2012 Rockbridge Area Community Health Improvement Plan
Photo by Michelle McCusker
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Health Center Planning Grant Staff Project Director, Suzanne Sheridan, Executive Director, RAFC Project Manager, Laura Simpson, RN Communications Manager, Katy Datz, Development Director, RAFC Technical Consultant, Pat Young, Community Works
MAPP Core Team Health Center Planning Grant Staff Ms. Deborah Bundy-Carpenter, RN, Nurse Manager, Central Shenandoah Health District Mr. Chuck Carr, Vice President, Carilion Stonewall Jackson Hospital Dr. Laura Kornegay, Local Physician Dr. Douglas Larsen, Director, Central Shenandoah Health District Ms. Melissa Mederios, Coordinator of Service Leadership, Washington and Lee University Ms. Holly Ostby, Community Health Coordinator, Carilion Stonewall Jackson Hospital
MAPP Steering Committee Mike Bell Rockbridge Area Community Services
Jeff Grossman RAFC, Board of Directors
Chris Blalock Rockbridge County Sheriff
Anne Hansen Physician; Community
Donna Gail Broussard Heritage Hall
Kathleen Heatwole Augusta Health, VP for Planning and Development
Cindy Crance Rockbridge County Schools, Director of Instruction Dennis Cropper Rockbridge Area Community Services Lisla Danas Virginia Military Institute, Alumni Timothy Diette Washington and Lee University Meredith Downey Department of Social Services
Joan Manley Valley Associates for Independent Living Lyle McClung Physician; RAFC Board of Directors Sammy Moore Chamber of Commerce, Executive Director
Bob Huch Southern Virginia University, VP of Finance
Lewis Plogger Buena Visa City Council
Michelle Jones Rockbridge Area Hospice
Alysan Raymond YMCA, Executive Director
Sharon Knick Community
Tim Root Rockbridge Area Transportation System
Betty LaRockk Rockbridge Area Transportation System, Executive Director
Jeri Schaff Maury River Senior Center; Valley Program for Aging Services
Mimi Elrod Lexington City, Mayor
Buster Lewis Rockbridge County Board of Supervisors
Mike Smith Rockbridge Area Community Services
Rusty Ford Rockbridge County, Board of Supervisors
Mary Lynn Lipscomb SJH Community Health Foundation Board; Health Consultant
Leonard Stewart Project Horizon; Lexington Police Department
Carole Green Virginia Military Institute, Alumni
Dan Lyons Lexington City Schools, Superintendent
Shane Watts Emergency Medical Services
ROCKBRIDGE AREA Community Health Improvement Plan
Table of Contents
Executive Summary……………………………………………………………………….… 4
A Year of Public Health Assessment and Planning………………………..…. 6 Top Priority Health Issues Issue One: Access to Health Services……………………………………… 10 Issue Two: Nutrition, Obesity, and Physical Activity………………..13 Issue Three: Mental Health………………………………………………….…16 Issue Four: Oral Health………………………………………………………….. 18
The Next Step…………………………………………………………………………………. 20
Special thanks to Cadet Michelle McCusker and COL Christina McDonald of Virginia Military Institute for their contributions to the Community Health Improvement Plan document completed as part of the VMI Summer Undergraduate Research Institute.
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Executive Summary Rockbridge area residents have long been interested in promoting equity and improving the community’s response to the needs of at-risk individuals. The Rockbridge Area Free Clinic, recognizing the need to further develop a sustainable system of care for the medically underserved in the Rockbridge area, applied for and was awarded an $80,000 Health Center Planning Grant by the United States Department of Health and Human Services. This grant was used to fund a 12-month project to broadly define and assess the health of our community and develop a community health improvement plan. This project, known as the Rockbridge Area MAPP Project, was conducted in partnership with Carilion Stonewall Jackson Hospital and the Central Shenandoah Health District. The Rockbridge Area
Community Health Needs Assessment (CHNA) provides a full report of the community-based visioning, assessment, and planning process conducted between September 2011 and August 2012. The information presented in the Community Health Needs Assessment was gathered through a variety of sources. The health status of the Rockbridge area was analyzed through a comparison of local and state data. Goals for health improvement are guided by national benchmarks set forth by Healthy People 2020. Focus groups were held to collect feedback from individuals across the lifespan and surveys were distributed to both a random sample of all area residents and a target population of medically underserved residents. The assessment data was used by the Steering Committee to identify
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the following top four health priority issues: 1. Access to Health Services 2. Nutrition, Physical Activity and Obesity 3. Oral Health 4. Mental Health The Committee constructed goals and objectives for each of the issues and identified existing resources that could facilitate the achievement of those goals. Based on the assessment and strategic planning results, the Community Health Improvement Plan has been developed to communicate
priority health issues and engage the community in a common goal of improved health. The assessment and strategic planning phases of the project have concluded, but the cyclical implementation and evaluation process aimed at improving the health and quality of life of all Rockbridge area residents has only just begun. The Rockbridge Area Community Health Improvement Plan represents the efforts of many organizations and individuals working together for a healthier community.
Vision Our vision is a Rockbridge community with improved health and quality of life for this and future generations supported by a comprehensive, accessible and sustainable community health system. Read the Rockbridge Area Community Health Needs Assessment here: http://www.rockbridgefreeclinic.org/resources/Updates/Rockbridge%20Area%20CHNA_2012_Final.pdf
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A Year of Public Health Assessment and Planning In September of 2011, an $80,000 Federal Planning Grant was awarded to the Rockbridge Area Free Clinic by the Health Resources and Services Administration (HRSA) Bureau of Primary Health Care. Upon notification of grant award, the Free Clinic formally invited Carilion Stonewall Jackson Hospital and Central Shenandoah Health District to partner in a year-long health assessment and planning project guided by the Mobilizing for Action through Planning and Partnerships (MAPP) model. MAPP was developed by the National Association of County and City Health Officials (NACCHO) and the Centers for Disease Control and Prevention (CDC) as a strategic planning tool for community-wide health
promotion. MAPP consists of six phases: 1. 2. 3. 4. 5. 6.
Organizing for Success Visioning Assessment Strategic Issues Goals and Strategies Action Cycle
In the initial Organizing for Success phase, a Steering Committee was formed to represent the public health system, including individuals from local governments, school systems, health and human service agencies, non-profit organizations, local colleges and law enforcement. Committee members attended a MAPP Project orientation, and then formed work groups in order
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to plan and implement the six phases of MAPP. In January, the Visioning phase was conducted with a community-wide event held at Virginia Military Institute. This community forum was held to engage the larger community and assess community values. With the feedback from this meeting, the Steering Committee crafted a vision statement that provides purpose and focus to long term health improvement efforts. Our vision is a Rockbridge community with improved health and quality of life for this and future generations supported by a comprehensive, accessible and sustainable community health system.
The Assessment phase utilized four assessment tools that allowed for a comprehensive understanding of the factors that affect the health outcomes of the Rockbridge community. The four MAPP Assessments include: 1. Community Themes and Strengths
2. Local Public Health System 3. Community Health Status 4. Forces of Change The Community Themes and Strengths Assessment was designed to identify the strengths and weaknesses of the community and explore health values. This information was gathered through focus group discussions with consumers of the health system and local leaders. Eleven focus group discussions were conducted with area stakeholders at the Visioning Event in January 2012. The Rockbridge Area MAPP team also sought out medically underserved populations and made an effort to hear from individuals across the lifespan and from all three localities. To this end, nine additional focus groups were held throughout the Rockbridge area during February and March 2012. Based on focus group guidelines published by the World Health Organization, participants were asked to brainstorm on their own definition of health, reflect upon recent experiences with the local health care system and identify sources of care, barriers to care, and assets of the current system.
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The Local Public Health System Assessment determines the capacity of the local public health system and identifies gaps in care. Sources of care, barriers to care, and gaps in services were reported by focus groups participants and survey respondents. Emergency room usage data was collected from Carilion Stonewall Jackson Hospital and Augusta Health. Information was collected from local providers and health and human services agencies. The Community Health Status Assessment documents the community’s health indicators and compares them to state data as well as national benchmarks outlined in Healthy People 2020. The Forces of Change Assessment was conducted by the Rockbridge Area Free Clinic, Carilion Stonewall Jackson Hospital, the Central Shenandoah Health District, and members of the MAPP Steering Committee in March 2012. The purpose of the Forces of Change Assessment is to identify external forces that affect the health of
the community and health care service operations. In May, the assessment findings were presented to the Steering Committee, and in June a community-wide strategic planning session was conducted to identify Strategic Issues. The strategic planning process was guided by a set of high-priority public health issues called the Healthy People 2020 Leading Health Indicators. The Leading Health Indicators are a smaller set of objectives selected by the Healthy People 2020 committee to communicate key issues and guide community efforts. Local data was examined for the twelve health indicators: 1) Access to Health Services, 2) Clinical Preventive Services, 3) Environmental Quality, 4) Tobacco, 5) Social Determinants, 6) Oral Health, 7) Nutrition, Physical Activity, and Obesity, 8) Injury and Violence, 9) Maternal and Child Health, 10) Mental Health, 11) Substance Abuse, 12) Reproductive and Sexual Health. The top four issues identified as priority issues for the Rockbridge area are:
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1. Access to Health Services 2. Nutrition, Physical Activity and Obesity 3. Oral Health 4. Mental Health In the Goals and Strategies phase, goals were set for improvement of the priority issues and strategies were suggested. Available resources and barriers to care were also identified. The goals and strategies presented here are meant to serve as a flexible, living tool for continued health improvement efforts. There are many valuable health and human resources available to
Rockbridge area community members that are not reflected in this report. The task now is to take stock of existing efforts related to the priority issues, further engage key stakeholders, and promote coordination of local action. The Rockbridge Area Free Clinic, Carilion Stonewall Jackson Hospital, the Central Shenandoah Health District, and many other concerned citizens are committed to the Action Cycle, a continuous process of refining goals, evaluating strategies and acting together to support initiatives that result in a healthier Rockbridge.1
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Image retrieved: http://www.naccho.org/topics/infrastructure/mapp/framework /clearinghouse/general.cfm
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Public Health Priority Issues ISSUE ONE: Access to Health Services Health care resources are only useful to a community if they are accessible to those who need them. The Health Resources and Services Administration (HRSA) defines the criteria for officially designating Medically Underserved Populations and Health Professional Shortage Areas for Primary Care, Dental, and Mental Health. These designations are used to identify barriers to health care access and prioritize health care needs in the United States. Low-income residents of Buena Vista, Lexington, and Rockbridge County are designated a Medically Underserved Population and a Primary Care Health Professional Shortage Area.
“Low-income� is defined by HRSA as an income at or below 200% of the Federal Poverty Level. In the Rockbridge area, 38 % of residents are low-income.2
The Rockbridge Area Free Clinic was founded in 1992 and relies heavily on area volunteers to provide access to health care for lowincome, uninsured individuals. Despite its role as a key safety net provider, limited funding currently prevents the Free Clinic from serving as a medical home to many underserved residents in the Rockbridge area.
Approximately 19% of Rockbridge area adults are uninsured.3 2
American Community Survey, 5-Year Estimates, US Census Bureau, 2006-2010
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Low-income and uninsured residents are less likely to have a source of ongoing care. The emergency room is often the only option, even for non-emergent illnesses and injuries. In some cases, even secure insurance status does not guarantee access to services. To remain in business, primary care practices often have to impose limits on the percentage of patients with public insurance. The current need for additional primary care providers who serve uninsured and underserved residents has been identified. This need is only expected to increase in future years. As the population ages, the number of Medicare recipients is expected to increase. As part of the Affordable Care Act, nearly one in five Virginians may be eligible for Medicaid in 2014. The U.S. Supreme Court recently ruled that 3
Virginia Atlas of Community Health, 2011
states may opt out of the Medicaid expansion. If Virginia decides to implement the expansion, it is predicted that the Rockbridge area will see an increase of about 3,844 new Medicaid enrollees.4 Although it is impossible to predict future federal and state legislative decisions, it is possible to respond to local demands. The need for comprehensive, local, and affordable health services is indisputable and community support is evident. 70% of survey respondents from a random sample of area households and 85% of survey respondents from the target medically underserved population indicated some level of interest in using a comprehensive, affordable community health center.5 4
Weldon Cooper Center for Public Service, UVA, Virginia Medicaid Now and Under Health Reform, 2010 5 Rockbridge Area Community Health Needs Assessment, 2012
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ISSUE ONE: Access to Health Services Goal
Optimize access to affordable healthcare that responds to the unique needs of our community. Barriers to Care: (identified by focus group participants) Convenience of Hours (no evening or weekend) Lack of culturally appropriate services Lack of Medicaid providers Lack of insurance/cost of care Organizational policies at local agencies Perception of local services Lack of awareness of local services Lack of transportation
Suggested Strategies • Develop a plan for a comprehensive community health center in the Rockbridge area • Develop a formal coalition that promotes the vision for a healthier Rockbridge • Develop a plan for recruitment and retention of health care professionals • Develop a plan to better utilize technology to meet identified health care needs Resources (not all inclusive) Rockbridge Area Free Clinic Central Shenandoah Health District Carilion Stonewall Jackson Hospital Local health care providers Augusta Health Rockbridge Area Community Services Augusta Health Care for Women Department of Social Services Valley Program for Aging Services Local schools Rockbridge Area Transportation System Local pharmacies
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ISSUE TWO: Nutrition, Physical Activity and Obesity Eating nutritious food and staying physically active directly impacts a person’s mental and physical health. Maintaining good diet and exercise habits can decrease the risk of many health issues. Obesity puts both children and adults at risk for a variety of health problems such as diabetes and high blood pressure.
High blood pressure is reported in 50.9 % of Rockbridge County residents, compared to 27.5% in Virginia.8
31% of adults in Rockbridge County are obese compared to 26.3% in Virginia.6
The age-adjusted diabetes prevalence rates for all three localities exceed both the state level and the national benchmark. The average (2006-2010) diabetes mortality rate in Buena Vista and Lexington was more than double the rate of Virginia and Rockbridge County during the same time period.9 7
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All black and white photos presented here were taken by local residents to promote food awareness. See the Rockbridge Area CHNA for full report. 68
, VDH, Office of Family Services, Behavior Risk Factor Surveillance System, 2010
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VDH, 2006-2010
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In 2010, 26.4% of children in Virginia were overweight or obese compared to 27.6% nationally. During the same time period, an average 42% of Rockbridge County elementary school children, 47% of middle school children and 50% of high school students were overweight or obese. The reported percentage of overweight school children in Rockbridge County decreased dramatically in the 2011-2012 school year. The latest measurement found that 10.75% of elementary school children, 25% of middle school children and 37% of high school students were identified as overweight or obese.10 These recent results are encouraging; however the root cause of the dramatic decrease remains unclear.
school children, and 35% of high school students were overweight or obese in the 2011-2012 school year.11
“They need something to teach the kids how to eat right. My son is overweight. All he wants is junk food.� ~Focus Group Participant
Buena Vista City Schools reported an average 53.5% of elementary school children, 42% of middle 11 10
Rockbridge County Schools 2010, 2012
Buena Vista City Schools, 2012; Please note: Lexington City Schools did not report BMI results.
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ISSUE TWO: Nutrition, Physical Activity, and Obesity Goal
Suggested Strategies
• Create a community-based wellness initiative that utilizes community health workers and promotes food security • Use currently formed groups as a venue for training lay people to support individuals in meeting physical activity goals • Pilot a community garden using master gardeners as trainers. Replicate existing school garden programs • Build a system for processing, storing and broadly distributing local food Barriers (identified by focus group Resources (not all inclusive) participants) Local school systems Lack of social support Rockbridge Area Relief Association State and Federal Policies YMCA Transportation Let’s Move Lexington Lack of affordable services The Community Table Lack of access to healthy food Primary Care providers Need for self-care education Registered Dieticians Perception of local services Cooperative Extension Services Cultural habits Rockbridge Area Conservation Council Local farmers
Reduce the rate of obesity in the Rockbridge area.
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ISSUE THREE: Mental Health Mental health is an essential part of a person’s well-being, healthy families, and productive communities. A recent study conducted by Washington & Lee University economists, Professors Arthur Goldsmith and Timothy Diette,12 shed light on the relationship between unemployment and poor mental health. The percentage of the Rockbridge area population which is unemployed has followed state trends and national trends and steadily increased over the past decade. Since 2008, local unemployment numbers have exceeded the state average.13 The stress associated with longterm unemployment not only causes emotional instability and worry, but also negatively impacts 12
http://news.blogs.wlu.edu/2011/10/21/wluecoonomists-unemployment/ 13 Virginia Employment Commission
the overall wellbeing of individuals, families, and communities. The suicide rate in Buena Vista (15 per 100,000) and Rockbridge County (17.9 per 100,000) exceeds state (11.9 per 100,000) and national (11.0 per 100,000) rates. “We’ve known he has problems for a long time, but we couldn’t get help because we couldn’t afford it. Eventually he snapped.” ~Focus Group Participant
The entire Rockbridge area, is designated a Mental Health Professional Shortage Area by the Health Resources and Services Administration.
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ISSUE THREE: Mental Health Goal
Increase access to mental health services. Barriers (identified by focus group participants) Lack of local services Lack of Medicaid providers Cost of services Perception of services available Transportation
Suggested Intervention Strategies • Develop a campaign to increase awareness of available services in the area • Increase the number of mental health providers in the area. • Develop a specialized, regional transportation plan for mental health patients • Ensure collaboration between agencies and organizations serving individuals and families with mental health needs • Develop and/or support programs that promote positive coping skills for individuals across the lifespan
Resources (not all inclusive) Rockbridge Area Community Services Rockbridge Area Free Clinic Crisis Intervention Team Local public schools Emergency Departments Law enforcement Rockbridge Area Transportation System Local providers Faith communities
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ISSUE FOUR: Oral Health Poor oral health has serious, lasting consequences and emergent dental care is costly compared to regular, preventive services. Approximately 50% of Rockbridge area residents have not had a dental visit in the past two years. This compares to “It has been 15 years since I went to the dentist.” ~Focus Group Participant
22.8% in Virginia.14 One of the top ten emergency room diagnoses at both Carilion Stonewall Jackson Hospital and
Augusta Health is “Dental Disorder.”15 In a survey of services that would be utilized from an affordable community health center, “dental” received the most number of responses from both the random sample of all area households and the target medically underserved population.16 Only one local provider, the Lexington Health Department, currently accepts new Medicaid pediatric patients. This practice is open two days a week, seeing 15 pediatric patients per day. Low-income residents of Buena Vista, Lexington and Rockbridge County live in a Dental Health Professional Shortage Area as designated by the Health Resources and Services Administration. 15
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VDH, Office of Family Health Services, Behavior Risk Factor Surveillance System, 2010
CSJH and AH, 2012 Rockbridge Area Community Health Needs Assessment, 2012 16
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ISSUE FOUR: Oral Health Goal
Suggested Intervention Strategies
Diminish barriers to access and improve education about oral health and hygiene. Barriers (identified by focus group participants) Lack of affordable local services Lack of Medicaid providers Use of the ER Lack of Culturally Appropriate Services Transportation
• Increase oral health education throughout the lifecycle in the Rockbridge community. • Increase access to affordable dental care by expanding capacity through a sustainable model of care for uninsured and underinsured people. • Encourage awareness of existing oral health services among both residents and services providers in the Rockbridge area.
Resources (not all inclusive) Carilion Stonewall Jackson Hospital Rockbridge Area Free Clinic Lexington Health Department Local dental providers Local school systems Remote Area Medial (RAM)
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The Next Step After identifying priority health needs in the Rockbridge area and developing a plan with goals and suggested strategies, the action cycle begins now. In order to progress towards improved health and quality of life for area residents, the community needs to coordinate systems of care and maximize available resources. The Rockbridge Area Free Clinic is currently working with other local service providers to develop a collaborative service delivery plan for comprehensive, affordable health care that incorporates all aspects of health, safety and wellness. Carilion Stonewall Jackson Hospital will use the Rockbridge Area Community Health Needs Assessment and Community Health Improvement Plan to ensure that its’ strategic plan responds to area needs and results in community benefit. The Central Shenandoah Health District is committed to working closely with other area providers to strengthen and streamline public services. These three partnering agencies will also continue to work with committed citizens to further engage interested stakeholders, refine the health improvement plan, and support coordination of care. Building a healthier community also depends upon the support and involvement of residents. Make a commitment to improve your own health. Volunteer your time to help others in need. Join the conversation, or just keep abreast of our progress. We look forward to seeing you on the journey!
ROCKBRIDGE AREA Community Health Improvement Plan