Tazewell Community Health Needs Assessment

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Table of Contents Table of Contents .................................................................................................................. 2 Disclaimer ............................................................................................................................. 4 Acknowledgments ................................................................................................................. 5 Project Management Team ................................................................................................... 5 Community Health Assessment Team Members .................................................................... 5 Data Collection and Analysis Team ........................................................................................ 6 Project Summary ................................................................................................................... 7 Community Health Needs Assessment ................................................................................. 10 Service Area ................................................................................................................... 12 Target Population .......................................................................................................... 13 Primary Data and Community Engagement .................................................................... 14 Stakeholder Surveys............................................................................................................. 14 Focus Group Meetings– Target Population ........................................................................... 18 Community Health Survey .................................................................................................... 22 Methodology ........................................................................................................................... 22 Survey Results ......................................................................................................................... 23 Community Survey Results ................................................................................................... 23

Secondary Data ............................................................................................................. 36 Demographics and Socioeconomic Status ............................................................................. 36 Population, Gender, Race and Age.......................................................................................... 36 Academic Attainment .............................................................................................................. 39 Income and Poverty Status ..................................................................................................... 41 Households and Marital Status ............................................................................................... 45 Employment Status ................................................................................................................. 47 Transportation......................................................................................................................... 48 Access to Health Care ........................................................................................................... 49 Health Staffing Shortages and Designations ........................................................................... 49 Health Services Professionals .................................................................................................. 50

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Source of Primary Care and Cost of Services .......................................................................... 51 Health Status of the Population ............................................................................................ 52 Death Rates ............................................................................................................................. 52 Prevention Quality Indicators.................................................................................................. 55 Mental Health and Substance Abuse ...................................................................................... 56 Prevention and Wellness...................................................................................................... 58 County Health Rankings .......................................................................................................... 59 Health Risk Factors .................................................................................................................. 59 Nutrition, Weight Status, and Physical Activity....................................................................... 60 Clinical Preventive Screenings ................................................................................................. 62 Maternal, Infant and Child Health ........................................................................................ 62 Prenatal and Perinatal Health Indicators ................................................................................ 63 Infectious Diseases............................................................................................................... 65 Social Environment .............................................................................................................. 66

Improvement Implementation Strategy 2014-2016 .............................................................. 67 Conclusion........................................................................................................................... 69 Appendices ......................................................................................................................... 70 Appendix 1: Work Plan and Timeline .............................................................................. 70 Appendix 2: CHAT Directory .......................................................................................... 72 Appendix 3: Stakeholder Survey .................................................................................... 73 Appendix 4: Community Survey ...................................................................................... 77 Appendix 5: When Asked, “What else do we need to know?� on the Community Health Survey: .......................................................................................................................... 79

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Disclaimer This document has been produced to benefit the community. Carilion Clinic encourages use of this report for planning purposes and is interested in learning of its utilization. Comments and questions are welcome and can be submitted to Aaron Harris-Boush (amharrisboush@carilonclinic.org).

Members of the Project Management team reviewed all documents prior to publication and provided critical edits. Every effort has been made to ensure the accuracy of the information presented in this report, however accuracy cannot be guaranteed. Members of the Tazewell Area Community Health Assessment Team cannot accept any responsibility for any consequences that result from the use of any information presented in this report.

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Acknowledgments Success of the Tazewell County Community Health Needs Assessment was due to the strong leadership and participation of its Project Management Team; the Community Health Assessment Team, and the Data Collection and Analysis Team, Members of these Teams.

Thank you to all of the community members who participated in the Community Health Survey and focus groups.

Project Management Team Project Director: Kathren Dowdy, Carilion Tazewell Community Hospital− Senior Director Community Hospital Project Manager: Rebecca Leblanc− Carilion Clinic Marketing Specialist CHNA Planning Manger: Sharon Honaker, Carilion Clinic− Planning Advisor

Community Health Assessment Team Members Kathren Dowdy, Carilion Tazewell Community Hospital Carol Weaver, Carilion Tazewell Community Hospital Regina Sawyers, Appalachian Agency for Senior Citizens (AASC) Jim Thompson, Carilion Tazewell Community Hospital Board of Directors Mike Hymes, Tazewell County Board of Supervisors Kerry Moore, Southwest Virginia Community Health Clinic Dr. Glenn L. Catron, DMD, Dentist Kathy Mitchell, Tazewell County Health Department Dave Darden, Clinch Valley Medical Center Bill Hawley, Bluefield Regional Medical Center Stephen Rhinehart, MD, Family Physician Jennifer Edwards, Carilion Clinic Family Medicine Tommy Parham, Four Seasons YMCA Susan White, Clinch Valley Community Action Dr. Brenda Lawson, Tazewell County Public Schools Superintendent Tom Hayes, Hayes Drug Store Jim Talbert, Richlands News Press Rita Ward, Lilies of the Field Thrift Store Ann Coates, Tazewell County Department of Social Services Page | 5

Loretta Remines, Carilion Clinic Home Care Norma Bourne, Clinch Valley Community Action - Family Crisis Services DeWitt Cooper, Town of Tazewell Police Chief Patti Cettin, Taking Action for Special Kids (TASK) Dwain Harwick, Abel Crisis Pregnancy Center John Quintier, Heritage Hall Helathcare and Rehabilitation Center Ginger Robinett, Southwest Virginia Community College Cathy Smith-Cox, Southwest Virginia Community College Lynne Bartlett, Tazewell County Public Library

Data Collection and Analysis Team Sharon K. Honaker, Carilion Clinic Planning Advisor Aaron Harris-Boush, Carilion Clinic Planning Analyst Tammy Nerenberg, Carilion Clinic Contact Center Director Carilion Direct Operators/Data Analysts Chani Jain, Virginia Tech Master of Public Health Student Intern

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Project Summary

Project Summary Introduction Many and varied organizations are involved in the essential work of improving and maintaining the health of any given community. It is important to assess the health concerns of each community periodically to ensure that current needs are being addressed. A Community Health Needs Assessment (CHNA) every few years will uncover issues, indicate where improvement goals are needed, and track and promote progress in key areas so that there is demonstrated, ongoing improvement. The work of conducting this CHNA, and the public availability of its findings is intended to enable health-oriented organizations across the community to plan effectively the vital work of maintaining and improving health.

This report contains the findings of the 2013 needs assessment for Tazewell County, including data on the target population and service area, as well as primary and secondary data.

Method A 30-member Community Health Assessment Team (CHAT) oversaw the assessment activities.

The service area included those living in Tazewell County. The target population included vulnerable populations, such as low-income, uninsured and/or underinsured, older adults, and those with chronic disease.

Beginning in January 2013, primary data collection included a Stakeholder/Professional Survey, Target Population Focus Groups and a Community Health Survey. CHAT Members took the Stakeholder/Professional Survey and encouraged co-workers and others working with target populations to participate as well. Focus Groups were conducted with an intention of utilizing locations and/or regularly-scheduled meetings of groups that include the target populations.

Community Surveys were available to be taken in print, over the phone or online. Secondary data were collected, including demographic and socioeconomic indicators, as well as health indicators addressing access to care, health status, prevention, wellness, risky behaviors and the social environment.

The final CHAT meeting was for the purpose of prioritizing the findings from all of these research methodologies. Participants were asked to rank the top 10 community health needs independently, and then rate each of their respective “top 10s� with regard to feasibility of addressing the need and the potential positive impact if the need were addressed.

Findings In summary, the findings of the Tazewell County Community Health Needs Assessment revealed an older, poorer, more racially homogeneous, and unhealthy county, in comparison to the state of Virginia as a whole.

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Project Summary There was a larger percentage of the population of Tazewell County living in poverty versus the state; and approximately the percent of Tazewell County residents on Medicaid, Medicare, dually eligible, or uninsured compared to the state of Virginia. Tazewell residents on employee sponsored insurance were half that of those in Virginia, though the unemployment rate was only slightly higher in Tazewell than Virginia overall. Median household income in Tazewell was significantly lower than Virginia, and a lower percentage of Tazewell residents hold a bachelor’s or master’s degree as compared to Virginia residents. Interestingly, Tazewell County had a higher percentage of home ownership than the state overall, though the median value of homes in Tazewell was much lower than Virginia’s.

In the 2013 Virginia County Health Rankings, Tazewell County was ranked 132 out of 133 counties and cities for health factors and outcomes. Tazewell had a higher than state average rate of deaths from malignant neoplasms, heart disease, cardiovascular disease, chronic lower respiratory disease, unintentional injury, drug/poison, prescription drugs and diabetes.

Tazewell had a higher rate of discharges (age-adjusted) for angina, bacterial pneumonia, COPD, CHF and hypertension. A higher percentage of Tazewell residents were obese and report no leisure time as compared to residents of the state overall. The percentage of births with no prenatal care was higher in Tazewell, and the infant mortality rate was higher. Tazewell residents also reported more mentally unhealthy days in the past month.

Tazewell did better than the state rate in age-adjusted discharges for diabetes, and the rate of sexually transmitted diseases of all kinds was significantly lower than that of the state.

Focus Groups identified the following as health-related factors in the community (in no particular order): availability of primary care, affordable insurance, expensive dental care, not utilizing mental health care for related issues and no services to support home-bound people.

The stakeholder survey also listed access to dental care, and mental health care as top obstacles to good health in Tazewell County, as well as language barriers and inability to get away from work and childcare responsibilities to take care of health issues. When asked the top three most important health problems in the community, over 80% of participants in the community survey chose alcohol and drug abuse as one of them. In addition, 55% chose prescription drug abuse. Next on the list was obesity (about 35%). Consistent with this, when asked the three most important “risky behaviors,” in the community, the highest responses were for drug abuse, alcohol abuse, poor eating habits and lack of exercise. Another risky behavior identified by many was cell phone use while driving.

Response Following the final CHAT meeting to identify the top priorities from the community health needs identified, the following areas of focus emerged: 1) 2) 3) 4)

Substance Abuse Prevalence Obesity Prevalence/Lack of Exercise Access to Primary Care Mental Health Disorders/access to psychiatric services Page | 8

Project Summary 5) High cost of Services to the Uninsured.

To address the needs of the community, Carilion Tazewell Community Hospital (CTCH) will develop a multi-disciplinary team to ensure that resources are aligned with the needs identified during the Community Health Needs Assessment. The team will initially consist of CTCH employees, but add membership from community agencies as needed to ensure improvements are achieved in the identified areas of focus.

In addition, the Town and County of Tazewell recently completed a workshop to kickoff a vision for economic development for the area. This project will lead to the creation of a strategic plan for the town. CTCH will actively participate in this project, in particular on the Community Health subgroup. This will provide a forum for alignment of community resources with identified community needs. Activities recommended for this group are very consistent with the CHNA findings: pilot and experiment with approaches to addressing prescription drug abuse and the Tazewell Wellness Movement.

Lastly, processes will be developed to track progress of improvements, ongoing.

This implementation strategy found on page 67 of this report has been presented to and approved by the CTCH Board of Directors and the Carilion Clinic Board of Directors in September 2013.

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Community Health Needs Assessment Tazewell County is located in southwest Virginia and borders West Virginia to its north. Since it contains portions of the Ridge and Valley Appalachians, and the Cumberland Plateau, Tazewell County has very distinct and beautiful geologic areas. Historically, what is now Tazewell County was a hunting ground for the Cherokee and Shawnee tribes. The area's abundance of wild game was a source of frequent skirmishes among these tribes. Tazewell County was created on December 20, 1799. The land for the county was taken from portions of the bordering Virginia counties of Wythe and Russell. Today, it is a rural area with about 87 people per square mile (less than half the population density of Virginia overall).

CTCH is a not-for-profit, 56-bed hospital owned by Carilion Clinic. CTCH is located in the Town of Tazewell in Tazewell County, Virginia and offers a full-service medical facility with imaging, therapy services, surgery, with a special emphasis on outpatient surgery, and a physician clinic within the facility. CTCH utilizes a unique model of care, with emergency/hospitalist physicians caring for patients across the continuum of emergency and inpatient care.

Carilion Clinic is a not-for-profit health care organization serving nearly one million people in Virginia through a physician specialty group, advanced primary care practices, hospitals and outpatient centers. Led by clinical teams with a shared philosophy that puts the patient first, Carilion is committed to improving the community’s health while advancing the quality of care through medical education and research. Carilion Clinic is based in Roanoke, Virginia. After providing management to Tazewell Community Hospital for 27 years, Carilion Clinic purchased the Tazewell-based hospital, now Carilion Tazewell Community Hospital (CTCH), in 2008.

As a not-for-profit hospital, CTCH has conducted an in-depth assessment, and plans to repeat the process every three years to identify and track the specific needs of the community it serves. This process enables the subsequent development of appropriate solutions to those needs. The project has fostered focused work with area safety net providers and key stakeholders, and will ensure that resources are focused on highest-priority areas. This work is of critical importance in creating solutions to improving health, and reducing disparities of the underserved in the Tazewell area.

The project examined the health of members of the community in the aggregate, from the various perspectives of stakeholders/providers that work in current systems of care, objective outcomes measures, community members, and at-risk populations. The goals of the project were:

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1. To conduct a comprehensive needs assessment; 2. To identify ways to develop effective solutions to high-priority health needs.

3. To continue to develop linkages and foster relationships in the community that ensures a seamless continuum of care for all persons.

As Carilion Clinic conducted Community Health Needs Assessments in four communities in 2013, a work plan was developed (Appendix 1: Work Plan and Timeline) to progress through the steps of the assessments concurrently in the four communities. As in the other areas, the Tazewell County Community Health Needs Assessment focused on high levels of community engagement involving health and human services leaders, stakeholders, and providers; the target population; and the community as a whole. A Community Health Assessment Team (CHAT) consisting of project management staff and representatives from area health and human services, law enforcement, faith-based communities, and schools led the 8-month initiative. (Appendix 2: CHAT Directory). Beginning in January 2013, the CHAT met four times to oversee the Tazewell County Community Health Needs Assessment. Meeting agendas were prepared for each meeting and distributed to CHAT members.

The Project Management Team included Carilion Clinic’s Regional Hospital Senior Director for CTCH, who served as the Project Director for the assessment; the Project Manger coordinated meeting logistics, distribution and collection of surveys, conducted some focus groups and scribed for some others. A Carilion Clinic Marketing Specialist performed in the role of Project Manager. Project Planners included a Planning Advisor with Carilion Clinic’s Strategic Development department, who assisted in all aspects of the project, including the development, distribution, and analysis of the Community Health Survey; facilitation and collection of minutes from focus groups and CHAT meetings; collection and analysis of secondary data and final project evaluation.

The Data Collection and Analysis Team included the Planning Advisors from Carilion Clinic Strategic Development and Carilion Direct. The Planning Advisors evaluated trends nationally and within Carilion Clinic regarding primary care, urgent care, and emergency services utilization data, and determined payor mixes and demographic information for the service area.

In addition, staff from Strategic Development, Carilion Direct, and an intern from Virginia Tech, were instrumental in entering survey data into Survey Monkey for the hundreds of paper Community Health Surveys received from across Tazewell County.

Beginning in January 2013, primary data collection included a stakeholder survey (17 participants), a community health survey (744 participants) and four target population focus groups. Secondary data were collected including demographic and socioeconomic indicators as

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well as health indicators addressing access to care, health status, prevention, wellness, risky behaviors, disease incidence and prevalence, and the social environment.

Service Area Carilion Tazewell Community Hospital (CTCH) is located in Tazewell, Virginia. In fiscal year 2012, CTCH served 702 unique inpatients. Patient origin data reveals that 88% of CTCH’s patients are from Tazewell County, 9% are from McDowell County in West Virginia, and 2% are from Bland County. Tazewell County is the primary service area for CTCH.

Land Mass and Persons per Square Miles (Quick Facts, U.S. Census Bureau, 2012) Virginia

Land area in square miles Persons per square miles

39,490.1 202.6

Tazewell County

518.9 86.9

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Target Population The community of Tazewell County, in rural Southwest Virginia, is the service area for the Community Health Needs Assessment. Although the intention was to assess the overall region for health issues and barriers, a special effort was made to hear from the target population, defined as those living in Tazewell County, especially vulnerable populations such as those with low-income, uninsured/underinsured, older adults, or those with chronic disease.

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Primary Data and Community Engagement In addition to the CHAT, members of the community were encouraged to take the community survey; stakeholders working with the targeted populations were asked to participate in stakeholder surveys; and target populations were engaged through focus groups.

Stakeholder Surveys CHAT members were asked to take the Stakeholder/Professional survey, as well as encourage their coworkers and others in health and human services positions to participate. These surveys were available in print and online versions. Questions on this survey tool focused on an inventory of organizations related to healthcare; the greatest challenge faced by each organization; obstacles and unmet healthcare needs. Seventeen of these surveys were returned. A copy of this survey is in Appendix 3: Stakeholder Survey.

Responses were received from: • • • • • • •

Carilion Clinic Clinch Valley Medical Center Lilies of the Field Thrift Store Tazewell County Department of Social Services Clinch Valley Community Action, Inc Virginia Department of Health - Cumberland Plateau Health District Abel Crisis Pregnancy Center

When asked what agencies are directly related to health care or the access to services in the community, stakeholders responded with these: Appalachian Agency for Senior Citizens Clinch Valley Community Action Tazewell County Health Department AllCare for Seniors Program of All-inclusive Care of the Elderly (PACE)ACE Carilion Tazewell Community Hospital Heritage Hall Rehab and Nursing Home Westwood Golden Age/Mayfair Home Health/Hospice Tazewell Community Health Interim Friendship Preferred HHC Legacy Hospice Reedy Tri-County Health Clinic Cumberland Mountain Community Services Clinch Valley Medical Center.

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When asked to state the single greatest challenge of their organization in their own words: • • •

•

• • • • • •

Patient responsibility in their own health care/patient compliance.

Affordable, quality healthcare for low/no income residents who do not have insurance.

Transportation to healthcare is a problem, since providers are often out of the county.

Very rural and large land-massed county with many small cubby-holes where transportation and service delivery are large barriers.

Quality healthcare for seniors, since specific geriatric care is not available. Aging population, reduced savings and retirement income to use for better healthcare, shrinking funding for preventative and intervention services.

Medications are prohibitively expensive for most.

Education and awareness.

Mental health.

Trying to assist/refer clients who do not qualify for Medicaid, cannot afford healthcare, or may be in upper lower to middle income categories, un- or underemployed.

No one-stop, easy to access resource for information, registration/application and determination of eligibility for a great variety of quality healthcare needs.

The greatest challenge we face is acquiring a physician and/or nurse practitioner fulltime.

Please rank order the below obstacles according to your opinion of HOW GREAT AN OBSTACLE each represents (1 is most significant/prevalent and 10 least)

Shortage of local MENTAL HEALTH providers

6.70

Shortage of local DENTAL providers

7.80

Shortage of local SPECIALTY health care…

6.40

Shortage of local PRIMARY CARE providers…

Too expensive (can’t afford out-of-pocket costs…

Lack of awareness of treatment…

3.70 2.10 4.40

Cultural barriers (literacy levels, customs, fears)

5.60

Language barriers (written and verbal)

7.10

Can’t get away from job/kids to attend medical…

Distance to providers (can’t find transportation;…

6.70 4.50

0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00

When asked why they ranked the way they did, participants responded: Page | 15

• •

• • • •

•

•

• •

It is a challenge to make a timely physician appointment.

My ranking was based on the number of residents calling or visiting DSS seeking assistance, my own experience at how busy my PCP is and is no longer accepting new patients, and many residents traveling out of town seeking specialists or good providers.

There is no public transportation in the outlying areas.

Patients are not interested in becoming responsible in their healthcare, which involves compliance and follow-up.

I used our requests for services and needs as a guideline for answering, as well as personal experience.

Cost, time, type of vehicle required and other barriers are significant in access to treatment and especially follow-up/wellness care. Tazewell citizens, especially for elderly/disabled are not eligible for Medicaid transportation. These folks “fall through the cracks”.

Not enough time or emphasis on health education because so much time and effort is spent taking care of problems that have already occurred. I don’t feel that education or awareness is a large part of the foundation.

Services are available and accessible to those with lower income/Medicaid. We have good coverage and bus service, but clients view riding the bus as “inconvenient.” The issue is getting care for uninsured in the middle or upper low income. OB providers won’t schedule those clients unless they have insurance or money upfront. We have clients coming for prenatal care that can’t qualify for Medicaid and don’t have insurance, which delays prenatal care for months. Once lower income pregnant clients deliver and they can’t get Medicaid, they usually don’t continue birth control if they have to pay for it. This is almost always with clients who are young adults in their late teens, early 20s.

I could provide multiple examples of how pride and lack of knowledge has caused significant barriers to receiving critical services and benefits needed.

That is the obstacle in our facility: not being able to get a family practice physician fulltime. Most of our patients are very poor and cannot afford healthcare. Thank God Carilion provides a way for patients to receive the medical attention they need.

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•

In terms of UNMET health care needs of community residents, please score each of the following according to this scale: 1 = very serious unmet need, 2 = somewhat serious unmet need, 3 = less serious unmet need, 4 = not an unmet need

In terms of UNMET health care needs of community residents, please score each of the following according to this scale: (1 is most significant and 10 least) School-based health care Hospice care In-home health care services Affordable medications Culturally and linguistically appropriate services Health transportation services Health navigator services (advocate and guide) Health education (for those with chronic disease) Preventive services Mental health/addictions care Dental care Specialty health care (excluding dental and‌ Primary health care (medical home) 0.00

1.00

2.00

3.00

4.00

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Focus Group Meetings– Target Population Tazewell Date

Time

Location

Description

3/11/13

7 p.m.

Tazewell Elementary School

Tazewell PTA

3/12/13

6 p.m.

Student Center Vocational School

TASK (Parents of Special Needs) Group

3/21/13

1 p.m.

Tazewell Head Start

Lower income with children, about 15 participants

4/4/13

11 a.m.

Four Seasons YMCA, Tazewell

Older population, 4 participants in a water aerobics class; focus group held after class.

Focus Group Format A point-of-contact at each host site attempted to recruit 8-12 adult participants for each meeting. The Project Manager facilitated the meetings and the Project Planner/Planning Analyst recorded discussions.

Prior to each meeting, participants were asked to read and sign a consent form to ensure conversations were kept confidential. Focus group meetings lasted for an hour and addressed personal and system-based barriers in accessing primary care, mental health, substance abuse, and dental services by participants and/or their families; transportation; and gaps in the current continuum of care. To protect the participants’ privacy, they had the option to address their own situation or address similar populations. Additional follow-up questions were asked based on the responses.

Focus Group Questions: 1. In one or two words, how would you describe good health?

2. What do you, or your family and friends, do when you need a checkup or are sick?

(1) How many participants have health insurance?

3. What do you, or your family and friends, do when you have a toothache or need your teeth cleaned?

(1) How many participants have dental insurance?

4. What do you, or your family and friends, do when you need to talk to someone about your nerves/stress/depression or need help with alcohol or drug addiction?

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5. Is there anything else you would like to tell us about your health or the health of others in Roanoke?

Focus Group Results: Themes and Quotes Availability of Primary Care is a problem, especially nights and weekends Quotes: • • • •

•

“Before I had insurance, we would go to MedExpress (Bluefield). There is also a clinic in Bastian with a sliding scale. Before I had a job with insurance we would go there.”

“I usually go to Abingdon. That’s where my doctor is because she moved.”

“I go to urgent care in Bluefield, but there’s none in Tazewell itself.”

“I need to find a doctor, because I come to the clinic at CTCH and the providers keep changing. I never know who I’m going to see, or if they are even going to have anyone there. I want to find a provider that I can count on. They need a regular PCP at the clinic at the hospital (CTCH).”

“Doctors are not here. If you do have to see doctors, you have to travel to Bluefield.

People can’t do it.”

Affordable Insurance Quotes: •

•

• • •

“I’m retired and I pay A LOT for insurance, as I am not yet eligible for Medicare. We pay over $700 every month and have a high deductible for myself and my husband. My insurance doesn’t cover prescription medications until the deductible is met. Luckily my husband is still working, so we can afford to pay for the insurance.”

“People don’t make that much money per month and can’t afford to pay for an insurance plan. I am afraid not to have insurance. My insurance has contracted with doctors, so my co-pay per visit isn’t so much. That helps.”

“I work and my husband works and we both have insurance, but still in the work environment, you know, I pay about $300-some dollars a month for insurance.

“I am qualified as a low level that has no other dependent than my wife. But still, you know, what I am thinking is if I can pay that, I can just pay my medical bill.”

“I know in my family, my husband has to pick which one of us will be on the insurance, so we always pick our daughter. I am on it right now instead of her, because I’m pregnant. So, we’re rotating who has insurance.

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Dental Care—available providers, but expensive Quotes: • •

“I can’t afford to go to dentist. My kids have dental insurance, and I take them when they need it.”

“The community has a general hygiene clinic, so if you call them and on certain days when they do it, I think it’s $15 for a cleaning.”

For stress, mental health—they don’t generally go to a mental health provider Quotes: • • • •

“I really don’t’ need that.”

“I guess I would go to another family member, my friends or my minister.”

“I talk to my hairdresser. I love my hairdresser.”

“If you go to a family physician, you can have him refer you to someone. They would refer you to Cumberland Mountain. Sometimes they refer you to Roanoke or wherever for various situations.”

No services to support home-bound people Quotes: •

•

• •

“I have one, when it comes to disabilities. I have a sibling that is older than I am that I care for. She cannot make phone calls. There is no assistance to help with her. I was told that if she can call she can get help. I do not agree with this. There is no extra help with people like that.”

“I agree with you. My mother has Alzheimer’s. I have nurses who go to her every couple of hours and stay with her, but they are only available for hour or two hours.

They have nobody who can stay with people who need their help. They do not have anyone to help with them, and they have nothing like that here in Tazewell. You go Richmond or Bluefield, but not here in Tazewell. Tazewell is always the worst place in situations like that.”

“It is because we are a small community. Maybe because they think we do not need it as much as the surrounding counties.”

“They think maybe you need to travel to Richmond or Bluefield. We cannot travel. My mother doesn’t drive anymore.”

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Community Health Survey Methodology Community members were encouraged to take the Community Health Survey. A news release ran in local newspapers, and a news story ran on the Bluefield television station. Posters and flyers were placed in the community letting community members know how to take the survey.

Two drawings for a $25 Wal-Mart gift card for those who completed the survey (one survey per person) were offered as an incentive. The survey was available in print, online or over the phone from February through Mid-May 2013. There were 744 surveys returned from Tazewell County. Surveys were analyzed and reported using Survey Monkey and Microsoft Excel. All responses were entered into Survey Monkey either directly by the respondents or by volunteers who entered responses from paper or phone surveys.

Participants were asked where they go for health care, dental care, mental health or substance abuse services, what services they or their child(ren) have accessed in the past 12 months, what services are difficult to access, what chronic conditions do they have, important factors for a healthy community, as well as health problems and risky behaviors. A copy of this survey is in Appendix 4: Community Survey.

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Survey Results There were 744 participants to the Tazewell Community Health Survey.

• • • • • • • • • •

The average age of respondents was 50 78% of respondents were female, while 21.9% were male 42% had children under 18 living in their household 92% had at least a high school diploma 94% were white 68% were married 61% worked full-time 45% of surveys were returned in printed format through partner agencies 18% were done online 37% were mailed in

Community Survey Results Where do you go for medical care? (Check all that apply)

90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0%

Other (please specify)

I do not go to the doctor for regular care

Tri-Area Community Health

Lake Christian Ministries of Moneta

Nurse Practitioner's office

Tazewell Community Health

Bedford Pregnancy Center

Johnson Health Center

Salem VA Medical Center

Urgent Care

Free Clinic (Ex. Bedford Christian, Central…

Emergency Room

Doctor’s office

0.0%

Health Department (Franklin, Tazewell, Floyd, Montg…

10.0%

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Rescue Mission Mental Health America Presbyterian Homes and Family Service Johnson Health Center Piedmont Community Services Intercept Youth Services Cumberland Mountain CSB New River Valley Community Services Mental Health Association of the NRV Saint Albans Behavioral Health

Dentist’s office Free Clinic (Ex. Franklin County, New River Valley, Bedford…

I do not go to the dentist for regular care Emergency Room

Mission of Mercy Project

Urgent Care Johnson Health Center / James River Dental Clinic Dental Aid Partners Dental Care Day Cumberland Mountain CSB

I do not use these services Other (please specify)

Other (please specify)

Where do you go for dental care? (Check all that apply)

Blue Ridge Behavioral Healthcare Free Clinic (New River Valley, etc.)

Where do you go for mental health, alcohol, or drug problems? (Check all that apply)

Emergency Room

90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Doctor/Counselor’s Office

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Most respondents get their medical care from a doctor’s office and dental care from a dentist’s office. A small percentage gets its medical care from the emergency room, an urgent care, a nurse practitioner or the health department. There is also a small percentage that does not get regular medical care (about 7.3%) or see a dentist for regular dental care (about 14.4%). When asked where they go for mental health, alcohol or drug-related issues, the vast majority said they do not use these services, while about 10% said they go to a doctor or counselor. These numbers are interesting in their contrast to additional findings that substance abuse issues are the most important health problems in the community (please see below).

Which health care services are hard to get in our community? (Check all that apply) 60.0% 50.0% 40.0% 30.0% 20.0%

Other (please specify)

Pediatric Services

Child dental care

Family Planning / Birth control

Physical therapy

End of life care / hospice

Specialty care (ex. heart doctor)

Mental health / counseling

Lab work

Chiropractic care

Medication / medical supplies

Urgent care / walk in clinic

Vision care

Inpatient hospital

Preventive care (ex. yearly…

X-rays / mammograms

Family Doctor

Emergency room care

Substance abuse services –…

Women’s health services

Adult dental care

Ambulance services

0.0%

Alternative therapy (ex.…

10.0%

In terms of access, community members said specialty care most often when asked about hardto-get services. “Alternative therapies” was next, followed by vision care and urgent care. The reason the most survey participants mentioned for not getting needed healthcare was lack of weekend/evening hours, followed by cost (separately, high co-pays and deductibles was listed by a significant number of survey respondents) and long waits for appointments.

Page | 25

Other (please specify)

No health insurance

Location of offices

Don’t know what types of services are available

High co-pay or high deductible

No transportation

Lack of evening and weekend services

Language services

Long waits for appointments

Can’t find providers that accept my insurance

Cost

Afraid to have check-ups

Don’t like accepting government assistance

Childcare

Don’t trust doctors / clinics

Have no regular source of healthcare

What do you feel prevents you from getting the healthcare you need? (Check all that apply)

50.0%

45.0%

40.0%

35.0%

30.0%

25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

Page | 26

Please check one of the following for each statement

800 700 600 500

Yes

400

No

300

Not applicable

200

0

I have had a dental exam or…

I have had an eye exam…

My doctor has told me that I… I take the medicine my…

I have had a counseling…

I have been to the emergency…

My child or dependent has…

My child or dependent has…

My child or dependent has…

My child or dependent…

My child or dependent has…

My child or dependent has…

100

The above graphs indicates health health-related related activity in the past 12 months with regard to dental, vision, emergency and mental health vi visits, long-term term illnesses and children’s health-related health appointments over the past 12 months.

Page | 27

Have you ever been told by a doctor that you have…(Check all that apply) 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% Other (please specify)

I have no health problems

Mental health / substance abuse

Depression or anxiety

Obesity

High cholesterol

High blood sugar or diabetes

Cancer

Asthma

Heart disease

High blood pressure or hypertension

0.0%

High blood pressure and high cholesterol are the two chronic health issues reported most by Tazewell County residents. The most important factors identified for a “healthy community” were access to health care, good jobs and healthy economy, and low crime/safe neighborhoods. (see below). The most important health problems were alcohol and illegal drug use (81% listed this in their top 3 most important health problems), prescription drug abuse (separate issue and listed by 55.7% of respondents), overweight/obesity (34.8%). The three most important “risky behaviors” corresponded with the “health problems”: drug abuse, alcohol abuse, and poor eating habits came in right after cell phone use while driving. Over 62% of survey participants had employer-provided health insurance, while 9% had no insurance. Of those without insurance, the primary reason was the expense.

Page | 28

How long has it been since you last visited a doctor for a routine checkup?

(Please check one)

Within the past year (1 to 12 months ago) Within the past 2 years (1 to 2 years ago) Within the past 5 years (2 to 5 years ago) 5 or more years ago

If applicable, how long has it been since your child or dependent visited a doctor for a routine checkup? (Please check one)

Within the past year (1 to 12 months ago) Within the past 2 years (1 to 2 years ago) Within the past 5 years (2 to 5 years ago) 5 or more years ago Not applicable

Page | 29

Other (please specify)

Homicide

Suicide

Diabetes

Cancers

Domestic violence

Overweight / obesity

Dental problems

HIV / AIDS

Heart disease and stroke

Gang activity

Mental health problems

Infant death

Child abuse / neglect

Lung disease

High blood pressure

Sexual assault

Motor vehicle crash injuries

Teenage pregnancy

Prescription drug abuse

Aging problems

Alcohol and illegal drug use

Access to healthy food Other (please specify)

Parks and recreation

Religious or spiritual values

Strong family life

Arts and cultural events Good jobs and healthy economy

Affordable housing

Clean environment

Access to health care Healthy behaviors and lifestyles

Good schools

Good place to raise children Low crime / safe neighborhoods Low level of child abuse

What do you think are the three most important factors for a “healthy community”? (Please check three)

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

What do you think are the three most important “health problems” in our community? (Please check three)

90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

Page | 30

No Health Insurance

No Dental Insurance

No Mental Health Insurance

Dental Insurance

Medicare Supplement

Health Savings Account

Medicare

Medicaid

Government (VA, Champus)

Mental Health Insurance

Private Insurance

Employer Provided Insurance

Other (please specify)

Cell phone use and driving

Dropping out of school

Tobacco use

Unsafe sex

Not using seat belts / child safety seats

Not using birth control

Drug abuse

Lack of exercise

Not getting “shots” to prevent disease

Poor eating habits

Alcohol abuse

What do you think are the three most important “risky behaviors” in our community? (Please check three)

90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

Which of the following describes your current type of health insurance?

(Check all that apply)

70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

Page | 31

If you have no health insurance, why don’t you have insurance? (Check all that apply)

80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Unemployed

Laid off

Too expensive

Other (please Not available Not at my job applicable- I specify) have health insurance

How many people live in your home?

2.50

2.00

1.50

1.00

.50

.00 Number who are 0 – 17 years of age:

Number who are 18 – 64 years of age :

Number who are 65 years of age or older:

Page | 32

What is your highest education level completed?

Less than high school Some high school High school diploma Associates Bachelors Masters / PhD

What is your race / ethnicity?

Other

Decline to answer

More than one race

Hispanic

American Indian / Alaskan Native

White

Black / African American

Asian

Native Hawaiian / Pacific Islander

100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

Page | 33

What is your marital status?

Married Single Divorced Widowed

What is your yearly household income?

$0 – $10,000 $10,001 – $20,000 $20,001 – $30,000 $30,001 – $40,000 $40,001 – $50,000 $50,001 – $60,000 $60,001 – $70,000 $70,001 – $100,000 $100,001 and above

Page | 34

What is your current employment status?

Full-time Part-time Unemployed Self-employed Retired Homemaker Full-time student

When asked “Is there anything else we should know?”

Comments about access issues made up 36.2% of the comments; Insurance or financial, 23.4%; quality of care, 13.8%; a family illness, 11.7; the rest were “other.” Please see Appendix 5: When Asked, “What else do we need to know?” on the Community Health Survey: for all comments.

Page | 35

Secondary Data Demographics and Socioeconomic Status Population, Gender, Race and Age Tazewell County is older than Virginia overall and also more racially homogeneous (90% white in Tazewell County Schools versus 54% in schools statewide).

Population Change Estimates, 2010 – 2030 (Virginia Employment Commission, 2012, http://www.vawc.virginia.gov/gsipub/index.asp?docid=359) Geography Virginia Tazewell County

2000 7079030 44598

2010 8001024 45078

2020 8811512 45300

2030 2040 9645281 10530229 45436 45535

% Change 2010 - 2030 31.6% 1.0%

Median Age by Geographic Location (American Community Survey 5-Year Estimates, DP05, U.S. Census Bureau, 2007-2011) Virginia Median age (years)

Tazewell County

37.3 43.6

Estimates of Population by Life Cycle, 5-Year Estimates, 2007 - 2011 (American Community Survey 5-Year Estimates, U.S. Census Bureau, 2007-2011) Estimates of Population by Life Cycle, 5-Year Estimates, 2007 - 2011 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 85 years and over

75 to 84 years

65 to 74 years

60 to 64 years

55 to 59 years

45 to 54 years

35 to 44 years

25 to 34 years

20 to 24 years

15 to 19 years

10 to 14 years

5 to 9 years

Under 5 years

Virginia Tazewell County

Page | 36

Race and Ethnicity, 5-Year Estimate, 2007-2011 (American Community Survey 5-Year Estimates, U.S. Census Bureau, 2007-2011) Race and Ethnicity, 5-Year Estimate, 2007-2011 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

White

American Black or Indian African and American Alaska Native

Asian

Native Hawaiian and Other Pacific Islander

Some other race

Two or more races

Hispanic Not or Latino Hispanic (of any or Latino race)

Virginia

69.7%

19.5%

0.3%

5.4%

0.1%

2.5%

2.5%

7.6%

92.4%

Tazewell County

95.2%

2.9%

0.2%

0.6%

0.0%

0.2%

1.0%

0.3%

99.7%

Public Schools Race / Ethnicity, 2011 (Virginia Department of Education, 2011 Student Membership by School, Grade, Ethnicity, & Gender, September 30, 2010)

School Name

White

Black or African American

American Indian/Alaska Native

Virginia Total

54.1%

24.1%

0.3%

Asian

Native Hawaiian/ Pacific Islander

Two or more races (NonHispanic)

Hispanic/ of any Race

Full-time & Part-time Students

5.8%

0.1%

4.1%

11.4%

1,253,038

Tazewell County ABBS VALLEYBOISSEVAIN ELEM

98.2%

1.8%

0.0%

0.0%

0.0%

0.0%

0.0%

164

CEDAR BLUFF ELEM.

99.2%

0.6%

0.0%

0.2%

0.0%

0.0%

0.0%

504

Page | 37

Asian

Native Hawaiian/ Pacific Islander

Two or more races (NonHispanic)

Hispanic/ of any Race

Full-time & Part-time Students

White

Black or African American

American Indian/Alaska Native

DUDLEY PRIMARY

92.5%

5.1%

0.0%

1.8%

0.0%

0.0%

0.6%

334

GRAHAM HIGH

91.9%

3.9%

0.0%

3.0%

0.0%

0.0%

1.1%

534

GRAHAM INTERMEDIATE

90.2%

7.1%

0.0%

2.4%

0.0%

0.0%

0.3%

297

GRAHAM MIDDLE

92.9%

4.8%

0.0%

1.4%

0.0%

0.7%

0.2%

434

NORTH TAZEWELL ELEM.

94.2%

5.2%

0.0%

0.0%

0.0%

0.7%

0.0%

291

RAVEN ELEM.

99.5%

0.0%

0.0%

0.0%

0.0%

0.0%

0.5%

210

RICHLANDS ELEM.

95.7%

1.8%

0.0%

0.5%

0.0%

2.0%

0.0%

598

RICHLANDS HIGH

97.2%

1.6%

0.1%

0.7%

0.0%

0.0%

0.3%

749

RICHLANDS MIDDLE

98.1%

0.5%

0.0%

0.5%

0.0%

0.7%

0.2%

589

SPRINGVILLE ELEM.

96.9%

3.1%

0.0%

0.0%

0.0%

0.0%

0.0%

162

TAZEWELL ELEM.

91.6%

2.5%

0.2%

1.2%

0.0%

3.7%

0.8%

593

TAZEWELL HIGH

95.9%

3.8%

0.0%

0.1%

0.0%

0.0%

0.0%

687

TAZEWELL MIDDLE

94.6%

3.7%

0.0%

0.4%

0.0%

0.6%

0.6%

484

Tazewell County Total

95.2%

2.9%

0.0%

0.9%

0.0%

0.7%

0.3%

6,630

School Name

Foreign Born Persons, Percent, 2007 - 2011 (QuickFacts, American Community Survey 5-Year Estimates, U.S. Census Bureau, 2007-2011) Geography

Percent

Virginia

11.0%

Tazewell County

1.2%

Page | 38

Population 5 years and over whom speak a language other than English at home, 2007 - 2011 (QuickFacts, American Community Survey 5-Year Estimates, U.S. Census Bureau, 2007-2011) Percent Geography Virginia

14.4%

Tazewell County

1.7%

Academic Attainment There is a direct link to educational attainment, health literacy, and positive health outcomes.

According to the most recent Virginia Health Equity report, Virginians who don’t attend or complete high school are more likely to die of heart disease, cancer and a dozen other leading causes of death than those who earn a diploma.1 Over 76% of Tazewell County residents have at least a high school education. This is far less than the 86.6% across the state. Tazewell County has a lower than state average achievement of Bachelor’s and Master’s degrees.

Academic Attainment for Population 25 and Over, 5-Year Estimate, 2007-2011 (Local Department of Social Services Profile Report, SFY 2012, American Community Survey 5Year Estimates, U.S. Census Bureau, 2007-2011) Educational Attainment (2011) Less than 9th grade 9th to 12th grade High school degree Some college, no degree Associate's degree Bachelor's degree Graduate/professional degree Have at least a high school degree Have at least a college degree

Statewide

Tazewell

Percent 5.4% 8.0% 25.6% 19.9% 6.7% 20.2% 14.2%

Count 3645 3983 10824 6981 2471 3064 1423

Percent 11.3% 12.3% 33.4% 21.6% 7.6% 9.5% 4.4%

86.6%

24763

76.5%

34.4%

4487

13.9%

1

Virginia Department of Health, Virginia Health Equity Report, 2012 http://www.vdh.state.va.us/healthpolicy/Documents/Health%20Equity%20Report%202012-%20FINAL%207-3112.pdf

Page | 39

Class of 2012 Graduation Statistics by School Division (Virginia Department of Education, 2012) Division Cohort Advanced Studies Diploma Standard Diploma Modified Standard Diploma Special Diploma Virginia On-Time Graduation Rate GED Cohort Completion Rate Total Completers Still Enrolled Dropouts Dropout Rate Long-Term Absence

Tazewell County 505 147 225 10 11 77.8 47 87.9 444 11 50 9.9 0

Page | 40

Income and Poverty Status The median household income in Tazewell County is only about 58% of the state median household income. In addition, there is a higher percentage of Tazewell County residents that lives in poverty, especially children, than the percentage in poverty across the state of Virginia.

Median Household Income, 5-Year Estimate, 2007-2011 (QuickFacts, American Community Survey 5-Year Estimates, U.S. Census Bureau, 2007 - 2011) Geography

Median Household Income

Virginia

$ 63,302

Tazewell County

$ 36,436

The Federal Poverty Guidelines (FPL) are used to determine eligibility for many local, state and federal assistance programs. The FLP is based on an individual’s or family’s annual cash income before taxes. Updated yearly by the Census Bureau, the 2012 guidelines are provided below as a reference.2 2013 Federal Poverty Guidelines for the 48 Contiguous States and the District of Columbia Persons in family/household Poverty guideline $ 11,490 1 2

$ 15,510

3

$ 19,530

4

$ 23,550

5

$ 27,570

6

$ 31,590

7

$ 35,610

8

$ 39,630

For families/households with more than eight persons, add $ 4,020 for each additional person.

2

http://aspe.hhs.gov/poverty/12poverty.shtml/#guidelines

Page | 41

Number of Residents Living in Poverty (Local Department of Social Services Profile Report, SFY 2012, U.S. Census Bureau, Small Area Income and Poverty Estimates (SAIPE)) Poverty Rate (%)

Statewide All ages 8.9% 8.8% 9.6% 9.9% 9.5% 10.0% 9.6% 9.9% 10.2% 10.6% 11.1% 11.6%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Tazewell

Children 12.2% 11.2% 12.5% 13.6% 12.2% 13.3% 12.3% 12.9% 13.6% 14.0% 14.6% 15.6%

All ages 15.5% 15.0% 16.6% 15.6% 15.7% 17.3% 16.5% 17.8% 17.6% 15.9% 18.5% 17.6%

Children 20.7% 18.4% 22.0% 24.0% 21.6% 23.7% 21.2% 23.5% 24.2% 21.6% 23.5% 23.1%

Number of Residents Living in Poverty 30.0% 25.0% 20.0%

Statewide All ages

15.0%

Statewide Children

10.0%

Tazewell All ages

5.0%

Tazewell Children 2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

0.0%

Page | 42

Income to Poverty Level Ratio in Past 12 Months, 2011 (Local Department of Social Services Profile Report, SFY 2012, U.S. Census Bureau American Community Survey 3-Year Estimates, 2007-2011) Statewide Percent Below poverty level (0-99%)

10.7%

Tazewell Count Percent 17.3% 7570

100% - 124%

3.4%

2714

125% - 149%

3.6%

2503

150% - 184%

5.3%

3808

185% - 199%

2.3%

1943

200% and above

74.7%

25256

6.2% 5.7% 8.7% 4.4% 57.7%

Income to Poverty Level Ratio in Past 12 Months, 2011 80.0%

Below poverty level (099%)

70.0% 60.0%

100% - 124%

50.0% 40.0%

125% - 149%

30.0% 20.0%

150% - 184%

10.0% 0.0%

185% - 199% Statewide

Tazewell

Page | 43

Public Assistance Recipients, SFY 2012 (Virginia Department of Social Services, 2012) # SNAP 10664

# Medicaid1 10018

# TANF 1398

% SNAP 10664

% Medicaid 10018

% TANF 1398

White

3357

4578

672

31.5%

45.7%

48.1%

Black

191

238

52

1.8%

2.4%

3.7%

Other

347

335

95

3.3%

3.3%

6.8%

White

5703

3554

527

53.5%

35.5%

37.7%

Black

199

103

24

1.9%

1.0%

1.7%

Other

310

64

28

2.9%

0.6%

2.0%

White

484

1092

0

4.5%

10.9%

0.0%

Black

24

39

0

0.2%

0.4%

0.0%

Other

49

15

0

0.5%

0.1%

0.0%

Total Recipients Children 017 years Tazewell

Adults 18-64 years Adults 65 years & older

Students Eligible for Free and Reduced Lunch Program, 2012- 2013 (Virginia Department of Education, Office of School Nutrition Program, National School Lunch Program Free & Reduced Price Eligibility Report, October 31, 2012) School System Tazewell County Public Schools Virginia School Division Totals

FREE

FREE Percentage (%)

REDUCED Price Eligible

REDUCED Price Percentage (%)

TOTAL F/R Eligible

TOTAL F/R Percentage (%)

6,440

2,771

43.03%

517

8.03%

3,288

51.06%

1,238,870

413,992

33.42%

82,779

6.68%

496,771

40.10%

SNP Membership

Page | 44

Households and Marital Status There is a higher rate of home ownership in Tazewell County, with 72.7% owning their homes.

The median value of homes in Tazewell, however, is much lower than the median value for Virginia. There is a high percentage of households in Tazewell County (62.2%) in which the grandparents are responsible for children compared with the percentage in Virginia overall (39.7%). The divorce rate in Tazewell is slightly higher than the state.

Housing Statistics (QuickFacts, American Community Survey 5-Year Estimates, U.S. Census Bureau, 2007-2011) Virginia

Tazewell County

3,364,939

20,773

Homeownership rate, 2007-2011

68.40%

72.70%

Housing units in multi-unit structures, percent, 2007-2011

21.40%

7.70%

Median value of owner-occupied housing units, 2007-2011

$254,600

$84,900

Households, 2007-2011

2,991,025

18,019

2.57

2.43

Housing units, 2010

Persons per household, 2007-2011

Marital Status, Population 15 Years and Over, 2007-2011, Percentage (U.S. Census Bureau, American Community Survey, 5-year Estimate, Table S1201, 2007-2011)

Geography

Total

Virginia Tazewell County

6,403,172 37,317

Now married (except separated) 51.5% 56.7%

Widowed

Divorced

Separated

Never married

5.7% 8.7%

9.7% 9.7%

2.6% 3.4%

30.5% 21.5%

Percent of Children Living in Single-Parent Households, 2010, by Race/Ethnicity* (Local Department of Social Services Profile Report, SFY 2012, U.S. Census Bureau, 2010 Census Summary File 1 (Table P31), 2010) Geography

Virginia Tazewell

Percent Count Percent

All races 27.2% 2116 27.0%

White 19.5% 1916 25.9%

Black 55.5% 88 55.0%

Hispanic 28.4% 19 25.3%

Page | 45

Percent of Grandparents Living with Grandchildren who are Responsible for their Grandchildren, 2007 - 2011 (Local Department of Social Services Profile Report, SFY 2012, American Community Survey 5Year Estimates, U.S. Census Bureau, 2007 - 2011)

Geography Estimate

Virginia

Number of grandparents living with own grandchildren under 18 years

Responsible for grandchildren

167,530

66,554

Percent Estimate

Tazewell County

39.7% 940

585

Percent

62.2%

2011 Divorces & Annulments (Local Department of Social Services Profile Report, SFY 2012, Source: Virginia Department of Health, Division of Health Statistics. Percent excludes cases where child count is unknown.)

Virginia Tazewell

Percent Count Percent

Total number of divorces -51 --

Not involving children 53.9% 126 55.0%

Involving children 43.2% 103 45.0%

2011 Divorce Rate (Local Department of Social Services Profile Report, SFY 2012, Source: Virginia Department of Health, Division of Health Statistics. Rate is per 1,000 total population.)

Virginia Tazewell

Rate (per 1,000 adults) 3.8 5.1

Page | 46

Employment Status Tazewell County’s unemployment rate has tracked with Virginia’s, staying just above the state rate every year since 2000, with the exception of 2010, in which Tazewell’s rate was lower than the state’s

Unemployment Rates, 2000-2012 (Local Department of Social Services Profile Report, SFY 2012, Virginia Employment Commission, Local Area Unemployment Statistics, 2001-2012, *2012 rates are based on an 11month average (through November))

Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012*

Virginia Rate (%) 2.3% 3.2% 4.2% 4.1% 3.7% 3.5% 3.0% 3.0% 3.9% 6.7% 6.9% 6.2% 5.7%

Tazewell Number 270 948 1162 1086 908 880 782 908 907 1620 1455 1399 1452.182

Rate (%) 3.3% 4.9% 5.8% 5.4% 4.6% 4.5% 3.9% 4.4% 4.4% 7.6% 6.8% 6.5% 6.7%

Page | 47

8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0%

Virginia

2012*

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

Tazewell 2000

Percent Unemployed

Unemployment Rates, 2000-2012

Year

Transportation

Occupied Housing Units with No Vehicles Available (QuickFacts, American Community Survey 5-Year Estimates, U.S. Census Bureau, 2007 - 2011)

Geography

Virginia Tazewell County

Occupied housing units Estimate 2,991,025 Percent 2,991,025 Estimate 18,019 Percent 18,019

No 1 vehicle vehicles available available

2 vehicles available

3 or more vehicles available

186,698 6.20% 1,646 9.10%

1,149,438 38.40% 7,077 39.30%

751,321 25.10% 4,243 23.50%

903,568 30.20% 5,053 28.00%

Page | 48

Access to Health Care Access to health services is one of Healthy People 2020’s Leading Health Indicators, and its goal is to improve access to comprehensive, quality health care services. Objectives related to this goal include: • • • •

Increase the proportion of persons with a usual primary care provider (AHS-3) Increase the number of practicing primary care providers (AHS-4) Increase the proportion of persons who have a specific source of ongoing care (AHS-5) Reduce the proportion of individuals who are unable to obtain, or delay in obtaining, necessary medical care, dental care, or prescription medicines (AHS-6)3

Disparities in access to health services directly affect quality of life and are impacted by having health insurance and ongoing sources of primary care. Individuals who have a medical home tend to receive preventive health care services, are better able to manage chronic disease conditions, and decrease Emergency Room visits for primary care services.4

Health Staffing Shortages and Designations

Health Professional Shortage Areas (Health Resources and Services Administration, http://muafind.hrsa.gov and http://hpsafind.hrsa.gov, accessed August 18, 2012)

Geography

MUA

MUP -

Tazewell County

Tazewell Service Area

Health Professional Shortage Area Primary Care Mental Dental HPSA HPSA Health HPSA Cumberland Low Income Tazewell Mountain County Service Area Tazewell

Tazewell

3

US Department of Health & Human Services, Healthy People 2020, Topics and Objectives, www.healthypeople.gov 4 Closing the Divide: How Medical Homes Promote Equity in Health Care: Results from the Commonwealth Fund 2006 Health Care Quality Survey, Volume 62, June 27, 2007

Page | 49

Health Services Professionals There is a direct relationship between the number of primary care providers in a community and improved health outcomes. Having an adequate supply of primary care providers is a measure of access to care and can be determined by calculating the ratio of the population to one Full-time Equivalent (FTE) provider. It is important to note that this information may at times under- or over-estimate the number of providers in the area; it does not take into account patient satisfaction; how care is provided and utilization of services by the patients; and finally this measure does not reflect how care is coordinated within a community.5 Tazewell fares worse than the state in access to dentists and mental health providers. The 2013 County Health Rankings statistics indicate slightly better access to primary care in Tazewell County than the state average.

Health Professionals Providers Population Ratio (County Health Rankings, 2013, Health Resources and Services Administration, Area Resource File, 2011-2012) Primary care physicians*

Dentists*

Mental health providers

Geography

# PCP

PCP Rate

PCP Ratio

# Dentists

Dentist Rate

Dentist Ratio

# MHP

MHP Rate

MHP Ratio

Virginia Tazewell County

5919 42

74 93

1355:1 1072:1

4563 14

55 30

1811:1 3336:1

3620 5

45 11

2216:1 9012:1

5

County Health Rankings, 2013 Data and Methods, http://www.countyhealthrankings.org/health-factors/accesscare accessed 9/4/13

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Source of Primary Care and Cost of Services A higher percentage of Tazewell County residents have been unable to access a physician because of cost. Tazewell has about twice the percentage of Medicare, Medicaid and Dual Eligible than Virginia, and about half the state’s percentage of employer-supplied privately insured residents.

Percent of People Who Could Not See a Doctor Due to Cost (County Health Rankings, 2013, Behavioral Risk Factor Surveillance System, 2005-2011) Geography Virginia

Tazewell County

Sample Size 38633 408

% Couldn't Access 11 19

2013 Health Insurance Status (Truven Market Planner Plus, 2013) Virginia #

%

Medicaid

761312

9.3%

Medicare

914520

11.1%

Medicare Dual Eligible

168493

2.1%

Private - Direct

403459

4.9%

Private - ESI

4972951

60.6%

Private - Exchange

0

0.0%

Uninsured

986755

12.0%

Grand Total

8207490

100.0%

Tazewell County # % 7998 17.3% 9574 20.7% 2004 4.3% 1409 3.0% 13738 29.7% 0 0.0% 11556 25.0% 46279 100.0%

2013 Health Insurance Status 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

Virginia Tazewell County

Page | 51

Health Status of the Population In Virginia, individuals are more likely to face high rates of disease, disability and death from a host of health conditions that span generations if they are poor, live in rural areas or inner-city communities, and are a racial or ethnic minority. In addition, residents with the least education have higher death rates. 6 Tazewell residents have almost twice the number of Poor to Fair Health and Physically Unhealthy Days when compared with Virginia residents overall.

Percent of Adults Reporting Fair to Poor Health and the Number of Poor Physical Health Days in the Past Month (Virginia Department of Health, Office of Family Health Services, Behavior Risk Factor Surveillance System, 2004-2010) Poor or Fair Health

Poor Physical Health Days

% Poor or Fair Health

Physically Unhealthy Days

Virginia

14

3.2

Tazewell

29

6.0

Geography

Death Rates Tazewell has higher death rates than the state from • malignant neoplasms, • heart disease, • cardiovascular disease, • chronic lower • respiratory disease • diabetes.

6

Virginia Department of Health, Office of Minority Health & Health Equity, Virginia Health Equity Report 2012

Page | 52

Geographic Area Death Profile, Age-Adjusted Rates per 100,000 (Virginia Department of Health, Division of Health Statistics, 2009 - 2011)

Total Deaths per 100,000 Population 1200 1000 800 600 400 200 0 2009

2010

2011

Virginia

745.8

739.2

735.8

Tazewell County

1120.6

739.2

1122.4

Malignant Neoplasms Deaths per 100,000 Population 250 200 150 100 50 0 2009

2010

2011

Virginia

175.8

170.9

169.5

Tazewell County

207.6

205.3

212.5

Page | 53

Heart Disease Deaths per 100,000 Population 350 300 250 200 150 100 50 0 2009

2010

2011

Virginia

170.8

167.6

161.3

Tazewell County

295.9

305.9

306.1

Cerebrovascular Disease Deaths per 100,000 Population 50 48 46 44 42 40 38 36 2009

2010

2011

Virginia

42.1

41.7

41.4

Tazewell County

40.8

43.7

48.9

Page | 54

Chronic Lower Respiratory Deaths per 100,000 Population 90 80 70 60 50 40 30 20 10 0 2009

2010

2011

Virginia

39.2

37.9

38.4

Tazewell County

79.3

73.6

78.8

Diabetes Mellitus Deaths per 100,000 Population 60 50 40 30 20 10 0 2009

2010

2011

Virginia

19.5

18.7

19.4

Tazewell County

30.1

38.9

49.7

Prevention Quality Indicators Prevention Quality Indicators (PQI) identify quality of care for ambulatory-sensitive conditions, conditions for which good outpatient care can prevent hospitalization or for which early intervention can prevent complications and severe disease. Tazewell County residents have higher age-adjusted discharge rates for all categories listed below, with the exception of diabetes.

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Prevention Quality Indicator, Age-Adjusted Discharge Rates per 100,000 (Virginia Department of Health, Division of Health Statistics, Virginia Atlas of Community Health, 2012 ,2010 Data) Age-Adjusted Discharge Rate per 100,000 Adult Asthma PQI Discharges Angina PQI Discharges Bacterial Pneumonia PQI Discharges Chronic Obstructive Pulmonary Disease (COPD) PQI Discharges Congestive Heart Failure PQI Discharges Diabetes PQI Hypertension PQI Discharges

Virginia

Tazewell County

76.0 9.6 184.5

90.1 85.9 327.6

125.6

358.9

238.1 134.0 34.6

331.4 108.9 41.7

Mental Health and Substance Abuse Approximately one in five Americans experienced some sort of mental illness in 2010 with approximately 5% of Americans suffering from such severe mental illness that it interfered with day-to-day school, work or family. Prevalence of any mental illness was higher in females (23.8%) than males (15.6%); higher for persons with Medicaid, or Children’s Health Insurance Coverage (33.4%); and higher for the uninsured (24.9%) than for persons with health insurance (16.1%).7 Serious psychological distress among adults 18 years and over is two times greater for those living in poverty (less than 100% of the FPL) as compared to those living 100%-200% of poverty and over.8 Mental Health and Disorders are a Leading Health Indicator for Healthy People 2020 with a goal to “improve mental health through prevention by ensuring access to appropriate, quality mental health services.”

Tazewell County residents have more mentally unhealthy days than the state. The county’s suicide rate, though down considerably from 2009, is still slightly higher than the rate in the state overall. The rate of unintentional injury deaths of Tazewell County residents is two to three times as high as the rate for Virginia residents. More startling is that Tazewell County has a death rate from drugs/poison that is five times the Virginia rate, and more than 7 times the Virginia rate of deaths from prescription drugs.

7

Substance Abuse and Mental Health Administration, Mental Health United States, 2010 http://www.samhsa.gov/data/2k12/MHUS2010/MHUS-2010.pdf 8 Centers for Disease Control, Health United States, Table 59, 2011 http://www.cdc.gov/nchs/data/hus/hus11.pdf

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Geography

Mentally Unhealthy Days in the Past Month

Virginia

3.1

Tazewell County

5.5

Tazewell Area Suicide Deaths per 100,000 Population (Virginia Department of Health, Division of Health Statistics, 2009-2011) Suicide Deaths per 100,000 Population 25.0 20.0 15.0 10.0 5.0 0.0 2009

2010

2011

Virginia

11.8

11.9

12.5

Tazewell County

23.0

13.2

14.0

Tazewell Area Unintentional Injury Deaths per 100,000 Population (Virginia Department of Health, Division of Health Statistics, 2009 – 2011) Unintentional Injury Deaths per 100,000 Population 100 90 80 70 60 50 40 30 20 10 0 2009

2010

2011

Virginia

32.9

32.2

33.4

Tazewell County

76.9

93.0

81.0

Page | 57

Tazewell Area Drug/Poison Deaths (age - adjusted rates per 100,000) (Virginia Department of Health, Office of the Chief Medical Examiners , 2010) Drug/Poison Deaths per 100,000 Population, Age-Adjusted

Virginia

Tazewell County

Drug/Poison

9.6

49.2

Prescription Drugs (FHMO)

4.6

35.8

Tazewell Area Drug/Poison Deaths (age-adjusted rates per 100,000) 60.0 50.0 40.0 Drug/Poison 30.0 Prescription Drugs (FHMO)

20.0 10.0 0.0 Virginia

Tazewell County

Prevention and Wellness In the United States, 7 of the 10 leading causes of death are due to chronic illnesses that can often be prevented by adopting healthy behaviors and reducing health risk factors such as tobacco use, physical inactivity, poor nutrition, and obesity.9 In addition to reducing risk factors, adherence to preventive screenings and care can greatly reduce the incidence of chronic disease and greatly improve quality of life.

9

Centers for Disease Control and Prevention, CDC’s Health Communities Program accessed 8/11/2012, http://www.cdc.gov/healthycommunitiesprogram/overview/diseasesandrisks.htm

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County Health Rankings

County Health Rankings have analyzed localities in all 50 states using measures to determine how healthy people are and how long they live. These measures include (1) health outcomes which look at how long people live (mortality) and how healthy people feel while alive (morbidity); and (2) health factors which represent what influences the health of a county, including health behaviors, clinical care, social and economic factors, and physical environment.10 The lower the overall ranking, the healthier the community is.

Tazewell County was ranked second to last in Health Outcomes, of all of the cities and counties in Virginia. It fared better in Health Factors, but was, nevertheless, in the bottom 25% of municipalities.

County Health Rankings-Health Outcomes (out of 133) Geography

2011

2012

2013

Tazewell County

124

126

132

County Health Rankings-Health Factors (out of 133) Geography Tazewell County

2011

2012

2013

82

103

107

Health Risk Factors

Tazewell was comparable to the state in the rate of adults having been told they have high blood pressure or high cholesterol, and in the percentage of adults who smoke daily.

10

University of Wisconsin Population Health Institute & the Robert Wood Johnson Foundation, County Health Rankings, www.countyhealthrankings.org, 2013

Page | 59

Health Risk Factors– High Blood Pressure and Cholesterol (Virginia Department of Health, Virginia Behavior Risk Factor Surveillance System, 2010) Adult Age 18+ Risk Profile

Virginia

Tazewell County

High Blood Pressure (told by doctor or other health professional)%

29.0

28.0

High Cholesterol (told by doctor or other health professional) %

30.0

32.0

Health Risk Factors– Adult Smoking (Virginia Department of Health, Virginia Behavior Risk Factor Surveillance System, 2005-2011) Geography Virginia Tazewell County

% Adults who smoke daily or most days 22 22

Nutrition, Weight Status, and Physical Activity A healthy body weight, good nutrition, and physical activity are positive predictors of good health and are a Healthy People 2020 Leading Health Indicator. The prevalence of overweight and obesity has increased tremendously in the past 30 years and is at epidemic proportions in the United States. These increasing rates raise concern because of their implications on health and their contribution to obesity-related diseases like diabetes and hypertension. Overall, persons who are obese spend 42% more for medical care than do normal weight adults.11 Reducing the proportion of adults who are obese to 30.6% is a Healthy People 2020 Leading Health Indicator (NWS-9).

The benefits of physical activity include weight control; reduction of risk for cardiovascular disease, diabetes, and some cancers; and increased strength and overall well-being.

Access to healthy foods directly impacts an individual’s (and community’s) ability to consume fruits, vegetables, and whole grains. Increasing the proportion of Americans who have access to a food retail outlet that sells a variety of foods encouraged by the Dietary Guidelines is an objective of Healthy People 2020 (NWS-4).

11

Centers for Disease Control and Prevention, Study Estimates Medical Cost of Obesity May be as High as $147 Billion Annually, July 27, 2009, www.cdc.gov/media/pressrel/2009/r090727.htm

Page | 60

Tazewell County has a higher percentage of obese individuals, and a higher percentage of people with no leisure time physical activity than Virginia’s percentages. Tazewell residents have less access to recreational facilities.

Health Risk Factors-Obesity and Physical Inactivity (National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation, 2009) Geography

Adult Obesity

Physical Inactivity

% Obese

% No Leisure Time Physical Activity

Virginia

28

24

Tazewell County

33

38

Access to Recreational Facilities rate per 100,000 Population (County Business Patterns, 2010) Geography Virginia Tazewell County

Recreational Facilities

Rec. Facility Rate

832

10.4

4

8.9

Limited Access to Health Foods (percent of population who lives in poverty and more than 1 or 10 miles from a grocery store) (U.S. Department of Agriculture, Food Environment Atlas 2012) Geography Virginia Tazewell County

# Limited Access

% Limited Access

295,609

4

3,121

7

Page | 61

Census Tract Food Deserts (United States Department of Agriculture, Ecomonic Research Service, 2010)

Geography

Census Tract FIPS

Total Population

% of people with low access to a supermarket or large grocery store

Tazewell

51185990500

3343

90.4

# of people with low access to a supermarket or large grocery store 3023

% of total population that is lowincome and has low access to a supermarket or large grocery store 18.5

# of total population that is low-income and has low access to a supermarket or large grocery store 618

Clinical Preventive Screenings According to the National Cancer Institute, deaths can be greatly reduced for breast, cervical, colon, and rectal cancer through early detection and screening tests.

Health Risk Factors– Cancer Screenings, 2010 (Virginia Department of Health, Virginia Behavior Risk Factor Surveillance System, 2010) Adult Age 18+ Risk Profile

Virginia

Tazewell County

Percent of women 18 and older with no Pap test in past 3 years

13.2

n/a

Percent of women 40 and older with no mammogram in past 3 years

13.2

n/a

Maternal, Infant and Child Health Maternal and child health is a Healthy People 2020 Leading Health Indicator with the goal to “improve the health and well-being of women, infants, children and families.” Infant mortality is affected by many factors, including the socio-economic status and health of the mother, prenatal care, birth weight of the infant, and quality of health services delivered to both the mother and child.

Healthy People 2020 objectives and targets are as follows:

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MICH- 1.3: Reduce the rate of infant deaths (within 1 year) to 6.0 infant deaths per 1,000 live births MICH- 8.1: Reduce low birth weight (LBW) to 7.8% of live births MICH- 10.1: Increase the proportion of pregnant women who receive early and adequate prenatal care to 77.9%

Prenatal and Perinatal Health Indicators Tazewell County had a higher than the state percentage of births with prenatal care starting after the first trimester; a higher percentage of low-birth weight births; and a higher infant death rate than the state. The five-year average infant mortality rate, however, was lower in Tazewell County than Virginia’s rate. The latest teen pregnancy rate for Tazewell is comparable to the state’s. A higher number of children have been tested for elevated Blood Lead Levels in Tazewell County than in the state

Tazewell Area Births without Early Prenatal Care (Virginia Atlas, VDH, Division of Health Statistics, 2011) Prenatal & Perinatal Health Information

Virginia

Tazewell County

Late Entry into Prenatal Care (after first trimester), % all births

17.3%

46.2%

Prenatal & Perinatal Health Indicators, Tazewell Area, 5-year average, 2006-2010 (Virginia Department of Health, Division of Health Statistics, 2006-2010) Prenatal & Perinatal Health Information Low Birth Weight Births % 5-Yr Average Infant Mortality Rate

Virginia 8 7.1

Tazewell County 11 6.7

Page | 63

Prenatal & Perinatal Health Indicators, Tazewell Area (Virginia Department of Health, Division of Health Statistics, 2011) Prenatal & Perinatal Health Information

Virginia

Tazewell County

Live Birth Rates per 1000 total Population

12.7

9.3

Live Birth Rates per 1000 (White)

11.8

9.5

Live Birth Rates per 1000 (Black)

13.2

4.6

Live Birth Rates per 1000 (Other)

19.7

7.6

Infant Death Rates per 1000 live births

6.7

9.6

5.2

9.8

12.8

n/a

3.8

n/a

Infant Death Rates per 1000 live births (White) Infant Death Rates per 1000 live births (Black) Infant Death Rates per 1000 live births (Other)

Tazewell Area Pregnancy Rate per 1000 Females ages 10-19 (per 1000 births) (Virginia Department of Health, Division of Health Statistics, 2009-2011) Geography

2009

2010

2011

Virginia

24.3

21.1

18.6

Tazewell County

22.1

31.4

20.8

Page | 64

Reported Number of Children Tested for Elevated Blood Lead Levels less than 36 Months old Virginia Department of Health, Lead-Safe Virginia Program, 2011 Virginia

Tazewell County

Elevated Blood Lead Level Testing Rate/1000

209

349

Percent Confirmed Elevated

0.2

0

Infectious Diseases One of the Healthy People 2020 goals is to “promote healthy sexual behaviors, strengthen community capacity, and increase access to quality services to prevent sexually transmitted diseases in their complications.�

Tazewell has a much lower prevalence of HIV and other sexually-transmitted infection rates than Virginia: Less than a quarter of the state prevalence of HIV and gonorrhea, and less than one third the state prevalence of syphillis, and chlamydia. In addition, Tazewell County has not reported any tuberculosis cases in the latest two years available.

HIV Infection Prevalence and Other Sexually Transmitted Infections Rate

Tazewell Area HIV Infection Prevalence, 2011 (Virginia Department of Health, HIV Surveillance Quarterly Report, 2011, http://www.vdh.virginia.gov/epidemiology/DiseasePrevention/DAta/#Profile)

HIV Prevalence Rate

Virginia

Tazewell County

307

65

Tazewell Area Sexually Transmitted Infection Rates (per 100,000) (Virginia Department of Health, Virginia STD Surveillance Quarterly Report, 2011, http://www.vdh.virginia.gov/epidemiology/DiseasePrevention/DAta/#Profile) Geography

Early Syphillis

Gonorrhea

Chlamydia

Virginia

6.4

81.5

431.6

Tazewell County

2.2

17.9

129.7

Page | 65

Tazewell Area Number of Reported Tuberculosis (TB) Rates per 100,000 (Virginia Department of Health, Division of Disease Prevention, 2008 - 2012) Geography Virginia Tazewell County

2008 3.9 2.2

2009 3.5 0

2010 3.4 0

Social Environment The rate of child abuse and neglect in Tazewell County has decreased in the past six years, and is now just slightly higher than the rate in Virginia overall.

Tazewell Area Rate of Child Abuse and Neglect (per 1000 children) (Virginia Department of Social Services, Voices for Virginia's Children, CPS Program and Statistical Reports, 2005-2011) Geography

2005

2006

2007

2008

2009

2010

2011

Virginia

3.9

3.9

3.4

3.3

3.2

3.9

3.3

Tazewell County

10.7

6.9

6.7

4.4

1.1

6.4

4.4

Page | 66

Improvement Implementation Strategy 2014-2016 Carilion Tazewell Community Hospital (CTCH) is a not-for-profit, 56-bed hospital located in the town of Tazewell, in Tazewell County. Tazewell County is an area of 518 square miles with population of approximately 45,700. CTCH offers acute care, 24-hour emergency care, diagnostic procedures, surgical services and comprehensive rehabilitative services. It utilizes a unique Emergency Physician/Hospitalist model for better care coordination.

In January 2013, CTCH began its seven-month Community Health Needs Assessment process. A Community Health Assessment Team (CHAT) was formed, inviting stakeholder agencies across Tazewell County involved in the health of the community, to advise and oversee the process. A total of about 30 participated in the CHAT meetings .

The process was led and informed by Carilion Clinic’s Planning Team. Primary data collection took place in the spring of 2013. Primary data collection included the implementation of a broad-based Community Health Survey, four Focus Group meetings with the target populations and a Stakeholder Survey given to individuals working in health-related areas.

Secondary data were collected through June 2013, including demographic and socioeconomic status as well as key indicators on access to health care, population health status, prevention and wellness, maternal and child health, infectious disease, and the social environment.

How the Implementation Strategy Was Developed Upon compiling all primary and secondary data, a review was conducted to complete a list of health needs identified through the assessment process. The CHAT then came together to prioritize the issues based upon the magnitude and severity of the need, ability to develop resources to address the issue, and the likelihood of improvement.

Target Area and Population The community of Tazewell County, in rural Southwest Virginia, is the service area for the Community Health Needs Assessment. The target population for the Community Health Needs Assessment was defined as those living in Tazewell County, especially vulnerable populations such as those with low-income or chronic disease.

Major Needs and How Priorities Were Established Each member of the CHAT in attendance reviewed the list of needs identified from the primary and secondary research and prioritized the top ten issues based upon the magnitude and severity of the need. Then a determination was made as to ability to focus resources on each issue, and the likelihood of improvement. These rankings were analyzed and combined into the following list: Page | 67

1) 2) 3) 4) 5)

Substance Abuse Prevalence Obesity Prevalence/Lack of Exercise Access to Primary Care Mental Health Disorders/access to psychiatric services High cost of Services to the Uninsured.

The findings clearly demonstrate the need to address substance abuse and psychiatric issues, and obesity prevalence, as well as access to primary care. The high cost of services to the uninsured is impactful to vulnerable populations and was seen by the CHAT to have high feasibility to address.

Description of What Carilion Tazewell Community Hospital Will Do to Address Community Needs To address the needs of the community, Carilion Tazewell Community Hospital will develop a multi-disciplinary team to ensure that resources are aligned with the needs identified during the Community Health Needs Assessment. The team will initially consist of CTCH employees, but add membership from community agencies as needed to ensure improvements are achieved in the identified areas of focus.

In addition, the Town and County of Tazewell recently completed a workshop to kickoff a vision for economic development for the area. This project will lead to the creation of a strategic plan for the town. CTCH will actively participate in this project, in particular on the Community Health subgroup. This will provide a forum for alignment of community resources with identified community needs. Activities recommended for this group are very consistent with the CHNA findings: pilot and experiment with approaches to addressing prescription drug abuse and the Tazewell Wellness Movement.

Lastly, processes will be developed to track progress of improvements, ongoing.

Priority Areas Not being Addressed and the Reasons Multiple other needs were identified during the CHNA process, including dental care for children, access to vision care, transportation and access to in-home care. Dental care is being addressed via the development of a new dental school, already under development. The process used by the CHAT to prioritize needs identified access to vision, transportation and inhome care as lower priorities. The number of items was limited to the top five so that resources are focused and effective.

Page | 68

Conclusion Each year the American Hospital Association (AHA) conducts an Environmental Scan of the state of the health care system in America to provide “insight and information about market forces that have a high probability of affecting the health care field.” In reviewing the 2013 Environmental Scan, each area identified as a focus in the Tazewell CHNA was recognized as an issue at the national level as well.

1) Substance Abuse Prevalence The “Consumers & Demographics” section of the Environmental Scan says, “Nearly half of Americans will develop a mental illness and 27 percent will suffer from a substance abuse problem in their lifetimes. In any given year, 25 percent of the American population experiences either a mental illness or a substance abuse problem.”

2) Obesity Prevalence/Lack of Exercise In the same section of the AHA’s Environmental Scan: “Rates of adult and childhood obesity in the United States vary significantly by region, race, ethnicity and age, but overall rates are high.”

3) Access to Primary Care In the “Provider Organizations & Physicians” section, the 2013 Scan says: “New delivery models are going to be essential, including more primary care-based, easy-access, lowcost models for patients to receive certain services…Relying on the current primary care system (physician offices and hospital EDs is not going to be adequate.”

4) Mental Health Disorders/access to psychiatric services In addition to the quotes above (Substance Abuse Prevalence), the Consumers & Demographics section says, “Treatment capacity for behavioral services is in critically short supply and getting worse.”

5) High cost of Services to the Uninsured The complex issue of health care costs affects insured and uninsured alike. The Insurance & Coverage section of the Environmental Scan states, “Health care costs continue to grow at a faster rate than wages. With the recession as a backdrop, employers sought to moderate their bottom-line impact by continuing to increase the portion of health care costs borne by employees.”

Clearly, the priority health needs identified in Tazewell County are not unique in the country. It will require coordinated efforts from diverse agencies, and innovative thinking to make positive impacts in these areas.

Page | 69

Appendices Appendix 1: Work Plan and Timeline

Step 1: Assessment •Collect Collect and review secondary data •Conduct Conduct stakeholder surveys •Conduct Conduct Target Population Focus Groups •Conduct Conduct Community Health Survey

Step 4: Evaluation (ongoing until next CNHA) Evaluate to determine progress being made on •Evaluate goals and objectives

Step 2: Planning •Review assessment data •Prioritize Health Needs •Develop Develop goals and objectives

Step 3: Implementation •Develop Develop a written implementation strategy (i.e. How the hospital will address needs) •Adoption Adoption of the implementation strategy by the hospital board •Complete Complete the CHNA report and make widely available to the community •Select Select approaches (interventions / strategies) that are most likely to succeed in addressing community health needs •Integrate Integrate the implementation strategy with community and hospital plan •Host Host event in the community to release the results of the CHNA

Form MGMT Team Form CHAT

Planning Phase

Assessment Phase

Implementation Phase

Page | 71

Appendix 2: CHAT Directory Kathren Dowdy, Carilion Tazewell Community Hospital Carol Weaver, Carilion Tazewell Community Hospital Regina Sawyers, Appalachian Agency for Senior Citizens (AASC) Jim Thompson, Carilion Tazewell Community Hospital Board of Directors Mike Hymes, Tazewell County Board of Supervisors Kerry Moore, Southwest Virginia Community Health Clinic Dr. Glenn L. Catron, DMD, Dentist Kathy Mitchell, Tazewell County Health Department Dave Darden, Clinch Valley Medical Center Bill Hawley, Bluefield Regional Medical Center Stephen Rhinehart, MD, Family Physician Jennifer Edwards, Carilion Clinic Family Medicine Tommy Parham, Four Seasons YMCA Susan White, Clinch Valley Community Action Dr. Brenda Lawson, Tazewell County Public Schools Superintendent Tom Hayes, Hayes Drug Store Jim Talbert, Richlands News Press Rita Ward, Lilies of the Field Thrift Store Ann Coates, Tazewell County Department of Social Services Loretta Remines, Carilion Clinic Home Care Norma Bourne, Clinch Valley Community Action - Family Crisis Services DeWitt Cooper, Town of Tazewell Police Chief Patti Cettin, Taking Action for Special Kids (TASK) Dwain Harwick, Abel Crisis Pregnancy Center John Quintier, Heritage Hall Helathcare and Rehabilitation Center Ginger Robinett, Southwest Virginia Community College Cathy Smith-Cox, Southwest Virginia Community College Lynne Bartlett, Tazewell County Public Library

Appendix 3: Stakeholder Survey Tazewell County Professional Informant Survey Barriers and Challenges faced by Residents and Health Care Providers of Tazewell County February 2013 Responses will not be identified, either in written material or verbally, by name or organization.

Thank you!

1. Your name, organization, and title: NAME: ___________________________________________ ORGANIZATION:__________________________________________ TITLE:

___________________________________________

2. Please attempt to list all Tazewell-based organizations involved in direct health care service delivery, or access to health care services (no need to list outpatient medical practices): _________________________________________________ _________________________________________________ 3. Please convey, in your own words, the single greatest challenge faced by your organization, as you attempt to provide/facilitate quality health care delivery to the residents of Tazewell County (3-4 sentences).

________________________________________________________________________ ________________________________________________________________________ 4. Please rank order the below obstacles according to your opinion of HOW GREAT AN OBSTACLE each represents for residents of Tazewell County. There are no right or wrong answers. This is your opinion.

Rank: 1 = most significant/prevalent obstacle; 10 = least significant/prevalent obstacle.

Use the numbers 1 - 10 only once (no ties allowed).

OBSTACLE

RANK

Distance to providers (can’t find transportation; vehicle unreliable) Can’t get away from job/kids to attend medical appointments (clinic/hospital hours don’t work with life schedule) Language barriers (written and verbal) Cultural barriers (literacy levels, customs, fears) Lack of awareness of treatment norms, prevention standards (don’t know when to seek help) Too expensive (can’t afford out-of-pocket costs if uninsured, or copays/deductibles if insured) Shortage of local PRIMARY CARE providers (can’t find a medical home) Shortage of local SPECIALTY health care providers (excluding dental and mental health) Shortage of local DENTAL providers Shortage of local MENTAL HEALTH providers

5. Comment on the above rankings. Why did your #1 obstacle earn the top spot? Why are some obstacles not ranked higher? Please provide a case example of a patient who experienced one of these obstacles (anonymous, of course).

________________________________________________________________________ ________________________________________________________________________

Page | 74

6. In terms of UNMET health care needs of Tazewell County residents, please score each of the following according to this scale: 1 = very serious unmet need 2 = somewhat serious unmet need 3 = less serious unmet need 4 = not an unmet need

HEALTH NEED FOR TAZEWELL RESIDENTS

SCORE (Score each independently, using the numerals 1-4)

Primary health care (medical home) Specialty health care (excluding dental and mental health) Dental care Mental health/addictions care Preventive services Health education (for those with chronic disease) Health navigator services (advocate and guide) Health transportation services Culturally and linguistically appropriate services Affordable medications In-home health care services Hospice care School-based health care Other (specify):

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Other (specify): Other (specify): Thank you for your input!

Questions: Please contact Sharon Honaker, 540-266-6591

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Appendix 4: Community Survey

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Appendix 5: When Asked, “What else do we need to know?� on the Community Health Survey: I am a hospice medical social worker. I see a great need for dental financial assistance with coworkers and families. Also a need for financial assistance for patients with ambulance fees and paid caregivers.

More help for families with working parents. Help for adult insurance for health.

Some way to help the people who work. I was told if I didn't have a job I would have help from Social Services.

Health insurance. Wife was told if you didn't have a job you would get help from Social Services. I think that’s wrong for people who are trying.

Affordable insurance for anyone that can't get it Make insurance affordable and not that Obamacare crap either.

My husband is looking for a job. Just waiting patiently.. need a VA clinic Husband takes kidney dialysis 3x week One of our 4 children is autistic.

Better preventative services & easy lab access.

We need more doctors & practitioners. Also Hospital Care Facilities.

Yes, we need more doctors in Tazewell so Carilion Tazewell Community Hosp. will be utilized. very good hospital Would like it to be easier for someone with low income to get medical care.

My oldest son is disabled; he receives routine tegretol levels and neurological checkups. As had numerous shunt replacements and suffered from a stroke in 2008. no eye care in Tazewell pastor in town Need better hospital in Tazewell, Need a veterans hosp in or near Tazewell Bring us doctors who know what they are doing and who actually care about people and not money.

Need more heart doctors and physicians to take care of the people.

I have home health The problems I have with my health are controlled by medication and doctor care.

Need doctors- tired of seeing only PA's Health providers do not know/try to use insurance very limited on health care choices not a handicap accessible area.

We need more qualified Doctor's in Tazewell. my mom has high BP and high cholesterol I think all health care facilities are not willing to help the elderly. They are mean to them! my boyfriend has high BP & no ins.

Find better doctors outside this area. More advanced in other areas, and care about the patients. More knowledgeable Tazewell Co. has so much prescription drug abuse. If you are really in pain you are subjected to disbelief by MD care givers.

For older women, mammograms should be done by a better method than the x-ray.

We need better doctors, and affordable access to recreation and healthy affordable food.

Needs to be more Free Clinics for people who don't have dental, medical, or vision insurance. RAM needs to occur more once a year at various locations.

Better help with dental for adults & vision as well.

Affordable health insurance. I cannot afford the co-pay for my husband & child to go on my insurance. My husband gets denied for private insurance due to pre-existing condition and we can no longer get child only policy. Because I work & my husband works we don't qualify for any assistance.

If doctors would quit prescribing pain pills like candy, a true emergency would be able to get better, quicker attention in the ER Need to offer an income based dental clinic for adults/children I miss enough work with my children's doctor appointments, getting sick that I do not have access to a doctor

working 8-4:30 myself. We need an evening shift doctor’s office for adults. I feel that would be very efficient in our area. They would have plenty of business with so many working parents in our area.

help for legally blind people Lack good hospital doctors.

I need a back/pain specialist in Tazewell. Right now, I'm having to drive all the way to Bristol to see a doctor.

And I have to drive to West Virginia to see my psychiatrist and therapist.

My daughter is going to school to finish and I help raise my grandson, who is 10 mos old now. I have help raise him since he has been born in my home.

My husband needs a better heart doctor.

Most doctors won't take any new patients A service that would help people with low income excluding SSI. Specialist care for elderly people I feel like doctors don't take enough interest in our older people. They are important no matter what age they are. That goes for government too. A lot are on fixed incomes & they pay a lot out for insurance. They have earned their keep all these years and deserve respect.

New hospital! I lived in Giles Co. 42yrs then moved to Tazewell 2005- had the same hospital but recently Giles Memorial got a new hospital they both were built back in the day.

All ER's in our area have much too long of a waiting period. If you are sick no one feels like waiting 4-5 hrs. for care. Need shorter ER wait time - more primary care doctors.

there is no orthopedic care for this area, we need quality care facility as well as quality physicians We need more doctors in the community for both adult and kids, good ones who care and not the ones who just want to get paid. lack of orthopedic care Too long wait- ER recently know people 4- 10 hr wait- night shift and rude nurses need more primary care physicians We need more affordable assisted living facilities and senior services.

More housing, healthcare, and jobs for felons, unemployed, homeless, etc.

Emergency Room shows no signs of urgency. Wait time is too long.

Knowledge of available care at our hospital - Tazewell Carilion Co-pays and deductable are too high for my income. Can't afford specialty services.

More psychiatric care for community - qualified psychiatrists to come to this area/ Mental Health professionals in general Someone for pediatric cancers My husband has high blood pressure and diabetes type 2 Need a VA Hospital I am a part time nurse, who lost a lot of weight over the last 3 years to improve my health and am pretty healthy at this time.

We need a good heart doctor. My husband has to be transported to VA in Johnson City every time he is sick and I have to be sent to Kingsport. We need better Heart Care in Tazewell.

We need more primary care physicians Specialist and good doctors.

We need more FMD's and a surgeon.

You cannot find a doctor... the ones that are here in Tazewell ARE NOT taking new patients.

The facilities around this area are small, with less modern equipment for testing.

Need have more jobs to provide insurance, more free clinic to where we can get checkups, some in our area.

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If the job market was better, it could contribute to better health. should have prepared more We need a local child neurologist Need exercise & weight control programs local & at a low monthly cost..

Some type of program where they can get medication when you don't have the money to pay for them.

Need more doctors in this area.

We need good mental health care and physicians in mental health.

Faster ER services Insurance premiums are so high it is hard to afford them. Feel like only working for insurance sometimes.

Our area needs more American doctors that may actually care about our healthcare needs.

There are no places for specialty care. I have to drive at least an hour or more to see any of my specialty care physicians.

Need some good doctors and easier access to them. Drs that aren't accepting new patients aren't a lot of help to sick people.

We also need more cancer related treatments in our area Access to equipment for a chairlift I am worried about cont of care Sjogrens gets very difficult. I am bed ridden on some days. Really need local Rheumatologist and therapy.

I am very interested in alternative care Urgent care facility would be a major addition to the Tazewell community. Expansion of Carillion Tazewell Community Hospital would also be a major plus for the community and the county as a whole.

We need an urgent care facility for non-emergency situations.

The other person in my household does not have health insurance We are having to travel over 100 miles one way to see heart specialist and Lung specialists...

Working with hospice patients, I see the need for assistance with their care and physical and emotional support for their caregivers.

I strongly recommend that CTCH provide 24/7 surgical services and trained/qualified security personnel to aid in assuring that patients and staff are provided a safe workplace.

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