanced technology enhances superior services. TCHC is keeping its rural health care system on the leading edge of technology as a pioneer in the use of telemedicine, and interactive video telecommunication system that allows physician specialists to examine patients and consult with local practitioners using special medical equipment adapted for television usage. The advanced technology makes experts available onsite for patient diagnosis, saving time and travel and improving the access to health care in our rural setting. 8 Introduction Executive Summary
Community Needs Health Assessment Minnesota non‐profit hospitals have moral obligations for the communities they serve. Under the Patient Protection and Affordable Care Act (ACA), the Community Health Needs Assessment is required for hospitals to maintain their tax‐exempt, 501 (c)(3) status. This requirement applies to tax years beginning after March 23, 2012. Tri‐County Health Care has joined with Wadena County Public Health, Todd County Health and Human Services, Lakewood Health System and CentraCare in order to make the most comprehensive assessment possible of our service areas and further enhance care in our rural healthcare community. This is being accomplished through regular meetings and e‐mail communication to provide and share information. Note: Tri‐County Health Care locations are marked by red pins and other local health care providers are in green. 9 Community Description The community that was included in this assessment was the service area of Tri‐County Health Care. This includes the counties of Otter Tail, Wadena and Todd in Central Minnesota. The total population for these counties is estimated at 96,225. All zip codes from these counties (see below) and this total population were used in the data analysis. The primary service area of Tri‐County Health Care includes the cities of Wadena, Sebeka, New York Mills, Bertha, Deer Creek, Hewitt, Aldrich, Verndale, Bluffton, Henning, Menahga and Ottertail. The estimated population for this area is 26,278. The clinics that make up Tri‐County Health Care are shown with red pins in the map on page 9 and the primary service area map is shown below. Ethnicity is primarily Caucasian (93.9 percent), followed by Hispanic (3.2 percent), African American (0.8 percent), American Indian/Alaskan Native (0.5 percent), Pacific Islander (0.1 percent) and Other/Mixed Race (1.4 percent). The poverty rate for the Tri‐County Health Care service area is at 15.4 percent (American Fact Finder: U.S. Census Bureau, 2012). Zip Codes and Counties Used in Secondary Data Collection Otter Tail County Battle Lake 56515 Bluffton 56518 Clitherall 56524 Dalton 56324 Deer Creek 56527 Dent 56528 Elizabeth 56533 Erhard 56534 Fergus Falls 56537 Henning 56551 New York Mills 56567 Ottertail 56571 Parkers Prairie 56361 Pelican Rapids 56572 Perham 56573 Richville 56576 Underwood 56586 Urbank 56361 Vergas 56587 Vining 56588 Todd County Bertha 56437 Browerville 56438 Burtrum 56318 Clarissa 56440 Eagle Bend 56446 Grey Eagle 56336 Hewitt 56453 Long Prairie 56347 West Union 56489 Wadena County Aldrich 56434 Menahga 56464 Nimrod 56477 Sebeka 56477 Staples 56479 Verndale 56481 Wadena 56482 10
Methods Primary Data Collection Group administered questionnaires were utilized to gather information and opinions from persons who represent the broad interests of the community served by the hospital. These questionnaires were distributed at various group meetings. A list of the interview group respondents can be found with a summary of the data collection findings on Page 15. Focus groups were conducted with open‐ended questions and led by a facilitator to identify specific areas of need within the Tri‐County Health Care service area in winter and spring 2013. A summary of the findings is discussed on Page 16. A community health survey was disseminated and analyzed during the community health needs assessment process in the Tri‐County Health Care service area. Surveys were sent out in February 2013 to a random sample via mail. This qualitative and quantitative data is being used to guide the work of Tri‐
County Health Care and local public health departments. It is discussed in greater detail on Page 20. Secondary Data Collection Secondary data was collected from a variety of local, county and state sources to compile a community profile, birth and death characteristics, access to health care, chronic disease, mental health and social issues, as well as school and social characteristics. When pertinent, this data was presented in the context of the Tri‐County Health Care service area and the state of Minnesota, framing the scope of an issue as it relates to a broader community. This report presents a summary that highlights the data findings and presents key needs and opportunities for action. What follows is a narrative that examines each of the data sets as well as state benchmark comparison data. 11
Community Needs Assessment Overview of Key Findings The key findings in this overview summarize the data analyzed. Further data descriptions, graphs and data sources are described in greater detail in the full report that follows. 
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Social and Environmental Factors: Tri‐County Health Care’s service area has an unemployment level that has been consistently higher than the state average for the last five years. The poverty level is high in the Tri‐County Health Care service area in comparison to state averages. There are a significant number of individuals in the service area paying 30 percent or more of their income just for housing. The crime rate is quite low in the Tri‐County Health Care service area. Homelessness is on the increase in greater Minnesota with an increase from 20 percent in 1991 to 32 percent in 2012. The Hispanic Focus Group mentioned that subsidized housing is out of reach financially and that a lot of the housing that is available is unsafe. There are more than 1,000 children in the service area who do not have health insurance. The inadequacy of prenatal care is higher than the state average within the service area. This is especially true within Todd County The teen pregnancy rate is at 29.4 (per 1,000) in the Tri‐County Health Care service area, which is lower than the state average of 33.2. Splitting up the counties again reveals higher rates in Wadena County (39.5), compared to Otter Tail (19.4) and Todd County (29.3). A high percentage of students receive free or reduced lunches compared to state averages. The community health survey respondents cited that 27 percent had delayed or not gotten medical care when they felt it was needed. Top cited reasons for this are 1) not serious enough, 2) costs too much, 3) deductible was too expensive, and 4) no insurance. Disease and Injury: Higher than average numbers of students in 6th grade reported suicidal thoughts within the past year. Students in 6th, 9th and 12th grades have higher than average percentages of alcohol utilization in the past year. Student smoking is a concern with higher than average percentages of students who have smoked in the last 30 days. A higher than state averages rate of 12th graders report having sexual intercourse. Graduation rates in The Tri‐County Health Care service area have been around state averages over the last few years. Adult smoking levels are below average in the Tri‐County Health Care service area (14.7 percent vs. Minnesota 17.0 percent) according to our secondary data analysis. Our local community health survey respondents cited the percentage of smokers was 17 percent. A higher number of mothers smoked during pregnancy within the Tri‐County Health Care service area at 18.6 percent, which is higher than the state average of 14.2 percent. 12
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The top mortality causes were heart disease, cancer, Alzheimer’s disease and stroke. The Tri‐County Health Care service area has higher than state average incidences of cancer, chronic obstructive pulmonary disorder and myocardial infarctions, while there is a lower incidence rate of asthma. Service area lower than Minnesota sexually transmitted infection rate (276 vs 67). 81.5 percent service area vs. 88 percent Minnesota received diabetic screenings. Similar mammography screenings within the service area (71 percent) compared to Minnesota (73 percent). Our Hispanic focus group, as well as the Tri‐County Health Care top problem codes, revealed that mental health is a large issue in the service area. According to our community health survey responses, 13 percent of respondents had been diagnosed with diabetes compared to the state average of 7.3 percent. 36 percent of respondents also said they had been diagnosed with high blood pressure compared to the 26 percent of Minnesota adults. Behavioral Risk Factor Surveillance System (BRFSS) prevalence data for Minnesota‐2012 reports 17.1 percent of respondents had been diagnosed with depression compared to 27 percent in the service area. 34 percent of respondents on the community health survey stated that they ate the recommended five or more servings of fruits/vegetables each day. The Tri‐County Health Care service area has higher than average obesity rates among adults (31 percent vs. Minnesota 26 percent). County Health Rankings, 2010. Most common injuries requiring hospitalization within the service area were falls, bites and stings, motor vehicle accidents to occupants, and poisonings per the Minnesota Injury Data Access System (MIDAS). The leading causes of hospitalization for all ages within the central region of Minnesota were 1) diseases of the circulatory system, 2) injury and poisoning, 3) diseases of the digestive tract, 4) diseases of the respiratory tract, and 5) complications of pregnancy, childbirth and the puerperium (six weeks after childbirth). (Minnesota Hospital Association, 2007). Vulnerable Population: The residents of the Tri‐County Health Care service area are vastly Caucasian at 93.9 percent, followed by Hispanic at 3.2 percent. The Hispanic population that resides in our service area cited a lack of Spanish‐speaking health providers within the service area as a barrier to seeking health care services with local hospitals, clinics and public health. According to census data statistics, the service area has a higher median age of 43.6 compared to 37.3 years for Minnesota. The population pyramid within the assessment also shows that the service area has a larger aging population compared to Minnesota. Additional health care services and providers will be needed to meet the needs of this subset of our population now and in the future. Low‐income data/statistics are discussed above in #1 because it pertains to access to health care. A population of Amish people also resides within the Tri‐County Health Care service area. Todd County has five separate settlements, and Wadena County has two districts and includes the oldest Minnesota Amish community. Eastern Otter Tail County is also home to some but is not as well documented. It is unclear the specific population numbers, but the Amish seem to be growing in numbers in America. 13
MAPP Process Overview: Mobilizing for Action through Planning and Partnerships (MAPP) Phase 1: Organize for Success and Partnership Development are part of the planning phase. This phase identifies who should be involved in the process and how the partnership will approach and organize the process. Phase 2: The Visioning phase is a collaborative and creative approach that leads to a shared community vision and common values. Phase 3: The Four Assessments inform the entire MAPP process. The assessment phase provides a comprehensive picture of a community in its current state using both qualitative and quantitative methods. The use of four different assessments is a unique feature of MAPP. Most planning processes look only at quantitative statistics and anecdotal data. MAPP provides tools to help communities analyze health issues through multiple lenses. Phase 4: Identify Strategic Issues uses the information gathered from the four assessments to determine the strategic issues a community must address in order to reach its vision. Phase 5: The Formulate Goals and Strategies phase involves specifying goals for each of the strategic issues identified in the previous phase. Many communities create a community health improvement plan at the end of this phase. Phase 6: The Action Cycle includes planning, implementation and evaluation of a community’s strategic plan 14
Visioning Sessions The research utilized quantitative methodology by the administration of a group administered questionnaire. These questionnaires were handed out at various meetings at Tri‐County Health Care and the Wadena Rotary Club during October of 2012. The Wadena Rotary Club includes many business leaders from the community. The three questions that were included on this survey were open ended eliciting various responses. The questions were as follows: 1) How do you describe a healthy community? 2) What kinds of resources create a healthy community? 3) Who is responsible for keeping a community healthy? Basic demographic information such as gender, race and age were also included. The groups that were involved included clinical leadership, medical staff, nursing supervisors, clinic advisory committee members (listed in the appendix) and local Rotarians. The top answers for question #1 were the availability of transportation, exercise opportunities and smoke free environment. The top three answers for question #2 were the availability of exercise facilities, public transportation and health care resources. For question #3, the vast majority of respondents agreed that it is everyone’s responsibility. Other comments on this question included health care providers and city leadership. Visioning Session Dates: 1. October 01, 2012: Medical Staff Meeting (physicians, physician assistants and nurse practitioners) 2. October 02, 2012: Clinical Leadership Meeting (clinical managers and supervisors) 3. October 09, 2012: Nursing Supervisors Meeting Respondents 4. October 24, 2012: Wadena Rotary Club 5. November 12, 2012: Clinic Advisory Committees Age 22‐30 31‐40 41‐50 51‐60 61‐70 71‐80 81 & + Male 1 3 3 9 10 1 1 Female 3 9 5 14 3 0 0 Eight respondents did not fully fill out the demographic section and are not included in above totals. 15
Focus Groups Visioning Sessions
Hispanic Focus Group February 25, 2013 10 a.m. Facilitator: Kaarin Lund, MPH Note Taker: David Determan Attendees: Four individuals (men and women): A local business owner representing the Hispanic community, a Todd County Health and Human Services nurse who translates for Hispanic clients, and two Hispanic clients who use social services. The Tri‐County Health Care service area has a small percentage of Hispanic minorities (3%), as described in the community profile information; Todd County Minnesota on the other hand is known for having a growing Hispanic population residing in the area. The community health survey was sent out only in English and we believed it was important to include the perspective of this potentially vulnerable portion of the population in our analysis. I’d like for you to describe any health‐related issues that you feel are important to the health of our community. 
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Need better access to Spanish‐speaking services at Health and Human Services (HHS). Need better access to physical activity options during winter months. Parents smoking around their kids. Underage alcohol use is not a big issue. It takes place at family events and celebrations. Mental health is a large issue, especially during the winter. o Kids grow up and move out. People lose their sense of purpose. People can’t afford the doctor’s appointments for meds and therapy. o Some communities have organizations that make products and sell them to get Hispanic women the socialization they need (e.g. piñata making). Other places offer classes or volunteer opportunities for people to get out and involved. Unsafe housing. The subsidized housing is out of reach. Lack of diabetes education. People are ignoring their disease and not treating it. Lack of Spanish speaking materials. Please describe any barriers that prevent our community from being healthier. 
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Unaware of available services at HHS (brought up twice). Lack of transportation to grocery store and health clinics. Information on Ruby’s Pantry and local food shelves is not shared with the Hispanic community, and the food shelf is at a difficult time for people who work. They hadn’t heard of Ruby’s Pantry. The telephone translation service is NOT well liked because it is a poor translation that most do not understand. People want to eat healthier but don’t know how. Lack of Spanish‐speaking health providers at HHS and health clinics. Not enough jobs in the area for people to get their foot in the door. Hard to get a Minnesota driver’s license if you aren’t from here but still need to drive for work. 16
Please describe any solutions that can address the health issues and barriers discussed. 
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HHS should offer options for physical activity (work with schools on open gym during the winter). Point them to library work out DVDs. Give them at home exercises. Have more physical activity options for families. The local Snap Fitness is not for kids. Grandmas at the Beach (volunteers who clean the beach) could potentially provide babysitting services. HHS could provide tobacco cessation materials (gum, patches, tobacco cessation messaging in Spanish). Transportation: work with Rainbow Rider to have a Spanish option. Advertise Rainbow Rider’s phone number and what it does. Could even have a Spanish‐speaking individual at a local business be the point person to call Rainbow Rider for Hispanic individual to make the pick‐up time. Please describe how our community is meeting health needs. 
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WIC is meeting needs. Snap Fitness is economical for families. Pretty expensive for individuals. 911 services are meeting emergency needs. Is there anything else you would like to share about ways to make our community a healthier place to live? 
No. Of all the things we discussed today, what do you believe is the most important? 
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Making people aware of the services available in our county. Healthy cooking class to bring people together and learn about healthy cooking for families. (Could use the extension materials and work with Hispanics to add healthier versions of traditional foods.) 17
Health 4 Life Nursing Student Survey Compilation Completed by Andrea Craig with 25 nursing students from M‐State Community and Technical College. May 20, 2013 1. In general, would you say your health is: Excellent 2 Very Good 17 Good 5 Fair 1 2. About how long has it been since you last visited a doctor or other health care professional for a routine checkup? Within the past year 12 Within the past two years 7 Within the past five years 4 5 or more years ago 1 Never 0 3. During the past 12 months, was there a time where you thought you needed medical care but did not get it or delayed getting it? Yes – 9 No – 16 4. Why did you not get or delay getting the medical care you thought you needed? The care I needed cost too much 2 My co‐pay was too expensive 1 My deductible was too expensive 1 I did not have insurance 1 I could not get an appointment 1 I didn’t think it was serious enough 6 5. How would you rate your overall level of stress? High 7 Medium 17 Low 1 6. During the past 30 days, for how many days have you felt sad, blue or depressed? 16 to 30 days 1 11 to 15 days 2 6 to 10 days 7 0‐5 days 15 7. During the past 12 months, was there a time when you wanted to talk with or seek help from a mental health professional about emotional problems such as stress, depression, excess worrying, troubling thoughts or emotional problems but did not or delayed talking to someone? 18
Yes – 7 No –17 8. Why did you not get or delay getting the care you thought you needed? The care I needed cost too much 2 My co‐pay was too expensive 2 Deductible was too expensive 1 I did not have insurance 2 I could not get an appointment 1 Not think it was serious enough 2 I did not know where to go 2 Other Comment: Lack of time and money 9. In the past six months, which statement best describes medications prescribed for you? I had no medications prescribed for me 14 I had medications prescribed for me and filled all 10 I had medications prescribed for me and I did not fill at least one of them 1 10. Why did you not fill at least one prescription? I did not like the side effects 1 11. Do you currently have any kind of health care coverage, including health insurance or government plans such as Medicaid, Medicare or Indian Health Services? Yes – 19 No – 5 12. Is your health insurance a high deductible plan? Yes – 5 No – 8 13. Which of the following types of health insurance do you have? Health Insurance or coverage through your employer or your spouse/partner, parent, or someone else’s employer Yes – 12 Health insurance or coverage bought directly by yourself or your family Yes – 2 Medicaid, Medical Assistance or Prepaid Medical Assistance 4 MinnesotaCare 5 14. Have you been told by a doctor or other health care professional that you have: Diabetes High Blood Pressure High Blood Cholesterol Depression and/or Anxiety 0 2 2 10 15. (a)A serving of fruit is one medium sized fruit or half cup chopped, cut or canned fruit. Yesterday, how many servings of fruit did you eat? (Do not include fruit juice.) 3 servings 1 0‐2 servings 24 (b) A serving of vegetables is a half cup of any vegetable or one cup of salad greens. Yesterday, how many servings of vegetables did you eat? 6 servings 1 3 servings 6 0‐2 servings 18 16. During an average week, whether at work, at home, or anywhere else, on how many days do you get at least 30 minutes of moderate physical activity? 0 days 2 1 day 1 2 days 4 3 days 7 4 days 5 5 days 3 6 days 0 7 days 1 17. How often do you feel safe in your community? Always 17 Often 8 Sometimes 0 Never 0 Where do you get your health information? Government websites 21 Non‐government website 17 Television 8 Magazines, newspapers or books 17 Doctor, nurse or other medical 23 professional f. Alternative health specialist 6 g. Family or friends 11 h. Other 1 When asked what issues they found important to the health of the community they answered the following: 18. How often do you smoke cigarettes? Always 5 Sometimes 2 Never 18 19. Do you. . . a. Perform monthly self‐exams for cancer (breast or testicular)? b. Get a yearly flu shot or flu immunization? c. Need medication to control a 14 24 4 6 20.
a.
b.
c.
d.
e.
chronic or physical condition? d. Have a family emergency plan? 19
1. An outreach to our Amish communities to do yearly health checks 2. Need serious intervention for suicide prevention 3. Immunization education 4. Self‐dependence education 5. Cost of health food 6. All the modified foods 7. Cost of living compared to wages in the area. 8. Lack of knowledge of disease prevention and nutrition 9. Lyme disease prevention 10. Depression 11. Public safety 12. Mental health 3 13. Heart disease 14. Diabetes management 2 15. Noise reduction in regards to the train. 16. There is no free government/public clinic available. 17. Affordable health care. 18. Obesity reduction 19. Hypertension reduction 20. Addiction counseling A community health survey was administered to a random sample in the Tri‐County Health Care service area February 2013. The survey instrument content was largely taken from a similar survey being conducted by neighboring Minnesota counties. The questions were developed by local public health staff with technical assistance from the Minnesota Department of Health Center for Health Statistics and Wilder Research. The survey was conducted as a collaborative endeavor of Todd County Health and Human Services, Morrison County Public Health, Wadena County Public Health, Cass County Public Health, Tri‐County Health Care and Lakewood Health System. It was paid for through the Community Transformation Grant (CDC). Analysis was conducted by Ann Kinney at the Minnesota Department of Health. This random sample survey provided stakeholders with findings that truly represent the service area population, are statistically significant and supplied health statistics and community opinions that may not have been brought up in focus groups or visioning session interviews. The community health survey was organized with personal health behavior questions first, followed by an “About You” section to obtain demographic information. Lastly, there is an opinion section where respondents could rank issues as “no problem” up to “serious problem” within their community. Graphs are provided below for the service area. Sample: For each county, a two‐stage sampling strategy was used. The first stage of sampling involved a random sample of county residential addresses purchased from the U.S. Postal Service to ensure all households would have an equal chance of being sampled. The second stage of sampling involved having the adult with the “most recent birthday” of within‐household respondents complete the survey. Survey Administration: Surveys were sent out to 1,200 households per county with a cover letter and a postage‐paid envelope. A reminder postcard was sent to all sampled households approximately 3 weeks after the initial mailing. Four weeks after the reminder postcard, another full survey packet was sent to households that still had not returned the survey. Response Rate: During the survey administration, 1,308 survey packets were returned as having “bad addresses”; 396 were then replaced by eligible addresses and 912 were not due to timing in the survey process. 1,704 adult residents of the four counties sent in the completed surveys giving an overall response rate of 43.8% (1,704/ (4,800‐912)). Todd County had 464 surveys and Wadena County had 356 surveys used for analysis. Weighting: To ensure the survey results were representative of the adult population within the four counties, the data were weighted when analyzed. The weighting accounts for the sample design by adjusting for the number of adults living in each sampled household and also includes a post‐stratification adjustment so age and gender distribution of the respondents mirrors the age and gender distribution of the adult population of each county, according to the U.S. Census Bureau 2010 estimates. Community Health Survey
20
Chronic Disease in the Tri‐County Health Care Service Area
Have you been diagnosed with high blood pressure by a health care professional?
Have you been diagnosed with diabetes by a health care professional?
Yes
13%
Yes
36%
No
64%
No
87%
According to the Minnesota Department of Health 2011, 7.3 percent of Minnesota adults have been diagnosed with diabetes (type 1 or 2), and approximately 26 percent of Minnesota adults reported having high blood pressure. A random sampling of survey recipients in the Tri‐County service area reports higher rates of both diabetes (MN 7.3 percent vs. service area 13 percent) and high blood pressure (MN 26 percent vs. service area 36 percent). www.health.state.mn.us/diabetes/pdf/Diabetes_in_Minnesota_final.pdf www.health.state.mn.us/divs/hpcd/chp/cvh/documents/2012mnhypertensionfactsheet.pdf Have you been diagnosed with high cholesterol by a health care professional?
Yes
35%
No
65%
The Minnesota Department of Health 2011 reports that approximately 35 percent of adults have high cholesterol, which is the same as the service area. www.health.state.mn.us/divs/hpcd/chp/cvh/documents/2013mnheartdiseasefactsheet.pdf
21
How would you rate your overall level of stress?
High
15%
Low
26%
Chronic Disease continued Medium
59%
During the past 30 days, about how many days have you felt sad, blue or depressed?
20‐29 days
5%
10‐19 days
11%
Accurate prevalence data pertaining to stress is hard to find, but stress is an important health topic because chronic stress can lower your immunity and lead to heart disease, high blood pressure, diabetes, depression and other illnesses. Behavioral Risk Factor Surveillance System prevalence data for Minnesota‐2012 reports 17.1 percent of respondents had been diagnosed with depression compared to 27 percent in the service area. apps.nccd.cdc.gov/brfss
/display.asp?cat=CH&yr
=2012&qkey=8441&stat
e=MN All 30 days
4%
0 days
42%
1‐9 days
38%
Have you been diagnosed with depression or anxiety by a health care professional?
Yes, 27.0
No, 73.1
22
Health Behaviors Percentage of People that Live with a Smoker
Smoking Status
Current smoker
17%
Yes
15%
Non‐
smoker
83%
No
85%
The prevalence of current smokers in Minnesota is 17 percent, the same as found in the service area respondents. No prevalence data was found for individuals that live with a smoker, but the health effects of second hand smoke are well documented. Data source: County Health Rankings and Roadmaps ,2013. How many days a week do you get at least 30 minutes of moderate physical activity?
Yesterday, how many servings of fruits and vegetables did you eat?
0 servings
6%
5 or more servings
34%
5‐7 days
45% 0‐4 days
55%
3‐4 servings
35%
1‐2 servings
25%
CDC BRFSS prevalence data reveals that 52.7 percent of adults get sufficient physical activity to meet public health recommendations (2009). Adults need moderate intensity exercise for five days a week, 30 minutes a day to meet recommendations. BRFSS (CDC) prevalence data for the state of Minnesota reports that 21.9 percent of adults consumed five or more fruits or vegetables per day and 78.1 percent consumed less than the recommended five (2009). 23
About how often do you consume More than sugar drinks?
Calculated BMI Based on Individual's Provided Height and Weight
once per day
10%
Once per day
11%
Never
33%
At least once per week but not daily
16%
Not overweig
ht
28%
Obese
35%
Overweig
ht not obese
37%
Occasionall
y but not every week
30%
According to NHANES (CDC), approximately half of the U.S. population consumes sugar drinks on any given day (2005‐2008). A Body Mass Index (BMI) 25.0‐29.9 is considered overweight and more than 30.0 is obese. Both terms are considered unhealthy weight. BRFSS (CDC) data report obesity prevalence in MN adults at 25.4 percent and overweight or obese at 63.1 percent (2010). Health Care
5 or more years ago
7%
During the past 12 months, was there a time when you thought you needed medical care but did not get it or delayed getting it?
What was the date of your last checkup?
Never
2%
Within the past 5 years
6%
Within the past 2 years
12%
Yes
27%
No
73%
Within the past year
73%
24
Reasons for delay of medical care
Other
Transportation problems
Not serious enough
Could not get appointment
No insurance
Insurance did not cover
Deductible too expensive
Copay too expensive
Cost too much
0
5
10
15
20
25
30
35
40
Percentage of Individuals
The reasons cited for delay of medical care and mental health care are similar: 1) Not serious enough, 2) Cost too much, and 3) Deductible too expensive. Delaying or not visiting a health care professional when needed negatively impacts quality of life and life expectancy. During the past 12 months, was there a time when you wanted to seek help from a health professional about emotional problems but did not?
Yes
13%
No
87%
Reasons for delay of mental health care
Other
Did not know where to go
Transportation problems
Not serious enough
Could not get appointment
No insurance
Insurance did not cover
Deductible too expensive
Copay too expensive
Cost too much
0
5
10
15
20
25
30
35
40
45
50
Percentage of Individuals 25
Where do you get health care information?
Family/Friend
59.5
Alt. Health
24.3
Dr./Nurse
87.9
Mags/Newspaper
56.4
TV
44.5
Other Websites
38.5
Gov Websites
20.4
0
20
40
60
80
100
Communication of effective health information is integral to a population’s health. Health Information National Trends Survey (HINTS) from the National Cancer Institute looks every two years at this changing trend. It found the following pertaining to the public’s view of trustworthy sources of health information: 1. Health care professional (66.8 percent), 2. Family (22.7 percent), 3. TV (20.6 percent), 4. Magazine (19.3 percent), and 5. Internet (18.5 percent). (2005) The community health survey respondents cited the following: 1. Dr./Nurse (87.9 percent), 2. Family/Friend (59.5 percent), 3. Magazine/Newspaper (56.4 percent), 4. TV, 5. Other non‐government websites (38.5 percent). This information is vital to developing communication strategies that meet the public’s needs, convey accurate health information, discern information usage barriers and inform health education spending. hints.cancer.gov/brief_7.aspx 26
Issues Marked as Moderate or Serious Problems within the Tri‐County Service Area Obesity among adults
Smoking other tobacco use
Parents with inadequate or poor parenting skills
Obesity among children
Unemployment
Children in poverty
Alcohol abuse by those over 21
People without health insurance
Alcohol use among those under 21
Diabetes
Heart disease and stroke
Mental health depression anxiety
Violence
Prescription drug abuse
Lack of access to public space
Infectious disease
Lack of safe and affordable housing
Lack of access to healthy foods
Lack of access to health care services
Pregnant women not getting prenatal care
Unintended injuries
Lack of safe places to walk or bike
82.20%
73.45%
72.30%
72.15%
71.90%
67.90%
67.90%
67.75%
64.95%
59.05%
57.75%
57.60%
52.15%
49.20%
34%
32.40%
29.95%
29.30%
28.40%
26.95%
23.65%
20.05%
0%
25%
50%
75%
100%
A random sampling of community members within the Tri‐County service area were asked to rate a variety of health issues on topics relating to the environment, health care delivery, social conditions, pregnancy, birth and child development, infectious disease, alcohol, tobacco and other drug use, health habits and chronic disease, injury and violence, and mental health. Opinion questions were rated from “no problem” to “serious problem” in the service area. The issues most frequently cited as serious are listed above. Obesity among adults (82.2 percent) and children (72.15 percent), smoking/other tobacco use (73.45 percent), and parents with inadequate/poor parenting skills (72.3 percent) were the most frequently cited problems. 27
Community Profile
Population Statistics Under 5 Years 5 to 19 Years 20 to 34 Years 35 to 54 Years 55 to 64 Years 65 and over Totals Service Area Percent Minnesota Percent 5812 6.27% 353120
6.70%
18490 19.73% 1076787 20.40%
14010 14.80% 1063617 20.20%
25552 26.47% 1501767 28.40%
13290 13.33% 610403 11.50%
18956 19.53% 672496 12.70%
96110 5278190
The population total for the Tri‐County Health Care service area and all three counties is 96,110. Children and youth ages 0‐19 make up 26 percent of the population; 41 percent are 20‐54 years of age; and 33 percent are older than 55. The area has higher percentages of individuals older than 55 years than the state as a whole, with Minnesota at 24 percent. 26,278 is the population of the primary service area as discussed on Page 10. Data obtained from: American Fact Finder, 2010. 5 year averages 2007‐2011. U.S. Census Bureau Quickfacts.census.gov Median Age (Yrs) Total Households Persons Per Household Service Area Minnesota 43.6 13,508 2.33 37.3 2,094,265 2.46 28
Population Pyramid for Minnesota
80 to 84 years
70 to 74 years
60 to 64 years
A 50 to 54 years
g 40 to 44 years
e
30 to 34 years
Male
Female
20 to 24 years
By looking at the population pyramids, Tri‐County Health Care has a service area that is aging. This is true for all rural areas of Minnesota compared to the metro regions. 10 to 14 years
Under 5 years
10
8
6
4
2
0
2
4
6
8
10
Population (%)
According to the Center for Rural Policy and Development, 32.3 percent of the projected total population within the service area will be 65 years of age and older by 2035. In 2010, this age group only comprised 19.8 percent of the total population. Population Pyramid of Tri‐County Health Care Service Area
80 to 84 years
70 to 74 years
60 to 64 years
A 50 to 54 years
g 40 to 44 years
e
30 to 34 years
Male
Female
20 to 24 years
10 to 14 years
Under 5 years
10
8
6
4
2
0
2
4
6
8
10
Population (%)
29
Minnesota Minority Population 18.4% Percentage of Race/Ethnicity Statistics White (82.4%)
Hispanic (4.9%)
Black (5.5%)
Am. Indian (1.3%)
The Tri‐County Health Care service area consists primarily of White/Caucasians (93.9 percent) compared to the state of Minnesota (82.4 percent). The Tri‐
County service area has a low minority population as compared to the state of Minnesota with a difference of 12 percent. Asian (4.4%)
Other/Mixed (2.2%)
Pacific Islander (0.1%)
Service Area Total Minority Pop 6.4% White (93.9%)
Hispanic (3.2%)
Black (0.8%)
Am. Indian (0.5%)
Asian (0.4%)
Other/Mixed (1.4%)
Pacific Islander (0.1%)
Data Sources: 
American Fact Finder, 2010
U.S. Census
www.quickfacts.census.gov

30
Labor Market Data
Unemployment Data August 2009 August 2010
August 2011
August 2012 August 2013
Service Area 9.5% 8.3%
7.3%
6.4% 5.3%
Minnesota 8.0% 7.4%
6.5%
5.6% 4.8%
Tri‐County Health Care Service Area vs. Minnesota Unemployment Rates
10.0
9.5
Unemployment Rates
9.0
8.0
8
8.3
7.4
7.0
7.3
6.5
Service Area
6.4
6.0
5.6
5.0
MN
5.3
4.8
4.0
Aug‐09
Aug‐10
Aug‐11
Aug‐12
Aug‐13
Years
The Tri‐County Health Care service area unemployment rate has been consistently higher than the state average. Data Source: Local Area Unemployment Statistics (LAUS) Minnesota Department of Employment and Economic Development. Retrieved November 11, 2013, from http://mn.gov/deed/data/data‐tools/laus.jsp 31
Per Capita Income Percent of workers who commute to a different county for work: Per Capita Income
$35,000
$30,000
$30,310
$25,000
$20,000
$21,986
$15,000
$10,000
$5,000
$0
Service Area
Minnesota
Service Area 36.9% Data Source: Local Area Unemployment Statistics (LAUS) (n.d.) .Minnesota Department of Employment and Economic Development. Retrieved November 11, 2013, from http://mn.gov/deed/data/data‐tools/laus.jsp Average Weekly Wages Average Weekly Wage
$1,000 Average Weekly Wage
$949 $750 $500 $630 $250 $0 Service Area
Minnesota
Data Source: Regional Labor Market Information. (n.d.). Minnesota Department of Employment and Economic Development. Retrieved November 11, 2013,from https://apps.deed.state.mn.us/lmi/rws/ 32
Poverty
Percentages of All Ages Living in Poverty State of Minnesota Service Area 2007 9.5% 13.3% 2008
9.6%
14.4% 2009 10.9%
14.5%
2010 11.5% 15.7% 2011
11.8%
15.4%
2010 15.0% 22.9% 2011
15.3%
21.9%
Percentages of People younger than 18 Living in Poverty State of Minnesota Service Area 2007 11.9% 18.2% 2008
11.4%
18.7% 2009 13.9%
20.2%
“Poverty” is defined by comparing an annual household income to a federally set poverty threshold determined by the U.S. Census Bureau and calculated based on household size and composition. This data is important because it shows the geographic distribution of poverty which can inform the public and decisions makers for program planning and evaluation. The Statistics indicate that children as well as adults in the Tri­County Health Care service area tend to have higher rates of poverty than the general population within Minnesota. Food Stamp Utilization (Av Monthly Households) State of Minnesota Service Area 2007 126,086 2303 2008
134,859
2436
2009
169,711
3043
2010 134,859 2436 2011
237,132
3970
Minnesota ranks 44 out of the 50 states in food stamp utilization by eligible persons. Less than half of eligible Minnesotans participate (household incomes at or below 130 percent of the Federal poverty level). Food stamps are utilized by some of the most vulnerable within a population (children, elderly, single parent families, etc.) and helps ensure better nutrition for those who can’t afford it. Data Source: Minnesota Center for Health Statistics, Minnesota Department of Health, Vital Statistics Trend Report www.health.state.mn.us/divs/chs SNAP to Health. www.snaptohealth.org 33
Housing Housing Costs Housing costs are rising in the state of Minnesota. In 2010, the cost of housing consumed more than half of income for almost 1 in 7 Minnesota households. In 2000, only 1 in 12 households experienced this level of cost burden. Housing is considered affordable if it consumes less than 30 percent of a household’s gross income. At greater than 30 percent, families need to choose between housing costs and other basic needs, such as food and medicine. (U.S. Census Bureau) (graphs retrieved from www.mhponline.org, Homes for All in Minnesota 2012) 34
Households Impacted Tri‐County Service Area Household Income Less than $20,000 2,940 Renters 3,375 Owners $20,000‐$34,999 680 Renters 2,366 Owners $35,000‐$49,000 75 Renters 1,803 Owners More than $50,000 4 Renters 1,675 Owners The U.S. Census Bureau estimates that there are 7,388 occupied units paying rent in the service area. The average cost of rental was $557. A worker within the service area must earn $11.21 per hour, 40 hours a week, all year long to afford rent and utilities for a safe, two‐bedroom, fair market value monthly rent of $583. A typical renter earns on average $7.39 in this area. Graphs and information retrieved from www.mhponline.org, Homes for All in Minnesota 2012 U.S. Census Bureau. 2007‐2011 American Community Survey 5‐Year Estimates. 35
Homelessness The chart below outlines homelessness in the central region of Minnesota, which includes Wadena County. Community Demographic and Assessment Information for the Minnesota counties of Becker, Hubbard, Mahnomen, Otter Tail and Wadena, 2012, Mahube‐Otwa Community Action Partnership, Inc. Minors <18 Male 7 In Shelters Not in ‐ Shelters Total 7 Minors <18 Female 14 Age 18‐21 Male 19 Age 18‐21 Female
33 Age 22‐54 Male 130 Age 22‐54 Female
80 Age 55+ Male 22 Age 55+ Female 3 Children TOTAL
with Parents 113 421 ‐ 2 4 15 19 2 3 16 61 14 21 37 145 99 24 6 129 482 Greater Minnesota has less than one‐third (32 percent) of the homeless population in Minnesota. This is an increase from 1991, when the proportion was 20 percent. Homelessness outside of metro areas is more invisible because fewer shelters exist to serve them. The homeless in our rural communities differ from those in the Twin Cities on the following measures: 





42% have a chronic health condition (vs. 48% in the metro area)
19% of homeless adults were American Indian (vs. 8% in the metro area)
24% of children were in informal arrangements (vs. 4% in the metro area)
55% homeless adults used formal shelter programs (vs. 82% metro area)
32% of women were escaping abuse (vs. 27% in the metro area)
17% of men were veterans (vs. 20% in the metro area)
(MN Homeless Survey, 2009, Wilder Research). The number of homeless people in Minnesota has risen sharply since 2006. A 25 percent increase was noted from 2006 to 2009 per the Wilder Homeless Study, with the total amount of homeless in Minnesota at 10,214 as of October 25, 2012. Nearly half (46 percent) of the 10,214 were younger than 21 years of age. The largest percent increase in homelessness was among older adults (48 percent increase) from 2009 to 2012. Forty percent of homeless adults report that they have either lost their last job or had their hours reduced causing them to lose their last housing. Fewer jobs, less income and increased food needs have all contributed to the drastic increase in homelessness within the state. 36
Violent crime rate per 100,000 population (2007‐2009) Minnesota 254 Service Area 110 Crime Statistics
2012‐2013 Crime Per Capita (100,000) Minnesota Murder Otter Tail Co. Todd Co. Wadena Co. 1.8 0.0 0.0 0.0 Rape 30.5 8.7 32.1 79.5 Robbery 64.6 3.5 4.0 0.0 Aggravated Assault 134.0 43.6 32.1 144.5 Burglary 471.8 275.7 470.0 332.3 Larceny 1,939.3 933.6 1116.7 1358.1 Vehicle Theft 157.2 38.4 52.2 57.8 These crimes are offenses involving face‐to‐face confrontation between the perpetrator and victim. This includes homicide, rape, robbery, aggravated assault. A higher rate of violent crimes in an area is important to health because it compromises the physical safety and psychological wellbeing of the population. It may also contribute to higher rates of obesity and hypertension by decreasing opportunities for physical activities and increasing chronic stress and poor mental health. These rates are garnered from Uniform Crime Reporting data which measures law enforcement agency reactions and not criminal behavior itself. The incidence of crimes in the Tri‐County Health Care Service Area is low in comparison to urban areas of the state. Data Source: criminalstatistics.org/states/mn County Health Rankings 2013. 37
Education K‐12 Public School Enrollment 2008 2009 2010 2011 2012 Minnesota Service Area 822,412 14,373 822,697 14,073 823,235 13,990 824,858 13,532 830,482 13,539 K‐12 Students Enrolled in Special Education 2008 2009 2010 2011 2012 Minnesota Service Area 107,168 2,005 108,286 2,012 109,552 2,056 110,567 2,000 111,221 1,976 Graduation Rate 2007 2008 2009 2010 2011 Minnesota Service Area 75.3% 79.5% 74.7% 79.4% 74.9% 78.6% 76.9% 77.7% 77.6% 77.8% Graduation rates for the service area have been better than or at state averages for the years 2007‐2011. Number of Students Receiving Free and Reduced Lunches 2007 2008 2009 2010 2011 Minnesota Service Area 31.8% 32.9% 53.9% 54.2% 35.6% 58.9% 36.7% 57.4% 37.3% 56.9% Free and reduced lunch prevalence is an indicator of the socioeconomic status of the student population within a school district. The service area of Tri‐County Health Care has had a significantly higher rate of students receiving free and reduced lunch compared to the state of Minnesota for the last five years. Data Source: Minnesota KIDS COUNT Data Center 38
Natality Statistics (2011) Birth Statistics
Number of Births Minnesota Otter Tail Todd Wadena Prenatal Care Minnesota Otter Tail Todd Wadena 68,416 597 318 187 Fertility Rate Birth Rate 65.5 71.2 81.7 88.5 12.8 10.4 12.8 13.6 Percent Adequacy of Prenatal Care, GINDEX Care 1st Trimester Adequate or Better 84.7% 85.5% 74.5% 84.8% 78.3% 80.4% 62.1% 74.1% Intermediate 17.8% 15.0% 24.8% 22.9% Inadequate or None 3.9% 4.6% 13.1% 2.9% Prematurity and Low Birth Weight of Singleton Births Low birth weight is a negative birth indicator because babies born at a lower birth rate are at higher risk for disease, disability and possibly death. The Tri‐County Health Care service area averaged has a slightly lower percentage of very low birth weight babies than Minnesota (0.467 percent vs. 0.8 percent). Minnesota Otter Tail Todd Wadena % Preterm Births % Low Birth Weight %Very Low Birth Weight % Small for Gest. Age 7.9% 3% 7.9% 6.5% 4.7% 3.8% 4.8% 2.2% 0.8% 0.6% 0.2% 0.6% 3.4% 4.2% 3.1% 1.8% (Preterm Births: Babies who are less than 37 weeks gestation at birth) (Low Birth Weight: Live births that are less than 2,500 grams at birth) (Very Low Birth Weight Births: Live births that are born weighing less than 1,500 grams) Data Source: Minnesota County Health Tables 2011: Minnesota Department of Health 39
Birth Outcomes/Socio‐Demographic Factors % Births to Unmarried Mothers Minnesota 32.8% Otter Tail 29.1% Todd 29.2% Wadena 36.9% Teen Pregnancy Rates 15‐19 Year Olds Minnesota Otter Tail Todd Wadena % No Father on Birth Certificate % Mother Smoked During Pregnancy 14.8% 14.6% 11.6% 14.4% 14.2% 12.5% 18.2% 25.1% Birth Rate Pregnancy Rate 13.4 10.8 13.4 13.5 33.2 19.4 29.3 39.5 Teen Birth Rate: Number of live births per 1,000 females in the population of the specified age. Teen Pregnancy Rate: The number of live births, fetal deaths and induced abortions per 1,000 females in the population of the specified age. Minnesota Department of Health Statistics. Vital Statistics 2011 Minnesota County Health Tables 2011: Minnesota Department of Health Number of Infant Deaths Minnesota Otter Tail Todd Wadena 1991‐1995 1996‐2000 2001‐2005 2006‐2010 2,340 27 8 11 1,990 16 8 3 1,728 15 8 3 1,836 5 9 8 Data Source: Minnesota County Health Tables 2011: Minnesota Department of Health There were 10,641 abortions in Minnesota in 2010. Numbers were not calculated for the Tri‐County Health Care service area on the Minnesota County Health Tables, as there were less than 20 events. Prenatal care is at an inadequate level per statistical information. There were higher than state averages of mothers that smoked during pregnancy (18.6 vs. 14.2). The teen pregnancy rate is a bit lower than the state average (33.2) for Otter Tail (19.4) and Todd (29.3) counties but higher in Wadena County (39.5). 40
Child and Youth Statistics
Average Annual Costs for Licensed Family‐Based Child Care (2012) Infant Toddler Preschooler Minnesota Service Area $7,737 $5830 $7,337 $5,707 $6,997 $5,601
School‐Age $6,326
$5,237
Average Monthly Enrollment for Medical Assistance for Children 0‐17 There are 88,701 children (0‐
19) in Minnesota who do not have health insurance. More than 1,059 of those children live in the Tri‐County Health Care service area. Minnesota 319,916 Service Area 1,433 Average Average Monthly Enrollment for MinnesotaCare for Children 0‐17 Minnesota 39,253 349 Service Area Average Childhood Immunization Coverage of Vaccine Series (2011): Minnesota 55.7% Service Area 43.7% Data Source: Minnesota KIDS COUNT Data Center 41
Determined Abuse and Neglect Cases for 2010 Neglect Physical Sexual
Mental
Medical Neglect
Minnesota 3,199 943 863 39 46 Service Area 8 12 15 0 0 Mothers and Children Receiving WIC (Special Supplemental Nutrition Program) 2006 2007 2008
2009
2010
Minnesota 227,376 234,855 228,715 240,041 230,110 Service Area 4,692 4,986 5,007 4,685 4,519 These numbers are defined by the total number of pregnant, post‐partum, and nursing women, infants and children less than 5 years of age who received WIC vouchers. (MDH: County Health Tables) Households with Children Receiving Supplemental Nutrition Assistance Program 2008 2009 2010
Minnesota 66,363 80,276 93,688 106,117 111,682 Service Area 1069 1341 1578 2011
1711 2012
1770 The average monthly enrollment of actual household with children receiving SNAP. As with WIC, not all income‐
eligible children participate in the program. (MN Dept of Human Services) Percentage of Students Receiving Free and Reduced Lunches 2008 2009 2010
2011
2012
Minnesota 32.9% 35.6% 36.7% 37.3% 38.3% Service Area 54.2% 58.9% 57.4% 56.9% 55.8% To qualify for free and reduced lunches, household income must be less than 185 percent of the Federal Poverty Guidelines to qualify. Not all income‐eligible students participate, and private/homeschooled children aren’t included. (Minnesota Department of Education: Data Center) Data Source: Minnesota KIDS COUNT Data Center 42
Minnesota Student Survey Results Percent of Students Who Feel Safe at School Grade 6 Grade 9 Grade 12 Minnesota Service Area
93.0% 93.0%
93.0% 93.8%
94.0% 95.8%
Had Suicidal Thoughts in the Past Year Grade 6 Grade 9 Grade 12 Minnesota Service Area
11.0% 14.0%
16.5% 15.7%
12.5% 12.0%
Used Alcohol One or More Times in the Past Year Grade 6 Grade 9 Grade 12 Minnesota Service Area
8.5% 16.0%
32.0% 35.3%
57.0% 58.0%
There was an elevated number of 6th grade students (in comparison to state averages) in the Tri‐County Health Care service area who have had suicidal thoughts within the past year. There also was a higher than state average of 6th, 9th, and 12th grade students who have used alcohol within the past year. Data obtained from the 2010 Student Survey completed by the Minnesota Departments of Education, Health, Human Services and Public Safety 43
Smoked Cigarettes during the Previous 30 Days Grade 6 Grade 9 Grade 12 Minnesota Service Area
1.5% 6.6%
9.0% 8.7%
20.0% 24.8%
Physically active for at least 30 Minutes or More on at least five of the last seven days Grade 6 Grade 9 Grade 12 Minnesota Service Area
48.0% 54.0%
56.5% 63.7%
44.0% 48.7%
Have Ever Had Sexual Intercourse Grade 9 Grade 12 Minnesota Service Area 20.0% 20.5%
50.5% 54.5%
Data obtained from the 2010 Student Survey completed by the Minnesota Departments of Education, Health, Human Services and Public Safety 44
Adult Health Adult Smoking Prevalence
Service Area
14.7%
State of Minnesota
17.0%
0.0%
25.0%
50.0%
75.0%
Adult smoking rates are less than the state average for the Tri‐
County Service Area. The community health survey measured 17 percent for the service area. 100.0%
Percentage of Adults that Smoke
Adult (ages 18 or older) cigarette smoking prevalence is an estimated percentage of adults that smoke every day/ most days based off the Behavior Risk Factor Surveillance System. Cigarette smoking is attributed to premature death, various cancers, low birth weight, cardiovascular disease, etc., and a high prevalence points communities to a need for cessation programs. Data Source: County Health Rankings and Roadmaps: A Healthier Nation County by County, 2010. Adult Obesity Prevalence
Service Area
The prevalence of adult obesity is higher in the Tri‐
County service area than in Minnesota. 31%
Minnesota 26%
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Percentage of Obese Adults
Adult obesity prevalence represents the adult population older than 20 years of age that has a body mass index greater than or equal to 30kg/m 2. This data is based off of the Behavior Risk Factor Surveillance System. Obesity prevalence is important because it increases the risk of heart disease, stroke, cancer, type 2 diabetes, sleep apnea and many other conditions. Data Source: County Health Rankings & Roadmaps: A Healthier Nation County by County, 2010. 45
Adult Physical Inactivity
Service Area
More adults report physical inactivity in the Tri‐County service area report than in Minnesota. 26%
State of Minnesota
19%
0%
25%
50%
75%
100%
Percent of adults 20+ reporting no leisure time physical activity
The percentage of adult physical inactivity is a self‐reported measure. The degree of intensity, duration or frequency for those who report physical activity was not listed. Physical inactivity is related to premature mortality, obesity, cardiovascular disease, stroke, type 2 diabetes, etc. Data Source: County Health Rankings & Roadmaps: A Healthier Nation County by County, 2009. 46
Disease Data and Preventative Practices
The Tri‐County service area (9.5 percent) has a higher percentage of diagnosed diabetics than the state of Minnesota (7 percent). Diabetes Diagnosed
Service Area
State of Minnesota
9.50%
7%
0%
25%
50%
75%
100%
Percentage of Population Diagnosed with Diabetes
The prevalence of individuals diagnosed with diabetes ascertained by asking individuals if they have been diagnosed by a doctor with diabetes. This doesn’t include gestational diabetes cases. Data Source: County Health Rankings & Roadmaps: A Healthier Nation, County by County, 2009. Diabetic Screening
Service Area
The Tri‐County service area (81.5 percent) has a lower percentage of diabetics receiving HbA1c screenings than the state of Minnesota (88 percent). 81.50%
State of Minnesota
88%
0%
20%
40%
60%
80%
100%
Percent of diabetic Medicare enrollees that receive screenin
Diabetic screening is measured as a percentage of diabetic Medicare enrollees whose blood was screened in the past year using a test of their glycated hemoglobin (HbA1c). Data Source: County Health Rankings & Roadmaps: A Healthier Nation County by County, 2010. 47
Mammography Screening Women Aged 67‐69
Service Area
71%
State of Minnesota
73%
0%
25%
50%
75%
100%
Percent of Women Aged 67‐69 Received Mammography Screening The Tri‐County service area (71 percent) has a lower percentage of women receiving mammography screenings than the state of Minnesota (73 percent). Mammography screening measures represent female Medicare enrollees 67‐69 years old that had at least one mammogram over a two‐year period. The sensitivity and specificity of mammograms are highest among older women, hence the use of this age group. Evidence suggests this screening is important because it reduces cancer mortality and morbidity when detected early. Data Source: County Health Rankings & Roadmaps: A Healthier Nation County by County, 2010. Sexually Transmitted Diseases Reported in MN and Service Area, 2011 Primary/Secondary Syphilis Minnesota 16,898 2,283 139 Service Area 112 4 0 Data Source: Minnesota County Health Tables by State and County, 2012. Chlamydia Gonorrhea 48
Syphilis‐ All Stages 366 1 HIV 292 0 Sexually Transmitted Infection Rate, 2010 Sexually Transmitted Infection Rate 276
Minnesota Wadena County 36
Todd County 76
Otter Tail County 87
Sexually transmitted infections are measured as chlamydia incidence (number of new reported cases) per 100,000. Chlamydia is the most common bacterial sexually transmitted infection in North America and is associated with unsafe sexual activity. It is important to note that communities with poor screening may have artificially low rates of chlamydia incidence. Data Source: County Health Rankings & Roadmaps: A Healthier Nation County by County, 2010 Incidence Rates of Asthma Hospitalizations, Cancer, COPD Hospitalizations, and MI Hospitalizations per 100,000 Asthma Hospitalizations Minnesota Service Area 7.4 6.7 Cancer
474.6
478.5
COPD Hospitalizations 32.6
35.8
MI Hospitalizations 30.7 34.4 Asthma hospitalizations, Chronic Obstructive Pulmonary Disorder (COPD) and Myocardial Infarction (MI) data was collected from the Minnesota Hospital Discharge Data, maintained by the Minnesota Hospital Association. Cases are calculated using U.S. Census Data as the denominator and patients having a primary discharge diagnosis of asthma, COPD, or MI as the numerator for the years 2008‐2010. Cancer data was collected by the Minnesota Cancer Surveillance System, MDH. Incidence rates for cancer, count all newly diagnosed cancer cases in a region for the years (2005‐2009) specified. Data Source: Minnesota Public Health Data Access, 2013 The service area has higher than state incidences of cancer and chronic obstructive pulmonary disorder, as well as myocardial infarctions with lower incidence rates of asthma hospitalizations. 49
Minnesota Injury Data Access System (MIDAS) Hospital data representing approximately 95 percent of all patient discharge data for injuries in service area, 2012 Falls Bites and Stings Motor Vehicle‐Occupant Poisoning ATV‐Motor Vehicle Rider Fire Firearm 1,545 259 199 165 29 16 9 Leading Causes of Hospitalizations for all ages in the Central Region of MN (encompasses Tri‐County Health Care service area). Diseases of the Circulatory System Injury and Poisoning Diseases of the Digestive System Diseases of the Respiratory System Complications of Pregnancy, Childbirth and the Puerperium Data Source: Minnesota Hospital Association, 2007. 50
Mental Health Children (0‐17 years of age) Minnesota Service Area Receiving Mental Health Services Crisis Services Outpatient Psychotherapy *Psychiatric Inpatient Rate 55,136 1,541 2,041
58
34,920
1,048
15.0
18.3
Receiving Mental Health Services Crisis Services Diagnostic Assessment *Psychiatric Inpatient Rate 145,789 3,505 7,812
148
74,327
1,730
24.0
21.0
Adult (Older than 18 years of age) Minnesota Service Area *Psychiatric Inpatient Rate is the number of patients per 10,000 capita. Data Source: Mental Health Management Reports (2011), Minnesota Department of Human Services, Mental Health Divisions More than 50 percent of visits made to family physicians are for health problems with significant social/behavioral components such as anxiety, depression, addictions, obesity, and pain. The rural setting presents unique challenges to providing quality mental health care: 
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Mental health providers are in short supply. Existing mental health clinics are located a considerable distance from residents. Seeking care from a mental health provider may carry a greater stigma. Financial barriers exist due to inadequacies in health insurance coverage and large numbers of rural residents with incomes below the poverty level. Data Source: Center for Rural Mental Health Studies, The University of Minnesota www.med.umn.edu/duluth‐internal‐resources/center‐for‐rural‐mental‐health‐
studies/index.htm 51
Mortality Top 15 Causes of Mortality Cause Minnesota Service Area Alzheimer’s Disease Cancer Cirrhosis Chronic Lower Respiratory Disease Diabetes Heart Disease Hypertension Nephritis Parkinson’s Pneumonia/Influenza Pneumonia due to solids/fluid Septicemia Stroke Suicide Unintentional Injury 1,449
9,468
436
2,174
1,179
7,234
489
708
475
669
321
338
2,145
684
2,309
50
250
11
62
38
226
9
16
17
23
5
8
67
14
38
Premature Death Minnesota 5,126 Service Area 5,756 Premature death is represented by the years of potential life lost (YPLL) before age 75. The YPLL measure is a rate per 100,000 population and age adjusted to the 2000 U.S. population. This measure emphasizes the death of young persons rather than the elderly, where focus is frequently on chronic diseases. It is important to note that many of these deaths can be prevented. This measure allows communities to focus resources on determining the causes of premature death and work toward extending years of life. Data Source: County Health Rankings and Roadmaps, 2013. Top Causes of Death (excluding “other” category”) Service Area 1.
2.
3.
4.
5.
Heart Disease Cancer Alzheimer’s Disease and Stroke Chronic Lower Respiratory Disease Diabetes Data Source: Minnesota County Health Tables: Mortality Table 1: Minnesota Leading Causes of Death by Age Group by State and County, 2010 52
Wadena County Public Health CHAAP Problem/Issue List 2008 Community Health Assessment and Action Planning Community Health Problem/Issues with High Priority 
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Health and economic costs from tobacco use Traumatic brain and spinal cord injuries Chronic disease Increased obesity in children and the general population Poor birth outcomes Ground water quality (e.g. nitrates for at risk population, old wells, etc.) Elderly and disabled at risk due to lack of long‐term care options and support services Population in poverty, lack of livable wages Uninsured or underinsured for health insurance Children/youth with increased numbers and younger age with mental health issues Teen pregnancy Excessive alcohol use including dependency, high use, binge drinking and pregnant women Drug abuse Mental illness and depression Suicide Violence for children and families Limited access to mental health services: assessment, treatment, inpatient, crisis, pediatric Lack of affordable and accessible child care Lack of stable funding for addressing essential public health services Difficulty recruiting/retaining experienced public health nurses Children at risk due to inadequate parenting Youth at risk due e.g. driving, safety, health knowledge, brain development, risk homes, parenting Unintended pregnancy Underage alcohol consumption Risk of food and water borne disease Indoor air health risks (e.g. radon, mold, community sites etc) Emergency preparedness including pandemic and family preparedness Limited access to dental care for public insurance recipients and affordable care for low income persons Lack of education regarding money management and living within means 53
Todd County Public Health
2007 Community Health Top Priorities 
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Alcohol and drug use in youth Alcohol abuse in adults (inappropriate alcohol use, alcohol use as an accepted norm) Meth and chemical abuse (impact on individuals and communities) Drinking and driving Access/availability of chemical abuse treatment programs Teen and adult tobacco use Teen’s sexual activity/teen pregnancy Parenting issues (single parenting, lack of support, parent education, truancy of children, parental irresponsibility, unstable families) Mental health issues – depression, anxiety, suicide Access/availability of mental health services for children Teen girl’s (9th grade) low esteem Obesity Nutrition – food choice, safety, school vending, hunger, dietary supplement overuse Chronic disease, cancer, heart, cardiovascular, lung, diabetes, etc. (prevention, early recognition, early treatment) Violence among teens, families, in school, gangs 54
Otter Tail County Public Health: Community Health Assessment (2012­2014)
Public Health Priorities by Area of Responsibility Area of Responsibility Issue Assuring access to quality of services Declining rates of well child checkups or child and teen checkups Increasing numbers of persons with disabilities or chronic health conditions Early identification of children being referred for special education evaluation and services. Community concern for lack of cardiology services Increasing rates of obesity Assuring access to quality of services Assuring access to quality of services Assuring access to quality of services Promoting Healthy Behaviors and Healthy Communities Promoting Healthy Behaviors and Healthy Communities Promoting Healthy Behaviors and Healthy Communities Promoting Healthy Behaviors and Healthy Communities Promoting Healthy Behaviors and Healthy Communities Promoting Healthy Behaviors and Healthy Communities Promoting Healthy Behaviors and Healthy Communities Promoting Healthy Behaviors and Healthy Communities Preventing infectious disease Preventing infectious disease Preventing infectious disease Preparing for and response to emergencies Protecting from environmental hazards Protecting from environmental hazards Lack of access to fresh fruit and vegetables, costs of food Declining rates of physical activity Rates of injury and fatality related to misuse of alcohol and lack of seat belt use Tobacco use Social determinants impact on health status, poverty, housing, employment, education and food insecurity Early identification of leading chronic health conditions of cancer, heart disease, and diabetes Lack of community engagement related to healthy behaviors Age‐appropriate immunizations Emerging infections Refugee health care coordination and screening persons at risk for tuberculosis Ongoing need for readiness and response Housing situations resulting in exposure to lead, radon, or other health hazards Local response to address issues for food, beverages, lodging, pools and water safety 55
Forces of Change in the Service Area with Threats and Opportunities Opportunity Threat Event Health Care Reform Improve Prevention
Covered Population Increases (Ins) Event Area Tornado Event Data Exchange 2015 Factor Economic Issues Factor Insurance Coverage Wellness Center Building
Community Involvement Improve Ability to Share Health Information Community Support
Volunteerism Priority Setting Covered Population Increases
Factor Increase in Minority Populations – Hispanic Amish Culturally Sensitive Care Models
Chemical Dependency Issues Youth Homes Cultural Sensitive Care Models
High Health Needs Cultural Sensitive Care Models
Discrimination Improve Access for Preventive Services Efficiency
Collaboration Ability to Meet Demands Trend Alcohol and Tobacco Use Regionalization / Consolidation of Health Care Services Trend Aging Population More Volunteerism
Wealth Trend Decreased Funding Trend Trend Rise in Infectious Disease Limited Work Force
Trend Rise in Obesity More Collaboration
Greater Efficiency Prevention Collaboration Recruitment Potential
Volunteerism Prevention Promotion
Trend Changes in Technology Trend Birth Rates & School Enrollment Factor Factor Factor Factor Culturally Sensitive Care Models
Easy Access to Information
Improve Consumer Knowledge / Better Informed Increase in Health Literacy Patient More Accountable Increased Need for Services
56
Provider Choice Increase Strain Effect on Small Businesses Housing Shortages Mental Health Issues Cost to Implement Poverty
Jobs Income Lower Standards Lower Reimbursement Discrimination – Less Services –
Language Barriers Seek Less Services – High Risk Population
Discrimination Less Choice
Less Access Economic Impact Less Local Control Increase Need of Health Services
Increase Costs for Healthcare Less Work Force Less Ability
Less Able to Manage Ability to Meet Demands of Aging Population Increase Cost Decrease in Life Satisfaction Increase in Chronic Disease Self Diagnosis Increased Need for Support Key Stakeholder Input
The key stakeholders who collaborated on this community health needs assessment represented a cross‐
section of health agencies serving the Tri‐County Health Care service area. Key stakeholders collected and analyzed the data gleaned from the primary and secondary data described above to come up with the following concerns/strategic issues, trends, barriers and plan. Vision Statement The following visioning statement was developed November 2012 by the stakeholders as one of the first steps in the visioning process. We will be a community whereby all are involved in healthy living through: • Safe and sustainable communities • Healthy environments (food, water, housing, recreation, transportation) • Vibrant economic opportunities • Dynamic, engaged community leadership (business, education, government, civic) • Nurturing social, cultural, and spiritual opportunities Concerns and Strategic Issues of Tri‐County Health Care Service Area 1. Mental Health (depression, anxiety, suicide) 2. Obesity 3. Diabetes, heart disease, stroke, high cholesterol, hypertension 4. Cancer 5. Unhealthy behaviors – exercise, diet, smoking, alcohol, compliance with care 6. Parenting (includes injury prevention, immunizations, etc.) 7. Access – affordable care, perception of importance, preventive care 8. Poverty 9. Aging demographic 10. Unintended injury 11. Social determinants of health, health equity (housing, employment, environment, transportation, etc.) 57
Clinical Advisory Focus Group November 2013 Meeting
To help further prioritize those issues identified as a moderate or serious problem by more than 50 percent of respondents on the community health survey, we worked through an exercise with all the TCHC clinic advisory groups at the November meeting. This group represents a diverse knowledge about the local community and health. Individuals involved work in banking, assisted living, public health, pharmacy, school administration and teaching, a mayor, business owners, and insurance (see appendix for more detail) . There were 48 people in attendance at the meeting, which included area business leaders, providers, and community members from towns within the service area including Wadena, Sebeka, Bertha, Henning and Ottertail. Those who attended the meeting were divided into seven different groups (four to eight people per group), and each group was to decide which issue was the most important to focus our resources and energy. The results of the community health survey opinion questions (shown on page 27) that were identified as moderate or serious by more than 50 percent of respondents were further categorized. Smoking, alcohol abuse and drug abuse were placed into a category called “Unhealthy Behaviors.” Unemployment, children in poverty, lack of health insurance, lack of access to health care services, etc. were consolidated into a separate category called “Social Determinants of Health.” We also combined obesity among children with obesity among adults, which became one category called “Obesity.” For those issues that were grouped together, the percentage used was the same percentage of the issue with the highest percentage. Six of the seven groups chose unhealthy behaviors as an area of focus. It was felt that this issue has the potential to affect several other issues such as obesity, diabetes, heart disease, mental health, etc. The seventh group chose social determinants of health as that also has the potential to affect many other issues such as parenting, violence, mental health, etc. However, it was felt that we lack the resources to address issues such as poverty, unemployment, etc. 58
Health Needs The following bulleted areas of need were identified as issues needing additional focus after completing the data analysis and receiving community input. We have chosen to organize these issues in three broad areas and ask ourselves. . . How Tri‐County Health Care’s community benefit plan can: 1.) Improve the community environment as it impacts health. 2.) Affect the prevalence, incidence and treatment of disease and injury in the service area. 3.) Reach the individuals and populations most vulnerable and at higher risk of health issues. 1. Socioeconomic and Environmental Factors 
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Access: affordable and preventative care Access: healthy food and physical activity opportunities Social Determinants of Health and Health Equity: housing, employment, environment, transportation Poverty 2. Disease and Injury 
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Mental Health: depression, anxiety, suicide, etc. Diabetes, Heart Disease, Stroke, High Cholesterol, Hypertension, etc. Cancer Unintended Injury Obesity: children and adults Unhealthy behaviors: alcohol, smoking, compliance with care, diet, exercise Parenting: Immunizations and injury prevention 3. At‐Risk/ Vulnerable Populations 
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Aging Demographic Low Income Minorities and Amish within the population 59
These key issues are based off of the following findings as referenced at the beginning of the assessment. Social and Environmental Factors: 
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Minnesota unemployment statistics reveal that Tri‐County Health Care’s service area has an unemployment level that has been consistently higher than the state average for the last five years. Additionally, our Hispanic focus group and community health survey responses (72 percent say it’s a serious issue) both cited unemployment/lack of employment opportunities as a serious problem. The poverty level is high in the Tri‐County Health Care service area in comparison to state averages. Most recent estimates cite 15.4 percent service area vs. Minnesota 11.8 percent. This is even more significant in people younger than 18 (21.9 percent vs. Minnesota 15.3 percent). There are a significant number of individuals in the service area paying 30 percent or more of their income just for housing. This high housing cost burden reduces the money families and individuals can spend on basic needs such as food and medicine. The crime rate is quite low in the Tri‐County Health Care service area. Homelessness is on the increase in Greater Minnesota, with an increase from 20 percent in 1991 to 32 percent in 2012. Unlike metro regions of Minnesota, rural Minnesota has less formal and emergency shelters to meet this growing need. Our visioning group top answers for “how do you describe a healthy community” and “what kinds of resources create a healthy community” repeatedly referenced availability of public transportation and exercise opportunities. Our Hispanic focus group described a lack of transportation to stores and health clinics as a barrier to their health and mentioned that telephone translation services for Rainbow Rider (public transportation) were difficult to understand. This service also needs to be advertised more, as many people did not know about it. Our Hispanic focus group mentioned that physical activity option in the winter months are limited in the service area and especially difficult for families. The Hispanic Focus Group mentioned that subsidized housing is out of reach financially, and a lot of the housing that is available is unsafe. There are more than 1,000 children residing in the service area who do not have health insurance. The inadequacy of prenatal care is higher than the state average within the service area; this is especially true within Todd County (MN 3.9 percent, Otter Tail 4.6 percent, Todd 13.9 percent, and Wadena 2.9 percent). The teen pregnancy rate is at 29.4 (per 1,000) in the Tri‐County Health Care service area, which is lower than the state average of 33.2. Splitting up the counties again reveals higher rates in Wadena County (39.5), compared to Otter Tail (19.4) and Todd county (29.3). There are a high percentage of students receiving free or reduced lunches in comparison to state averages. The average percentage for Minnesota was 37.3 percent in 2011 with the Tri‐County Health Care service area being at 56.9 percent of the student population. The community health survey respondents cited 27 percent had delayed or not gotten medical care when they felt it was needed. Top cited reasons for this were 1) not serious enough, 2) cost too much, 3) deductible too expensive, and 4) no insurance. These same top four responses were cited as the reasons people did not seek mental health care when felt they needed it. 60
Disease and Injury: 
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Higher than average numbers of students in 6th grade reported suicidal thoughts within the past year. Students in 6th, 9th and 12th grades have higher than average percentages of alcohol utilization in the past year. Student smoking is a concern with higher than average percentages of students who have smoked in the last 30 days. A higher than state averages rate of 12th graders report having sexual intercourse. Graduation rates in The Tri‐County Health Care service area have been around state averages over the last few years. Adult smoking levels are below average in the Tri‐County Health Care service area (14.7 percent vs. Minnesota 17 percent). County Health Rankings, 2010. Our community health survey analysis revealed that 17 percent of respondents smoked. A higher number of mothers smoked during pregnancy within the Tri‐County Health Care service area at 18.6 percent, which is higher than the state average of 14.2 percent. This data is even more enlightening when the counties are broken down: Otter Tail (12.5 percent), Todd (18.2 percent) and Wadena (25.1 percent). The top mortality causes were heart disease, cancer, Alzheimer’s disease and stroke. The Tri‐County Health Care service area has higher than state average incidences of cancer and chronic obstructive pulmonary disorder, as well as myocardial infarctions, while there is a lower incidence rate of asthma. Lower than Minnesota sexually transmitted infection rate (276 vs. 67). 81.5 percent service area vs. 88 percent Minnesota received diabetic screenings. Similar rates of diabetes diagnoses in the areas. Similar mammography screenings within the service area 71 percent compared to Minnesota 73 percent. Our Hispanic focus group as well as the Tri‐County Health Care top problem codes revealed that mental health is large issue in the service area. Our focus group also said they want to eat healthier but they weren’t sure how to do this. According to our community health survey responses, 13 percent of respondents had been diagnosed with diabetes compared to the state average of 7.3 percent. 36 percent of respondents also said they had been diagnosed with high blood pressure compared to the 26 percent of Minnesota adults. Behavioral Risk Factor Surveillance System prevalence data for Minnesota‐2012 reports 17.1 percent of respondents had been diagnosed with depression compared to 27 percent in the service area. 34 percent of respondents on the community health survey stated that they ate the recommended five or more servings of fruits/vegetables each day. This is higher than the state average of 22 percent but still much lower than hoped. The Tri‐County Health Care service area has higher than average obesity rates among adults (31 percent vs. Minnesota 26 percent). County Health Rankings, 2010. The calculated BMIs for our service area referenced from the community health survey: 35 percent obese and 37 precent overweight but not obese. When asked to rate the severity of health topics in the community, 82.2 percent of people saw obesity as the most concerning issue of all. 61
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Most common injuries requiring hospitalization within the service area were falls, bites and stings, motor vehicle accidents to occupants, and poisonings. MIDAS. The leading causes of hospitalization for all ages within the central region of Minnesota were 1) diseases of the circulatory system, 2) injury and poisoning, 3) diseases of the digestive tract, 4) diseases of the respiratory tract, and 5) complications of pregnancy, childbirth and the puerperium. Minnesota Hospital Association, 2007. Vulnerable Population: 
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The residents of the Tri‐County Health Care service area are 93.9 percent Caucasian, followed by Hispanic at 3.2 percent. This being said, the Hispanic population that resides in our service area mentioned that diabetes education in Spanish is lacking and people are not treating their disease. They also cited a lack of Spanish‐speaking health providers within the service area as a barrier to seeking healthcare services with local hospitals, clinics and public health. According to census data statistics, the service area has a higher median age of 43.6 compared to 37.3 years for Minnesota. Approximately one‐third of the area population (32.8 percent) is older than 55 in comparison to the state average of 24.2 percent. The population pyramid within the assessment also displays the service area has a larger aging population compared to Minnesota. This is true for most rural areas in Minnesota compared to the metro area. Additional health care services and providers will be needed to meet the needs of this subset of our population. Low‐income data/statistics are discussed above in #1 because it pertains to access to health care. A population of Amish people resides within the Tri‐County Health Care service area. Todd County has five separate settlements, and Wadena County has two districts and includes the oldest Minnesota Amish community. As previously mentioned, eastern Otter Tail County is also home to Amish. It is unclear the specific population numbers, but the Amish seem to be growing in numbers in America. The Amish are known for seeking more alternative forms of medical treatment than doctors and hospitals, but their health does impact the community as seen in 2005, when a polio outbreak occurred in Todd County. 62
Current Tri­County Health Care Initiatives in the Service Area
Todd­Wadena Healthy Connections
Goals: Collaboration on building healthy communities.
Partners: Lakewood Health System, Todd County Health and Human Services, Wadena County Public Health, CentraCare and Tri‐County Health Care
Workgroups: Maternal Child Health, Health Education, and Community Health Assessment
Activities: Car seat clinics, 5‐2‐1‐0 educational handouts for community and schools, health fairs, Pregnancy to Parenthood guide.
Support Groups and Support: Grief, Diabetes, and Memory Loss Support Groups. LactationConsultant.
Classes: Infant massage, breastfeeding techniques and benefits, prenatal classes, American Heart Association CPR and first aid, babysitting (CPR, first aid, etc.).
Summer Block Party: Bike rodeo, backpack fittings,
emergency vehicle tours, music, food, etc.
E­Newsletters: Monthly My Health, New Parent, or Pregnancy E‐newsletters filled with up‐to‐date health information and latest news.
February Festival of Health: 75 exhibits from local agencies promoting health and wellness. Free health screenings: blood pressure, blood glucose, pulmonary function, body fat analysis and more.
Women’s and Men’s Days Out: Free health education programs, lab work certificates, cooking demonstration, educational sessions on wellness, nutrition, sex and relationships.
Venture Crew 54: Twice monthly opportunity for high school student thinking about medical careers to get hands‐
on experience in skills from Minnesota First Responder Course.
Tri­County Health Care Foundation scholarships:
Provides 13 scholarships for students pursuing health care careers.
Healthy Times Newsletter: quarterly publication of success
stories and educational information for all
Internships: medical and nursing students
63
Health Care Resources in the Service Area
County Public Health Departments Todd County Health and Human Services Wadena County Public Health Otter Tail County Public Health Assisted Living Facilities Comfort Care Cottages – Wadena Fair Oaks Apartments – Wadena Nelson Home Inc. – New York Mills Heritage Manor Inc. – New York Mills Our Home Your Home – Henning Willow Creek Senior Living – Henning Greenwood Connections – Menahga Wood Side Manor – Menahga Pharmacies/Drug Stores Thrifty White Pharmacy – Wadena Walmart Pharmacy – Wadena Seip Drug – Bertha, Menahga, New York Mills, Henning, Ottertail Other Northern Pines Mental Health – Wadena Aneway Treatment Center – Wadena Bell Hill Recovery Center – Wadena ShareHouse Stepping Stones – New York Mills Rewind Inc. Drug and Alcohol Treatment – Perham Endeavor Place LLC – Verndale Nursing Homes Elders Homes Inc. – New York Mills Fair Oaks Lodge, Inc. – Wadena Green Pine Acres Nursing Home – Menahga Golden LivingCenter – Henning Home Health Agencies Legacy Home Health and Hospice Services of Wadena – Wadena Caring Hands Home Care – Sebeka Lake Country Home Care – New York Mills Fair Oaks Lodge, Inc. – Wadena Tender Hearts Home Care – New York Mills CK Home Health Care – Ottertail Transportation Services Friendly Rider Transit – Wadena County and S
Staples, Bertha, Hewitt of Todd County Peoples Express – Wadena Medi Van – Detroit Lakes, serving all of Otter Tail County Rainbow Rider Bus – Todd County Otter Tail County Volunteer Transportation Program – Ottertail Hospitals Tri‐County Health Care – Wadena Minnesota Specialty Health System – Wadena (focusing on adult mental illness) Clinics Tri‐County Health Care – Sebeka, Ottertail, Bertha, Henning, and Wadena locations Essentia Health – Menahga Sanford Health – Ottertail, New York Mills 64
Opportunities for Health Improvements
Maslowski Wellness and Research Center: An EF4 tornado came through the Wadena area on June 17, 2010 destroying local homes, businesses and a school. The Wadena area has used this tragic event as an opportunity to build a better community. A new development in the area is the creation of a local wellness center. The Maslowski Wellness and Research Center site preparation was started in October 2013, and construction is expected to be completed on the center November 2014. The mission of the center is “to provide the citizens of Wadena and the surrounding area, including Ottertail, Todd and Wadena counties, with a community center that responds to their cultural, educational, health, social, recreational and wellness needs.” The facility will be located near the new Wadena Deer Creek Middle/High School and will have an area of 50,000 feet. Some amenities of the facility will include a family recreational area, lap pool and swimming area, locker rooms, whirlpool and therapy pool with wheelchair access. The fitness space on the second level will include weight machines and cardiovascular equipment with adjacent classrooms for health education and aerobic exercise. A walking track will encompass this area. A full‐size gym is also planned with racquetball courts. This wellness center will play a pivotal role in the Tri‐County Health Care goal of addressing unhealthy behaviors. A description of the research study is included on the following page. 65
Frank and Eleanor Maslowski Charitable Trust Research Study Proposal Tri‐County Health Care and Wadena Regional Wellness Center Subject: To identify factors that may be predictive or explanatory of health risk status of various resident cohorts in the Tri‐County Health Care service area population. Scope of Project: Using three population sample cohorts in the Tri‐County Health Care service area, we will analyze the current and future health risk status of the sample groups. The goal is to improve health risk status by various interventions including:  Awareness of health risk status through testing and education of subjects.  Medical interventions for subjects as indicated.  Education and tools to improve nutritional intelligence and practiced habits.  Education and implementation of physical activity programs.  Development of support groups and other subject networking opportunities.  Other areas of intervention yet to be determined to impact spiritual, mental and social health. Project Background: Tri‐County Health Care and the Wadena Regional Wellness Center, along with several other key community organizations including but not limited to the City of Wadena and Wadena‐Deer Creek School District, have been working to redevelop a replacement facility for the Wadena Community Center, which was destroyed when an EF4 tornado hit the Wadena Area on June 17, 2010. There are multiple funding sources for this facility includes insurance proceeds (although the facility was significantly under‐insured), Minnesota State Department of Employment and Economic Development grants, and private fundraising. Addition funds are being requested from the Maslowski Trust to help complete the project. As part of this project, we have been working hard to not replace an activity‐centered facility but rather create a results‐oriented wellness initiative for the Wadena community the surrounding area. The Wadena trade area is consistent with the service area for Tri‐County Health Care, which consists of approximately 23,000 residents in Wadena, Todd and Otter Tail Counties. Primary communities included are Wadena, Bertha, Hewitt, Henning, New York Mills, Ottertail, Deer Creek, Bluffton, Sebeka, Menahga, Verndale and Aldrich. These areas present a population base that consistently rank in the bottom 10 percent of per capita income in the state of Minnesota and are amongst the highest in poverty and the use of free and reduced meals in the school lunch programs. Additionally, as you are aware, a grant has been awarded for a similar project in the Bertha community. We will include in this study a Bertha population sample cohort. This high level of poverty, along with other factors has contributed to a very low health status of the population of the area residents. For the 2010 and 2011, the Robert Wood Johnson Foundation, in 66
conjunction with the University of Wisconsin Population Health Institute published a County Health Rankings Report. The following is relevant for the counties of Wadena and Todd. Note that Ottertail County ranks better on these reports, however, the demographics of the county in which the larger communities of Fergus Falls and Perham, along with a greater of lake community residents live in the Western portion of Ottertail County. Eastern Ottertail County is more similar to their brethren to their east in Wadena and Todd Counties than to the western portion. Ranking of 85 Counties: Wadena Todd 2010 2011 2010 2011 Health Outcomes: 82 84 66 76 Mortality 82 82 69 74 Morbidity 71 76 57 69 As evidenced by these health outcomes that measure premature death, poor or fair health, poor or fair physical and mental health days, and low birth weight, there is work to do in the area. Research Question: The primary research question to be considered is: What interventions can impact population health risk status over the course of a 7‐10‐year period in a highly impoverished area? Research Design and Requirements: We envision a research study of 7‐10 years using three cohort groups.  Year one will entail the captive sample group that is made of the Tri‐County Health Care employee group. This is a group of approximately 400 individuals.  Year two will add the dependents (spouses and children), an additional group of 600, along with one other area employer group and a Bertha area group with an expectation of another 100‐
125 participants.  Year three will add three additional employee groups (another 125), plus a voluntary group of participants in the Tri‐County Health Care Men’s and Women’s Nite Out health fairs (approximately 1,000 potential participants available, although less than 50 percent will likely volunteer).  Years beyond will follow the groups to track long‐term health risk status. In partnership with the Wellness Council of America (WELCOA), we will utilize health biometric screenings along with a health risk assessment tool to determine health risk status of the study groups into low, moderate and high risk categories. The intention is that through various interventions, we will indicate that it is possible to maintain low status and prevent the more natural maturation to higher risk categories, maintain or reduce moderate status based on quick and definitive interventions, and maintain high risk individuals as high risk vs. catastrophic and potentially prolong life and/or improve quality of life. We have already initiated discussions with the University of Minnesota School of Public Health to potentially provide assistance in the design and implementation of this study and the data analysis. 67
Conceptual Model Cohort #1 – Tri‐County Health Care Employees (Year 1) Testing and Interventions:
Health risk status of group before interventions: Low, Moderate, High  Test outcome awareness and education  Medical interventions  Nutrition education and tracking  Activity education and tracking  Networking  Others to be determined
Health risk status of group after interventions: Low, Moderate, High Cohort #2 – Cohort #1 Plus Tri‐County Health Care Dependents, 1 Wadena Area Employer, and Bertha area group (Year 2) Testing and Interventions:
Health risk status of group before interventions: Low, Moderate, High  Test outcome awareness and education  Medical interventions  Nutrition education and tracking  Activity education and tracking  Networking  Others to be determined Health risk status of group after interventions: Low, Moderate, High Cohort #3– Cohort #2 Plus 3 Additional Wadena Area Employers and Men’s and Women’s Nite‐Out Participants (Year 3) Testing and Interventions:
Health risk status of group before interventions: Low, Moderate, High Dependent Variable: Operational Definition:  Test outcome awareness and education  Medical interventions  Nutrition education and tracking  Activity education and tracking  Networking  Others to be determined Health Risk Status as measured over time. Using analysis tools including health biometric screenings in conjunction with a health risk assessment query tool, to determine the health risk status of the population cohorts. Health risk status of group after interventions: Low, Moderate, High 68
Tri­County Health Care 2014­2016 Strategic Plan Strategies and Objectives Strategy Objective – Current Fee for Service Environment (Foot on the Dock) 1) Community
Building,
Education &
Employer
Partnerships







Objective – Future Accountable Care Environment (Foot in the Boat) 

Increase population
Improve socio-economic status
Payer mix less reliant on government sources
To build/enhance community reputation
Build goodwill and reputation
Enhance current FFS revenue opportunities
Begin education on wellness (Maslowski
research study)




2) Philanthropy


3) Maximize
Resources



4) Relationship
Development


5) Targeted
Program
Development


Primary care and specialty services to
maximize fee for service opportunities
Negotiate increased coverage and local
services from outreach providers
Culture Community

Build endowment funds
Fundraising and community awareness of
needs for program-specific support
Everyone practicing/working at the top of
their license or capabilities
Right work, right person, right time, right
way.
Improve efficiency and effectiveness for fee
for service business development and
improved access
Evaluate affiliation/partnership
opportunities/needs
Develop regional and local
affiliations/partnerships as indicated
69
Same plus:
Community health status
improvement
Improved care coordination and
resource utilization
Community health status
improvement
Improved care coordination and
resource utilization
Long-term report of outcomes from
the Maslowski research study
Same


Same plus:
Best value for accountable care
purchasers

Become a partner in Accountable
Care Organization (s)

Provide a comprehensive program to
be attractive to accountable care
purchasers
Resources Strategy 6)
Objective – Current Fee for Service Environment (Foot on the Dock) Develop Culture of
Excellence
 Care
Coordination
Program
 Use of evidence
based medicine
and standards of
care
 Patient
satisfaction
initiatives
 Compliance
program
 Pay for
performance
 Unified
direction and
objectives
 Transition and
change
management

Everyone practicing/working at the top of
their license or capabilities
Right work, right person, right time, right
way.
Improve efficiency and effectiveness for fee
for service business development and
improved access
Enhance reputation, be provider of choice,
employer of choice, best place to practice
Be a guide in decision-making and
execution strategies
Recognition as a best practice provider to
differentiate ourselves with constituents
Minimize risk to the organization
Unified support for strategic direction,
goals, objectives and tactics by all internal
participants
o Improved engagement
o Enhance “Will to Succeed”
Be a Learning Organization that is prepare
for health care reform (all internal members
and the public)








Objective – Future Accountable Care Environment (Foot in the Boat) 




7) Facility Development

Determine short-term needs (1 - 3 years)


8) Review and/or Revise
Mission/Vision/Standard
s of Excellence

Mission and Vision are consistent with our
exempt status, State and IRS requirements
and provide a guiding light for our
organizational decision-making and
execution of this plan.

Same plus:
Expanded and more
comprehensive use of data to
improve care outcomes and
community improvement health
status
Continuing knowledge gain for
ongoing success
Gain incentive payments, avoid
payment penalties
Ability to practice successfully
(independently) in the accountable
care environment
Long-term facility needs
Determine facility vs. virtual
provider/program environment in
an accountable care environment
Same
Culture Community
70
Resources Implementation Plan
Concerns & Strategic Issues of Tri County Health Care Service Area in order of Priority 1. Unhealthy Behaviors – This item was identified as the first priority as successful results in this area may also have positive impacts on obesity, heart disease, stroke, diabetes, high cholesterol, high blood pressure, cancer, etc. Includes exercise, diet, smoking, alcohol use, drug use, and healthcare compliance. CHC is partnering with Wadena Regional Wellness Center, City of Wadena, Wadena Deer Creek Schools, Wadena 2.0 Tornado Recovery Committee, and several other key community organizations to build a community wellness center and create a results‐oriented wellness initiative for the Wadena Community and surrounding area. Groundbreaking for the physical structure began fall of 2013. The building is expected to be completed mid‐year of 2014. With the aide of the Frank and Eleanor Maslowski Charitable Trust and the Wadena Regional Wellness Center, TCHC is conducting a research study to identify factors that may be predictive or explanatory of health risk status in the TCHC service area population. The first phase of the research study began in 2013 as TCHC with compiling baseline healthcare data from the TCHC employee group. TCHC will be implementing healthcare initiatives and education within the employee group and analyzing the effect of those initiatives for the employees. The next phase of this project is to conduct this same activity with groups from Wadena and Bertha communities. See pages 66 and 65 for more detail on this project. Healthcare compliance will be addressed through TCHC’s strategic plan found on pages 69 and 67 of this document, specifically item #3 “Care Coordination Program.” Other items will be addressed in the Strategic Plan items #1 “Community Building, Education, and Employer Partnerships”, #5 “Relationship Development”, #6 “Develop Culture of Excellence”, #7 “Targeted Program Development”, and #8 “Facility Development”. 2. Obesity – This can be addressed with the initiatives being undertaken for unhealthy behaviors. See items #1 “Community Building, Education, and Employer Partnerships” and #6 “Develop Culture of Excellence” in the Strategic Plan. 3. Chronic Disease – Includes diabetes, heart disease, stroke, high cholesterol, high blood pressure, cancer, etc. In addition to the wellness initiatives being undertaken for unhealthy behaviors, TCHC will be implementing a Medical Home program to aide persons with chronic illnesses and help them manage these conditions to remain compliant with their care and achieve positive outcomes. TCHC will also be implementing Care Coordination Programs to identify and monitor patients due for preventive care and contacting those patients in an effort to identify patients at risk earlier in the disease process. TCHC will continue to offer the diabetic education and diabetic support group. Items #1 “Community Building, Education, and Employer Partnerships”, #3 “Care Coordination Program”, #6 “Develop Culture of Excellence” in the Strategic Plan discusses this in more detail. 4. Mental Health – In November of 2012, TCHC hired Dr. Aaron Larson and Andrea Craig, FNP to provide full‐time psychiatric services in the Wadena clinic. Dr. Larson conducts visits at area 71
group homes in an effort to see to the needs of persons unable to live independently. TCHC offers grief and memory loss support groups. This is further discussed in the Strategic Plan item #7 “Targeted Program Development” and #5 “Relationship Development”. 5. Parenting ‐ TCHC provides educational classes to the community for parents on injury prevention by offering car seat clinics, bike rodeo and helmet fittings for children, first aide/CPR, prenatal and breastfeeding classes, lactation consultations and babysitting classes. TCHC also partners with the Child Protective Program for Wadena County, including law enforcement agencies, social services, public health and school representatives to identify and assist at‐risk children. This item is covered under the Strategic Plan item #1 “Community Building, Education and Employer Partnerships”. 6. Access to Health Care – TCHC offers an Uncompensated Care plan for patients who do not have the ability to pay. This plan is offered to persons with annual income at 150% of federal poverty guidelines. TCHC is located in a health care professional shortage area where access to a provider may be limited at times. TCHC has developed a provider recruitment plan to recruit more physicians to the TCHC area. In addition, TCHC is working on developing a model that utilizes Nurse Practitioners and Physician Assistants to practice alongside the physician to provide necessary services in a more cost effective manner. In an effort to improve access to health care, TCHC is working to implement a walk‐in clinic which will have extended hours Monday through Thursday and Saturday mornings. It is our plan to implement this in 2014. As part of our care coordination plan, TCHC is collaborating with payor plans to implement necessary health screenings for specific diseases in an effort to prevent/detect specific issues such as lead testing, chlamydia screenings for specified age groups, etc. These issues are covered in the Strategic Plan under items #3 “Care Coordination Program” and #4 “Maximize Resources”. 7. Poverty – TCHC lacks the resources to fully address this issue. In partnership with Wadena County Social Services, TCHC has a County financial worker on site to assist patients with financial difficulty to determine eligibility for public assistance. In addition, TCHC offers an uncompensated care program for persons with an annual income less than 150% of federal poverty guidelines. TCHC’s Social Services Department assesses both inpatient and clinic patients and makes referrals as necessary. TCHC provides for transportation services to appointments via our local public transportation “Friendly Rider” (handicap accessible) at no cost to the patient. It is TCHC’s plan to partner with local government and business leaders to collaborate on community building in an effort to increase population, improve socio‐economic status, and build/enhance community reputation. This is discussed further in the Strategic Plan item #1 “Community Building, Education & Employer Partnerships”. 8. Aging Demographic – An increased demand for services goes along with an aging demographic. TCHC will be addressing this issue by implementing care coordination plans as identified above, utilizing more physician assistants and nurse practitioners to meet the increasing demand, and implementing the wellness initiatives identified above. Our elderly population is an area of vulnerability in the sense that many of these people are living on a fixed income with high healthcare needs. TCHC will continue to assess the system for ease of scheduling, care 72
coordination, and use of technology to improve access. This population also takes advantage of the free public transportation services subsidized by TCHC. This priority will also be addressed in the Strategic Plan item numbers #3 “Care Coordination”, #6 “Develop Culture of Excellence”, and #7 “Targeted Program Development”. 9. Unintended Injury – The top injuries requiring hospitalization from our analysis included bites and stings, car/ATV accidents, poisonings, and fires. TCHC provides a level IV trauma facility for patients in need. Injury education is provided through various means such as CPR classes, bike rodeo for children, car seat safety classes, etc. TCHC has chosen not to focus on this item at this time to more fully address the health issues listed above. As discussed above in the “Parenting” section, educational classes are offered such as prenatal and babysitting. 10. Social Determinants of Health – Includes health equity, housing, employment, environment, and transportation. As with the issue of poverty above, TCHC lacks the resources to fully address this issue, but plans to partner with local government and business leaders to collaborate on community building in an effort to increase population, improve socio‐economic status, and build/enhance the community reputation. Please see Strategic Plan items #1” Community Building, Education & Employer Partnerships” and #5 “Relationship Development”. TCHC will continue to help pay for car seats and bike helmets for safe transportation of infants and children. TCHC will continue subsidize fare for individuals utilizing Friendly Rider public transportation services to get to their appointments at TCHC. 73
References American Fact Finder (2012). United States of America Census Bureau. Retrieved October 22, 2013 from: http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml Brief 7: Health Communication: Considerations to developing effective health communication strategies. (2007.). HINTS: Health Information National Trends Survey Briefs: Brief 7. Retrieved October 10, 2013, from http://hints.cancer.gov/brief_7.aspx Center for Rural Mental Health Studies (2012). Retrieved November 16, 2013 from: http://www.med.umn.edu/duluth‐internal‐resources/center‐for‐rural‐mental‐health‐studies/index.htm Community Demographic and Assessment Information for the Minnesota Counties of Becker, Hubbard, Mahnomen, Ottertail and Wadena (2012). Mahube‐Otwa Community Action Partnership Inc. Community Health Reports. (2007). Minnesota Public Health Reports: Minnesota Hospital Association Retrieved November 22, 2013, from http://www.mha‐apps.com/chr/reports.aspx County Health Rankings and Roadmaps: A Healthier Nation County by County (2013). Robert Wood Johnson Foundation and University of Wisconsin Retrieved from: http://www.countyhealthrankings.org/print/county/snapshots/2012/27/153+159 CriminalStatistics.org. US County‐level Criminal Records and Statistics. (2012). Retrieved November 29, 2013 from: http://criminalstatistics.org/ Diabetes in Minnesota. (2013). Minnesota Department of Health. Retrieved November 11, 2013, from http://www.health.state.mn.us/diabetes/pdf/Diabetes_in_Minnesota_final.pdf Heart Disease in Minnesota. (2013). Minnesota Department of Health. Retrieved November 11, 2013, from http://www.health.state.mn.us/divs/hpcd/chp/cvh/documents/2013mnheartdiseasefactsheet.pdf High Blood Pressure in Minnesota. (2012). Minnesota Department of Health. Retrieved October 10, 2013, from http://www.health.state.mn.us/divs/hpcd/chp/cvh/documents/2012mnhypertensionfactsheet.pdf Homes for All in Minnesota (2012). Minnesota Housing Partnership. Retrieved Oct 15, 2013 from: http://www.mhponline.org/images/stories/docs/research/countyprofiles/2012/Minnesota.pdf Homes for All in Otter Tail County (2012). Minnesota Housing Partnership. Retrieved October 15, 2013 from: http://mhponline.org/images/stories/docs/research/countyprofiles/2012/OtterTail.pdf Homes for All in Todd County (2012). Minnesota Housing Partnership. Retrieved October 15, 2013 from: http://mhponline.org/images/stories/docs/research/countyprofiles/2012/Todd.pdf Homes for All in Wadena County (2012). Minnesota Housing Partnership. Retrieved October 15, 2013 from: http://mhponline.org/images/stories/docs/research/countyprofiles/2012/Wadena.pdf 74
Mental Health Management Reports (2011). Minnesota Department of Human Services, Mental Health Divisions. Minnesota Department of Health. (n.d.). 2012 Minnesota County Health Tables. Retrieved September 9, 2013, from http://www.health.state.mn.us/divs/chs/countytables/profiles2012/index.html Local Area Unemployment Statistics (LAUS) (n.d.) .Minnesota Department of Employment and Economic Development. Retrieved November 11, 2013, from http://mn.gov/deed/data/data‐tools/laus.jsp Minnesota Homelessness Survey (2009). Wilder Research. Retrieved September 10, 2013, from http://www.wilder.org/Wilder‐Research/Research‐Areas/Homelessness/Pages/default.aspx Minnesota Department of Health. (n.d.). Minnesota Center for Health Statistics. Retrieved November 11, 2013, from http://www.health.state.mn.us/divs/chs/ Minnesota Department of Health. (n.d.). Minnesota Injury Data Access System (MIDAS). Retrieved November 22, 2013 from http://www.health.state.mn.us/injury/midas/ub92/index.cfm Minnesota KIDS COUNT Data Center (2012). Retrieved October 15, 2013 from: http://datacenter.kidscount.org/data#MN/2/0 Minnesota Student Survey (2010). Minnesota Department of Education, Health, Human Services And Public Safety. Retrieved September 10, 2013 from http://www.health.state.mn.us/divs/chs/mss/ Minnesota State, County, and Community Health Board Vital Statistics Trend Report. (1991‐2010). Minnesota Center for Health Statistics, Minnesota Department of Health. Retrieved October 27, 2013 from: www.health.state.mn.us/divs/chs Minnesota QuickFacts from the US Census Bureau (2011). Retrieved October 16, 2012 from: www.quickfactscensus.gov Mobilizing for Action through Planning and Partnerships (MAPP) (2013). National Association of County and City Health Officials. Retrieved October 10, 2013 from http://www.naccho.org/topics/infrastructure/mapp/ NHANES ‐ Key Statistics from NHANES. (2013) Centers for Disease Control and Prevention. Retrieved October 10, 2013, from http://wwwn.cdc.gov/nchs/nhanes/bibliography/key_statistics.aspx Prevalence and Trends Data. (n.d.). BRFSS. Retrieved December 1, 2013 from http://apps.nccd.cdc.gov/brfss/ Regional Labor Market Information. (n.d.). Minnesota Department of Employment and Economic Development. Retrieved November 11, 2013,from https://apps.deed.state.mn.us/lmi/rws/ The State of Rural Minnesota 2013 | Center for Rural Policy and Development. (2013). Center for Rural Policy and Development RSS. Retrieved October 7, 2013, from http://www.ruralmn.org/publications/sorm‐2013/ 75
Appendix
Todd and Wadena Healthy Connections Organizations Tri‐County Health Care Todd County Health and Human Services Wadena County Public Health Lakewood Health System TCHC Clinic Advisory Group Members Bertha Hewitt School administrator City of Bertha‐ employee Star Bank employee Community Members for each Advisory Group; Bertha, Henning, Sebeka, Ottertail and Wadena Seip Drug pharmacy employees Henning Independent School district administrator and staff Ottertail County Public Health employee Todd County Health and Human Services administrator Willow Creek Assisted Living administrator and employee Sebeka Public School administrator Insurance Agent Local business owners Station Manager of KWAD superstation 76