TABLEOFCONTENTSSECTION PAGE

1. INTRODUCTIONANDORGANIZATIONALBACKGROUND 1

2. CHNAPROCESSOVERVIEW 3

3. REVIEWOFEXISTINGHEALTHINDICATORS 6

a. CharacteristicsofCountyResidents 7b. SocialandEconomicCharacteristics 7c. QualityofLifeIndicators 8d. HealthOutcomes 9e. ClinicalCharacteristics 10f. MortalityIndicators 11g. BehaviorsandBehavioralFactors12h. Summary 13

4. 2018COMMUNITYCHNASURVEY 14

a. SurveyMethods 14b. SurveyResults 19

i. DescriptionofParticipants 19ii. PerceptionsofHealthandWell-Being22iii. HealthCareAccess&Engagement25iv. PersonalHealth-RelatedBehaviors28v. SocialDeterminantsofHealth28vi. ImportanceofCommunityServices29vii. PerceivedPriorityHealthNeeds30viii. PerceivedPrioritiesforResourceAllocation32ix. ComparisonofNeedsandResources34

5. CHNAFOCUSGROUP 35

6. PRIORITIZATIONPROCESS 38

APPENDICESA. CommunitySurveyB. FocusGroupSummariesC. PrioritizationProcessSlidesD. PotentialCommunityResources

1. INTRODUCTION,ORGANIZATIONALBACKGROUND,ANDSERVICEAREAIntroductionThisreportprovidesacomprehensiveoverviewofthe2018CommunityHealthNeedsAssessment(CHNA)conductedcollaborativelybyRiverviewHealth.ThechaptersofthisreportprovideanoverviewofthemethodsusedtoconducttheCHNA,summariesofexistinghealthindicatordatathatwasreviewed,primarydatathatwascollectedforpurposesoftheCHNA,andadescriptionoftheprocessandoutcomesofaprioritizationprocesstoestablishthehealthprioritiesthatwilldrivethehospital’sactivitiesinthesubsequentyears.AboutRiverviewHealthRiverviewHealthisacomprehensivehealthcarenetworkcomprisedofafull-service,156-bedhospitallocatedinNoblesville,Indianaaswellas25primaryandspecialtycarefacilitieslocatedthroughoutHamiltonCounty.AtRiverviewHealth,morethan350physicians—manyofwhomareboardcertifiedorfellowshiptrained—providehealthcareservicesin35medicalspecialties.Theirexpertise,coupledwithexceptionalspecialistsandnursingstaff,isoneofthereasonsRiverviewHealthisfrequentlyrecognizedforclinicalandserviceexcellence.Theorganization’sgoalistoprovidecompassionate,patient-centeredcaretoeveryoneinthecommunity.RiverviewHealthpromotesaprogressive,nurturingenvironment—andsupportsthecommunitythrougheducationalseminars,screeningsandothereventsaimedathelpingtheindividualandfamilystaywell.AsoneofthelargestemployersinHamiltonCounty,RiverviewHealthplaysanimportantroleinthelocalbusinesscommunityaswell.RiverviewHealthisanonprofitorganizationownedbyHamiltonCounty,thoughitdoesnotreceivetaxdollarsforoperatingexpenses.RiverviewHealthisgovernedbyaseven-memberBoardofTrusteesappointedbytheHamiltonCountycommissionerswhichoverseeshospitalpolicyandstrategicdirection.RiverviewHealthisaccreditedbyanumberofleadingregulatoryagencies,including:

• AmericanAcademyofSleepMedicine(AASM)• AmericanAssociationofBloodBanks(AABB)• AmericanAssociationofCardiovascularandPulmonaryRehabilitation(AACVPR)• AmericanCollegeofRadiology(ACR)• AmericanDiabetesAssociation(ADA)• CollegeofAmericanPathologists(CAP)• CommissiononAccreditationofRehabilitationFacilities(CARF)• CommissiononCancer(CoC)• HealthcareFacilitiesAccreditationProgram(HFAP)• SocietyofChestPainCenters(SCPC)

AbouttheServiceAreaRiverviewHealthprovidesservicestopopulationsinHamiltonCounty,Indiana.TheserviceareadefinedfordatacollectioninthisCHNAwasHamiltonCounty.

2.CHNAPROCESSANDMETHODSCHNAOverviewToconducttheCHNA,thehospitalsworkedwitharangeofcommunityandacademicpartnerstoconductacomprehensivecommunityhealthneedsassessment(CHNA).Thepurposeoftheassessmenttoidentifythesignificanthealthneedsinthecommunityandgapsthatmayexistinservicesprovided.Itwasalsodevelopedtoprovidethecommunitywithinformationtoassessessentialhealthcare,preventivecare,andtreatmentservices.Thisendeavorrepresentseffortstoshareinformationthatcanleadtoimprovedaccesstocareandqualityofcareavailabletothecommunity,whilereinforcingandaugmentingtheexistinginfrastructureofservicesandproviders.CHNAActivitiesandMethodsTheCHNAwasconductedbeginningin2017andbeingcompletedin2018,theresultsofwhicharereflectedinthisreport.Table1providesanoverviewoftheoverallprocessandspecificmethodsrelatedtoeach.Withineachrespectivesectionofthisreport,additionaldetailsregardingmethods,participants,andmeasuresareprovided.CHNAPartnersConductingtheCHNAnecessitatedcollaborationwitharangeofpublichealthandsocialservicepartnerstoensurethatdiversescientificandcommunity-basedinsightswereincludedthroughouttheprocess.Ofparticularimportancewastoensurethatindividualswhodirectlyorindirectlyrepresentedtheneedsofthreeimportantgroupsincluding:1)thosewithparticularexpertiseinpublichealthpracticeandresearch,2)thosewhoaremedicallyunderserved,low-income,orconsideredamongtheminoritypopulationsservedbythehospital,and3)thebroadercommunityatlargeandthosewhorepresentthebroadinterestsandneedsofthecommunityserved.Keypartnerorganizationsincluded:• TheUniversityofEvansville.Faculty,staff,andstudentsinpublichealthareascollaborated

withthehospitalonthedata-orientedaspectsoftheproject.• IndianaUniversitySchoolofPublicHealth.Facultyandstudentscollaboratedwiththe

hospitalthroughoutthesurveyprocess.• IndianaUniversityCenterforSurveyResearch.Facultyandstaffprovidedin-depth

technicalassistanceandguidancethroughoutthesurveyprocess,andworkedcloselywithRiverviewHealthandtheUniversityofEvansvilletofieldthecommunityhealthsurvey.

• MeasuresMatter,LLC.MeasuresMatterisacommunity-basedresearchconsultingfirmbasedinBloomington,IndianaandPalmSprings,California.MeasuresMatterconductedan

independentanalysisofthesurveydataandalsofacilitatedtheprioritizationprocesswiththehospitalanditspartners.

• CountyHealthDepartment.RepresentativesoftheHamiltonCountyHealthDepartmentwereactiveparticipantsintheCHNAactivities.

• CommunityHealthandSocialServiceOrganizations.Awiderangeofcommunity-basedhealthandsocialserviceorganizationscollaboratedthroughouttheCHNAprocesstoconsiderdatafromtheCHNA,makedecisionsregardinghealthpriorities,andinitiateconsiderationsofsubsequentactionsbasedontheCHNA.Inparticular,awideanddiverserangeoforganizationalpartnersandcommunityconstituentsparticipatedinthefocusgroupdiscussions.ListingsofthosecommunitypartnersareincludedintheAppendicessectionofthisreport(AppendixB)andalsolistedinthePrioritizationProcesssectionasapplicable(Section6).

Table1.DescriptionofCHNAActivitiesCHNAACTIVITIES DESCRIPTIONOFACTIVITIES

IdentificationoftheServicePopulation

Hospitalstaffworkedtogethertoidentifyitscommunityservedthroughareviewofpatient-relateddataandothergeographicboundariesrelatedtothehospital'sservicearea.

ReviewofExistingHealthIndicatorData

Incollaborationwithpublichealthresearchers,thehospitalconductedareviewofexistingdataandindicatorsrelevanttothisassessment.Subsequenttothisreviewofdata,keyinsightswereincorporatedintosubsequentCHNAactivitiesandconsideredduringtheselectionofhealthpriorities.

CommunityHealthSurvey

Incollaborationwithnineotherhospitalsystems,healthdepartmentrepresentatives,communityorganizations,andwithfacultyresearchersfromtheUniversityofEvansvilleandIndianaUniversityBloomington,asurveywasdevelopedandconductedtocollectdatafromresidentsinthehospital'sservicearea.Thesurveyprocessincludedarandomsamplethatrecruitedproportionatelyfromallzipcodesintheservicearea.

CommunityFocusGroupDiscussions

ThreecommunityfocusgroupdiscussionswereheldinHamiltonCounty.Thepurposeofthesefocusgroupwastoprovideaforumforin-depthconsiderationofthehealthissuesandpopulationsmostinneedofattentioninHamiltonCounty.

HealthNeedsPrioritizationSession

HospitalstaffheldameetingofkeystakeholdersandorganizationalleadershipinordertoreviewdatafromallactivitiesconductedfortheCHNA.Subsequenttoaformalpresentationanddiscussionofthedata,attendeesinthemeetingparticipatedinanominalgroupprocesstoidentifythetophealthneedsthatwouldinformthedevelopmentoftheimplementationplan.

ReviewofResourcesandPartners

BasedupontheresultsoftheCHNAactivities,alistoflocalresourcesandpartnershipsthatwouldberelevanttoaddressingtheneedsidentifiedviatheCHNAandthesubsequentimplementationplan.

3.REVIEWOFEXISTINGHEALTHINDICATORSIntroductionThissectionofthereportprovidesanoverviewofexistingdataandindicatorsthatofferinsightintothehealthandsocialissuesoftheservicearea.ThesedatawereusedinarangeofwaysthroughouttheCHNAprocess,including:

• toinformthedevelopmentofissuesthatwouldbefurtherexploredinthe2018CHNACommunitySurvey,

• toguidespecificanalysesofdatafromthe2018CHNACommunitySurvey,• toprovidedatasummariesandotherinsightstocommunitymembers,organizational

stakeholders,andHospitalstaffduringCHNArelatedmeetingsanddiscussions,and• asafoundationforthereviewofongoingeffortsandkeydecisionsabouttheservices

offeredbytheHospital.DataSourcesToensureconsistencythroughouttheCHNAprocess,thereviewofexistingdataincludedthemostrecentlyavailabledatarelatedtothefollowingcommunityindicators:

• demographiccharacteristicsofresidentsintheservicearea,• socialandeconomiccharacteristicsoftheservicearea,• leadinghealthoutcomes,• clinicalcharacteristicsoftheservicearea,withafocusonaccesstocare,• qualityoflifeindicators,and• health-relatedbehaviorsandassociatedfactors.

Datapresentedinthissectionofthereportweresourcedfromthe2018versionofCountyHealthRankings&Roadmaps,aprojectofthePopulationHealthInstituteoftheUniversityofWisconsinthatissupportedbytheRobertWoodJohnsonFoundation.DataalsoincludedthosefromtheIndianaStateDepartmentofHealth.Throughoutthesedata,indicatorsarepresentedforthecountyofinterest,thestateofIndiana,andtheTopU.S.Performers(indicatorsthatrepresentthetop10%bestperformingcountiesinthecountry).Whilecomparisonsacrossthesedataarevaluableforidentifyingareasinaparticularcountywhereimprovementscanbemade,suchcomparisonsshouldalwaysbemadewithinthecontextofthevastdifferencesthatexistacrossthecountiesinthecountry.

PopulationCharacteristicsDemographiccharacteristicsofaparticularregionprovideimportantinsightsforthedevelopmentanddeliveryofhealth-relatedservicesandprograms.HamiltonCountyislargelyhomogeneousintermsofracialandethnicitycharacteristicsalthoughitdoeshavealargerAsianpopulationthanthetypicalIndianacounty.Itisevenlysplitwithregardtogender,withlowproportionsofindividualslivinginareasconsideredrural.HamiltonCounty’spopulationof313,373personsissummarizedinTable2.Table2.CharacteristicsofHamiltonCounty’sPopulation

CountyPopulationCharacteristics HamiltonCounty Indiana

PopulationSize 313,373 6,633,053

%Below18yearsofage 27.8% 23.8%%65andolder 11.4% 14.9%

%Non-HispanicAfricanAmerican 4.0% 9.3%%AmericanIndianandAlaskanNative 0.2% 0.4%%Asian 6.0% 2.2%%NativeHawaiian/OtherPacificIslander 0.1% 0.1%%Hispanic 3.9% 6.8%%Non-Hispanicwhite 84.2% 79.6%

%NotproficientinEnglish 1% 2%

%Females 51.2% 50.7%

%Rural 5.60% 27.6%SocialandEconomicCharacteristicsSocialandeconomicfactorsarewellestablishedasimportantdeterminantsofhealthandwell-being.ForpurposesoftheCHNA,thesefactorsprovidevaluableinsightintothecontextofhealthandwell-beingindicatorsandofferafoundationforconsideringthemannerinwhichahospital’sprogramsareconnectedtoawidersocialservicesnetwork.HamiltonCounty’spopulationfaresbetterthanmanycommunitiesinIndiana,withhigherlevelsofeducationalattainment,lowerlevelsofpoverty,andlowerlevelsofunemployment.Thecounty,onmanysocialandeconomicindicators,performsatalevelequaltoorbetterthanthetopU.S.performers.Table3providesasummaryofprimarysocialandeconomicfactorsinHamiltonCounty.

Table3.SocialandEconomicFactors,HamiltonCounty

SocialandEconomicFactors HamiltonCounty TopUSPerformers Indiana

Highschoolgraduation 94% 95% 87%Somecollege 86% 72% 62%Unemployment 3.20% 3.20% 4.40%Childreninpoverty 5% 12% 19%Incomeinequality 3.9 3.7 4.4

Childreninsingle-parenthouseholds 18% 20% 34%

Socialassociations 9.8 22.1 12.3Violentcrime(per100,000) 37 62 356Injurydeaths(per100,000) 37 55 70QualityofLifeIndicatorsSelf-reportedrankingsofoverallhealthstatus,andthenumberofdaysinagivenmonthforwhichindividualswouldratetheirphysicalandmentalhealthasbeingpoor,offerimportantinsightsintothefactorsthatofteninfluenceindividualstoseekcareorsupport,andsharewelldocumentedassociationswithcareoutcomes.Additionally,lowbirthweightiscommonlyusedasagaugefortheexistenceofmulti-facetedpublichealthproblems.HamiltonCountyperformsquitewelloneachoftheseimportantindicatorsasissummarizedinTable4.Table4.QualityofLifeIndicators

QualityofLifeIndicators HamiltonCounty TopUSPerformers Indiana

Poororfairhealth 10% 12% 18%Poorphysicalhealthdays 2.6 3 3.9Poormentalhealthdays 3.0 3.1 4.3Lowbirthweight 7% 6% 8%

HealthOutcomesCommonhealthindicatorsthatprovideinsightintothegeneralhealthstateofacommunityincludeprematuremortality,infantmortality,chronicdisease(diabetes),infectiousdisease(HIV)andbothphysicalandmentaldistress.Ontheseindicators,HamiltoncountylargelyfaresbetterthantheaveragesforthestateofIndiana.However,whilethesevaluesplaceHamiltonCountywithinthetopquartilesofthestateonmostindicators,boththestateandcountyhavesomehealthoutcomesthatareworsethanthetopU.S.performingregionsandsuggestareasforcontinuingimprovement.Table5providesanoverviewoftheseleadinghealthindicatorsforHamiltonCounty.Table5.HealthOutcomeIndicators,HamiltonCountyHealthOutcomeIndicators HamiltonCounty TopUSPerformers IndianaPrematureage-adjustedmortality(per100,000) 210 270 390

Childmortality(per100,000) 30 40 60Infantmortality(per100,000) 4 4 7Frequentphysicaldistress 8% 9% 12%Frequentmentaldistress 9% 10% 13%Diabetesprevalence 9% 8% 11%HIVprevalence(per100,000) 88 49 196ClinicalCharacteristicsOfparticularimportancetothehospitalweredatathathelptoassessandconsiderissuesthatarecloselyalignedwiththenation’sobjectivestocontinueimprovingaccesstocare,reducinghealthcarecosts,andimprovingboththeproportionofthepopulationthathashealthinsurance(particularlychildren)andadherencetopreventivescreeningsandchronicdiseasemonitoring.UninsuredratesinHamiltonCounty,whilesimilartothestateaverage,aresimilartothetopperformingareasoftheU.S.,asisthecasewithmanyotherindicatorsforHamiltonCounty.HamiltonCounty,basedontheavailabilityofhealthcareproviders,ranksamongthebestcountiesinthestate,withtheexceptionofmentalhealthproviders.Otherindicatorsrelatedtopreventivescreeningandchronicdiseasemanagementarewithinthetoprangesofboththestateandnation.Table6providesasummaryoftheseclinicalcharacteristicsofHamiltonCounty.

Table6.ClinicalCareCharacteristics,HamiltonCountyClinicalCharacteristics HamiltonCounty TopUSPerformers IndianaUninsured 6% 6% 11%Uninsuredadults 7% 7% 13%Uninsuredchildren 5% 3% 7%Primarycarephysicians 710:1 1,030:1 1,500:1Dentists 1,350:1 1,280:1 1,850:1Mentalhealthproviders 760:1 330:1 700:1Otherprimarycareproviders 1,566:1 782:01 1,367:1Preventablehospitalstays(per100,000) 33 35 57Diabetesmonitoring 89% 91% 85%Mammographyscreening 70% 71% 62%Healthcarecosts $9,281 $9,992LeadingCausesofMortalityAnexaminationoftheleadingcausesofmortalityprovidesvaluableinsightintothemajorhealthissuesfacingacommunity.Presentedintermsoftheratesofdisease-specificdeathby100,000membersofapopulation,thesedataserveasanindicatoroftheissuesmostlikelytorequiresignificantattentionfromhospitalsandotherhealthandsocialserviceorganizations.Whilethesedataaremortality-specific,theyalsohelptoserveasanindicatorofacommunity’smorbiditygiventhatmanyindividualslivewiththesediseasesforextendedperiodsoftime.Theyalsoprovideahelpfulguidetoprevention-focusedprogramsgiventhatbehavioraldeterminantsoftheseleadinghealthissuesarefairlyunderstood.Table7providesasummaryoftheseindicators.

Table7.MortalityIndicatorsforHamiltonCounty,2016

RATES PER 100,000 Population(Age-Adjusted)

ALLCAUSES 922.14Malignantneoplasms(cancer) 125.61Malignantneoplasmofstomach 1.59Malignantneoplasmsofcolon,rectumandanus 11.41Malignantneoplasmofpancreas 10.00Malignantneoplasmsoftrachea,bronchusandlung 26.52Malignantneoplasmofbreast 9.83Malignantneoplasmsofcervixuteri,corpusuteriandovary 5.47Malignantneoplasmofprostate 7.34Malignantneoplasmsofurinarytract 7.54Non-Hodgkin'slymphoma 3.15Leukemia 5.37Othermalignantneoplasms 37.39

Diabetesmellitus 20.73Alzheimer'sdisease 27.73

Majorcardiovasculardiseases 184.33Diseasesofheart 142.13Hypertensiveheartdiseasewithorwithoutrenaldisease 6.98Ischemicheartdiseases 87.69Otherdiseasesofheart 47.45Essentialhypertensionandhypertensiverenaldisease 4.88Cerebrovasculardiseases(stroke) 34.4Atherosclerosis 0.36Otherdiseasesofcirculatorysystem 2.57

Influenzaandpneumonia 7.68Chroniclowerrespiratorydiseases 38.89Pepticulcer 0Chronicliverdiseaseandcirrhosis 6.69Nephritis,nephroticsyndromeandnephrosis(kidneydisease) 14.85Pregnancy,childbirthandthepuerperium 0.63Certainconditionsoriginatingintheperinatalperiod 3.56Congenitalmalformations,deformationsandchromosomalabnormalities 2.71Suddeninfantdeathsyndrome(SIDS) 0Symptoms,signsandabnormalclinicalandlaboratoryfindings,notelsewhereclassified(excludingSIDS) 3.34Allotherdiseases 130.62Motorvehicleaccidents 5.46Allotherandunspecifiedaccidentsandadverseeffects 25.18Intentionalself-harm(suicide) 12.13Assault(homicide) 0.71Allotherexternalcauses 1.26

ICD 10 Description of Mortality Causes

Source:IndianaStateDepartmentofHealth,EpidemiologyResourceCenter.SummaryProducedSeptember12,2017

BehavioralFactorsForpurposesoftheCHNA,arangeofleadinghealthbehaviorindicatorswereassessed.Eachoftheselectedindicatorsshareimportantassociationswithleadingcausesofmorbidityandmortalityinthecountry.Table8providesanoverviewoftheleadinghealthbehaviorsthatnotonlyofferinsightsintothebehavioraldeterminantsofleadinghealthchallengesinHamiltonCountyandopportunitiesfortheongoingdevelopmentandimplementationofhealthandsocialserviceprograms.Table8.HealthBehaviorsandBehavioralOutcomes,HamiltonCountyHealthBehaviors HamiltonCounty TopUSPerformers IndianaAdultsmoking 13% 14% 21%Adultobesity 27% 26% 32%Foodenvironmentindex 8.8 8.6 7Physicalinactivity 16% 20% 27%Accesstoexerciseopportunities 89% 91% 77%Excessivedrinking 20% 13% 19%Alcohol-impaireddrivingdeaths 24% 13% 22%Sexuallytransmittedinfections 204.5 145.1 437.9Teenbirths 8 15 30Table9alsoprovidesanoverviewofadditionalbehavioralfactorsthatareimportantforthecontextoftheCHNAactivities.Table9.OtherBehavioralFactors,HamiltonCountyOtherBehavioralFactors HamiltonCounty TopUSPerformers Indiana

Foodinsecurity 9% 10% 14%

Limitedaccesstohealthyfoods 4% 2% 7%

Drugoverdosedeaths(per100,000) 11 10 20

Motorvehiclecrashdeaths(per100,000) 5 9 12

Insufficientsleep 30% 27% 36%

SummaryAreviewofleadingindicatorsrelatedtothehealthandwell-beingofacommunityprovidesanimportantfoundationfortheremainingCHNAactivities.Thesedataofferinsightsintothefactorsunderlyingthehealthissuesthatareperceivedbyproviders,organizationalstakeholders,andcommunitymembersasbeingamongthoseneedingpriorityattention.ThesedatasummarieswereusedduringsubsequentCHNAactivities,receivingparticularattentionduringtheprioritizationprocessthatisdescribedinsectionsixofthisreport(PrioritizationProcess).

2018COMMUNITYCHNASURVEYSurveyMethods

PurposeoftheSurveyTocollectprimarydatafromresidentsofcommunitiesinthehospital’sserviceareaofHamiltonCounty,asurveywasdesigned,fielded,andanalyzed.Thissectionofthereportincludesadescriptionofthesurveymethodsandtheresultsoftheresponsestothesurvey.SurveyDevelopmentTodevelopthesurveyusedfortheCHNA,thehospitalpartneredwithfacultyfromIndiana-baseduniversitieswhohadparticularexpertiseincommunity-basedsurveyresearch.Dr.WilliamMcConnelloftheUniversityofEvansvilleservedastheleadresearcherontheproject,inpartnershipwithDr.MichaelReeceandDr.CatherineSherwood-Laughlin(bothoftheIndianaUniversitySchoolofPublicHealth).TheUniversityofEvansvillecontractedwiththeCenterforSurveyResearch(CSR)atIndianaUniversitytoadministerthissurvey.ThesurveywasconductedwithapprovaloftheInstitutionalReviewBoard(IRB)oftheUniversityofEvansville.Planninganddevelopmentforthesurveybeganinthewinterof2017.TheuniversityfacultyjoinedacollaborativeofeightmajorhospitalsystemsthatservedpopulationsinIndianaandIllinois.Agoalofthecollaborativewastoalignsurveyactivitiesinordertoincreasecost-efficiencyandtoworktowardthedevelopmentofadatainfrastructurethatwouldbeusefulacrossthesystemsandalsoofenhancedutilitytothehealthandsocialserviceorganizationswithwhichthosehospitalspartneroninitiativestoimprovehealthintheirrespectivelocalcommunities.Usingaconstruct-basedapproachthatidentifiedtheleadingareastobeincludedonthesurvey,thehospitalsandfacultydevelopedasurvey.ThesurveyincludedmeasuresthathadbeenvalidatedforuseinsimilarprojectsbyotherresearchersandadditionalmeasuresthatweredevelopedbythepartnersforspecificneedsofthisCHNA.Thesurveycoveredtenmajorareas.Table10providesanoverviewoftheconstructscoveredinthesurveyandadescriptionofthemeasuresassociatedwitheachconstruct.AcopyofthesurveyisincludedasAppendixA.SampleDevelopmentDatawerecollectedviaarandomsampleofindividualsrepresentativeofthehospital’sservicearea.ThetargetpopulationforPhaseIofthe2018CommunityHealthNeedsAssessmentSurveyconsistedofnoninstitutionalizedadultresidents,aged18yearsorolder,inthecatchmentareastheparticipatinghospitals.Samplingwasperformedonahouseholdbasisusinganaddress-basedsample.

Table10.SurveyConstructsandMeasures

Thefacultycollaboratedwiththehospitalstodeterminecatchmentareasusingcountyandzipcodeboundaries.Geographicareasthatweresharedbetweenhospitalswerereducedsuchthateachgeographicareawassampledonetime.Samplingwasdeterminedusingamultistagesamplingdesign.Atthefirststage,sampleunitsweredrawnrandomlyfromanaddress-basedsamplingframeofeacharea.SampleframeswerelimitedtoresidentialaddressesexcludingP.O.boxes(unlessmarkedinthesampleframeas‘onlywaytogetmail’),seasonal,vacant,throwback,anddrop-offpointaddresses.Atthe

SURVEYCONSTRUCTS DESCRIPTIONOFMEASURES

Demographics Thissectionincludedmeasuresrelatedtothesocio-demographicsofthesurveyparticipants,including:countyofresidence,age,gender,ethnicity,race,education,householdincome,employment,andnumberofadultsandchildreninhousehold.

PerceivedHealthandWell-Being

ThissectionincludedarevisedversionoftheU.S.CentersforDiseaseControlandPrevention'sHealth-RelatedQualityofLifemeasure.Itemsincludedthesingle-itemHRQOLassessmentofperceivedoverallhealthandadditionalassessmentsofphysicalhealth,mentalhealth,andsocialwell-being.Alsoincludedwasameasureofoveralllifesatisfactionandameasureofcurrentleveloflifestress.

HealthCareCoverageandRelationships Thissectionincludedasinglemeasureofwhethertheparticipanthadhealthinsuranceorsomeothertypeofcoverageforhealthcareandasinglemeasureofwhethertheyhadacurrentpersonalhealthcareprovider.

HealthCareEngagement Thissectionincludedameasurerelatedtothetypesofcarewithwhichtheparticipanthadengagedintheprevious12months.Atotalof14specifictypesofhealthcareengagementwereassessed.

Health-RelatedBehaviors Thissectionincludedameasurethataskedparticipantstoself-reporttheirparticipationinarangeofhealth-relatedbehaviors.Atotalof11healthbehaviorswereassessed.

HealthCareResourceChallenges

Thissectionincludedmeasuresrelatedtotheextenttowhichparticipantshadfoundthemselvesinneedofavoidingcareduetoalackoffiscalresources.Specificallyassessedwastheextenttowhichparticipantshadtoforegothreetypesofhealthcare,includingseeingamedicalprovider,fillingaprescription,andsecuringtransportationforahealthpurposeorappointment.

FeltSocialDeterminantsThissectionincludedmeasurestoassesstheextenttowhichparticipantsfelttheimpactoftenspecificsocialdeterminants,includingeconomics,education,communitycohesion,policy,environment,housing,psychosocial,transportation,socialecological,andemployment.

PerceivedPriorityHealthNeeds Thissectionincludedameasuretoassessparticipants'perceptionsoftheimportanceof21healthissuestotheirlocalcommunity.

PerceivedResourceAllocationPriorities Thissectionincludedameasuretoassessparticipants'perceptionsoftheextenttowhich21healthissueswereofpriorityfortheallocationofresourcesintheirlocalcommunity.

PerceivedImportanceofSocialandHealthServices Thissectionincludedameasuretoassesstheextenttowhichparticipantsperceived20differenthealthandsocialserviceprogramstobeofimportancetotheircommunity.

secondstage,awithin-householdrespondentwasselectedbyaskingtheadultwiththemostrecentbirthdaytocompletethesurvey.Todevelopthehospital’ssamplearea,asetof4,445address-basedrecordsrepresentingthehospital’sservicepopulationwerepurchasedfromMarketingSystemsGroup(MSG).MSGusedproprietarysamplingmethodsandprovidedassuranceofappropriateandaccuratecoverageforthetargetpopulation.ThesamplelistdeliveredbyMSGincludedpostaladdressinformation,FIPScode(countydesignator),andappendeddemographicinformationforage,gender,Hispanicsurname,Asiansurname,numberofadultsataddress,numberofchildrenataddress,householdincomeclass,maritalstatus,ethnicity,andhomeownershipstatus.Uponreceiptofthesample,itwasstoredinasecuredatabasecreatedandmaintainedbytheCSRandwasreviewedandcorrectedforanyclericalerrors.Usingtheserecords,arecruitmentsamplewasconstructedforthehospital’sservicepopulation.DataCollectionThequestionnairewasprintedasafour-pagebookletonasingle11”x17”sheetwithafoldinthecenter.Eachquestionnairewasprintedwithaunique,numericsurveyidentifierthatmatcheduparecordinthesample.Aseparatesheetwasfoldedoverthequestionnaireandprintedwithacoverletter,studyinformationsheet,andreturnmailinginstructions.Thequestionnairepacketwasassembledina9”x12”windowedenvelopeandincludedan8¾”x11½”postage-paid,businessreplyenvelopeforsurveyreturns.Thefieldperiodforthe2018CommunityHealthNeedsAssessmentSurveywasApril2,2018,throughJune29,2018.Eachsampledaddressreceiveduptotwoquestionnaireattempts.TheaddressesweredividedintofourbatchesbasedonUSPSpre-sort,andeachbatchwasmailedoneatatimeoverthecourseofatwo-weekperiod.Thesecondquestionnaireforeachaddresswasmailedapproximately4weeksafterthefirstquestionnaire.Theaddressesofreturnedquestionnaireswereexcludedfromthelistsforthesecondquestionnaireattempt.Afterthesecondquestionnaireattempt,apostcardfollow-upwasreintroducedinhopesofincreasingresponse.Inadditiontoremindingpeopletomailintheircompletedquestionnaires,thepostcardalsoprovidedawebsiteaddressthatallowedpeopletotakethesurveyonlineasamemberofthesecondaryconveniencesample.PaperquestionnaireswerereturnedtoCSRinpostage-paid,businessreplyenvelopesprovidedinthequestionnairepacket.Completedsurveyreturnswerecounted,checkedforunclearmarks,batchedingroupsof50surveys,andscannedintoABBYYFlexiCaptureOCRsoftwarefordataprocessing.CSR’sscanningpartner,DataForce(dbaMJT,US),receivedthescannedsurveyimageselectronicallyandreviewedthedataviaABBYYFlexiCapturedataverificationsoftwaretoensurequalitycontrol.Missingresponsesandmultipleresponsestoasingleitemwereflagged.ThecompileddatawastransmittedbacktoCSRviaasecurefiletransferprotocol(SFTP)server.

DataManagementAllsurveyswerereturnedtoCSRforscanningandorganization.DatafileswerestoredbyCSRonasecurefileserverandprocessedusingRstatisticalprogrammingsoftware.Respondent-providedcountiesandzipcodeswerecross-checkedagainstthesamplefile.Discrepanciesandmisspellingswereverifiedagainsttheoriginalscannedimageoftheresponseand,ifreasonablysimilar,correctedpriortofinaldatasubmission.Afterdataprocessing,identifierstoallowfilteringbyhospitalcatchmentareaandweightingvariableswereadded(onlyfortherandomsample).ThefinaldatasetwasconvertedtoaformatforanalysisinSTATAstatisticalanalysissoftwareandtransmittedtotheresearchersviaSlashtmp,IndianaUniversity’ssecurefiletransfersystem.WeightingofSamplesThissectionprovidesanoverviewofweightingactivitiesforthe2018CommunityHealthNeedsAssessment.Twoweightingadjustmentsweremadetoenhanceconsistencybetweenthesurveysampleandthecharacteristicsofthehospital’sservicepopulation.Thefirstwasabaseweightadjustmenttoaccountforunequalprobabilitiesofselectionwithinhousehold.Thesecondwasapost-stratificationadjustmenttoU.S.CensusBureau2012-2016AmericanCommunitySurveyfive-yearpopulationestimates.Thetwoweightingadjustmentsweremultipliedtocalculateapreliminaryfinalweightforeachhospital’scatchmentarea.Thesepreliminaryweightswerethentrimmedandscaledsothatthefinalweightssummedtothenumberofrespondentsineachcatchmentarea.DatasetpreparationandweightingactivitieswereconductedusingSASVersions13.1and14.1andExcel.AmericanCommunitySurveydatawereobtainedusingAmericanFactFinder(https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml).SurveyResponsePatternsRegardingtherandomsample,ofthe4,445address-basedrecordsreceivedduringsampleconstruction,4,113weredeemedeligibleforparticipationinthesurveyandreceivedrecruitmentmaterialsbymail.Ofthosehouseholds,atotalof505returnedacompletedsurvey.TheresponserateforHamiltonCountywasthus12.28%.Table11providesanoverviewofsurveyresponsesbyzipcodesincludedinthehospital’sservicepopulation.DataAnalysesDataanalyseswereconductedbyMeasuresMatter,LLC,aresearchconsultinggroupwithexpertiseincommunity-basedparticipatoryresearch.Priortoanalyses,MeasuresMatterstaffconsultedwiththehospitaltodevelopapreliminaryplanfortheanalysisofdataandthepresentationofresults.Toretaintheintegrityofthephaseonerandomsampleandthemethodologicalrigorofferedbythatsample,analyseswereconductedseparatelyforthephaseonerandomsampleandthephasetwoconveniencesample.

Table11.HamiltonCountyResponsePatternsbyZipCode

County/Zip CountofRespondentHouseholdsCountofHouseholdsAssumed

Eligible ResponseRateHAMILTON 505 4113 12.28%46030 1 26 3.85%46031 1 19 5.26%46032 89 652 13.65%46033 73 463 15.77%46034 9 88 10.23%46037 55 526 10.46%46038 67 544 12.32%46040 5 64 7.81%46055 1 35 2.86%46060 60 553 10.85%46062 54 461 11.71%46069 13 72 18.06%46074 50 445 11.24%46077 2 21 9.52%46250 1 6 16.67%46256 2 15 13.33%46260 0 1 0.00%46280 21 119 17.65%46290 1 3 33.33%Total 505 4113 12.28%

SURVEYRESULTS

DescriptionofParticipantsAtotalof505participantsreturnedacompletedsurveyfromthephaseonerandomsample.Inthissectionofthesurvey,theprimarypresentationofresultsincludesthese505individualsfromtherandomsample.CountyofResidence.Ofthe214participants,95.3%(n=481)indicatedthattheirprimaryresidencewaslocatedinHamiltonCounty.AlthoughallhouseholdsreceivingthesurveywerelocatedinHamiltonCounty,someparticipants(4.8%,n=24)refusedtoprovidetheircountyofresidenceorindicatedthatitwaslocatedinanadjacentcounty.Figure1providesanoverviewoftheparticipants’reportedcountyofresidence.AdultsandChildreninHousehold.Participantswereaskedtoindicatethenumberofadults(18yearsandover)andchildren(under18years)wholivedintheirhousehold.Oftheparticipants,76.1%(n=374)indicatedthattwoorfeweradultslivedinthehousehold.Ofthoseprovidingaresponsetothequestionaboutchildreninthehousehold,themajority(54.2%,n=274)indicatednochildrenundertheageof18yearsinthehome.Someparticipantsdidreportchildreninthehome,withmost(34.6%,n=174)indicatedtwoorfewerchildrenandonlyasmallproportion(10.3%,n=52)reportingthreeormorechildreninthehome.Gender.Participantswereaskedtoreporttheirgender.Morewomenparticipatedinthesurveythandidmen,andfewrefusedtorespondtothequestionaboutgender.Figure2providesanoverviewofparticipantgender.Mostparticipantsintheconveniencesamplewerealsowomen.

Figure1.Participant’sReportedCountyofResidence,by%ofParticipants

95.3

1.0 3.80.0

20.0

40.0

60.0

80.0

100.0

120.0

Hamilton Other Unknown

SurveyParpcipants'ReportedCountyofHousehold,%(n=505)

Hamilton

Other

Unknown

Figure2.ReportedGenderofSurveyParticipants,by%ofParticipants

Age.Participantswereaskedtoprovidetheyearinwhichtheywereborn.Thosedataweresubsequentlyanalyzedtocomputetheestimatedageoftheindividualatthetimethesurveywasreturned.Figure3providesacategoricaloverviewoftheageofparticipants

Figure3.ReportedAgeofParticipants,by%inYears

41.1

58.4

0.40.0

10.0

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50.0

60.0

70.0

Male Female NotAnswered

ReportedGenderofSurveyParpcipants,%(n=505)

18.1

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65+ 50-64 35-49 24-34 Under24

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tofP

arpcipants

AgeinYears

AgeofSurveyParpcipants,%(n=504)

Race.Participantswereaskedtorespondtoaquestionregardingtheracewithwhichtheidentify.Participantswereinvitedtoselectmorethanonerace.Thevastmajority(92.2%,n=465)indicatedthattheywereof“Caucasian/White”race,with1.6%(n=8)describingtheirraceas“Black/AfricanAmerican”and5.6%(n=28)describingtheirraceas“Asian.”Lessthanonepercentselectedanyotherrace.Figure4providesanoverviewoftheracecharacteristicsandthoseindicatingtheirethnicityasHispanic.

Ethnicity.ParticipantswereaskedwhethertheywereofHispanic,Latino,orSpanishorigin.Slightlylessthanthreepercentofparticipants(2.5%,n=13)respondedintheaffirmative.

Figure4.ReportedRaceandEthnicity,byCategory%HouseholdIncome.Participantswereaskedtorespondtoaquestionregardingthetotalincomeofthehouseholdinwhichtheylived(includingallsources).Sevenparticipantsdidnotprovidearesponsetothisquestion.Asmallproportionofparticipants(6.7%,n=34)reportedtotalhouseholdincomeoflessthan$35,000.00,more(17.3%,n=87)reportedincomeofbetween$35,000.00and$74,999.00,andthelargestproportion(72.4%,n=366)reportedtotalhouseholdincomeof$75,000.00ormore.Figure5providesacategoricalsummaryofthereportedhouseholdincomeofparticipants.

92.2

1.6 5.6 1.7 2.50

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50

60

70

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90

100

Caucasian BlackorAfricanAmerican

Asian Other Hispanic

ReportedRace ReportedEthnicity

Percen

tofP

arpcipants

ReportedRaceandEthnicityofSurveyParpcipants,%byEach(n=500)

Figure5.ReportedTotalHouseholdIncome,byCategory%

LevelofEducation.Participantswereaskedtoreporttheirhighestlevelofattainededucationbasedonspecificcategories.Aproportionofparticipants(47.0%,n=395)reportedhavingcompletedanassociate’sorbachelor’sdegreefromacollegeoruniversityand35.4%(n=179)reportedhavingattainedagraduateorprofessionaldegree.Others(10.5%,n=53)indicatedthattheyhadadiplomaorcertificatefromatechnicalorvocationalschoolorthattheyhadcompletedsomecollege.Also,4.1%(n=20)reportedhavingreceivedahighschooldiplomaorGED,andonly1.4%(n=7)reportedthattheyhadsomehighschooleducationbuthadnotgraduated.Someindividuals(1.5%)chose“other”withoutclarificationandonparticipantchosenottoprovidearesponsetothisquestion.Employment.Participantswereaskedtodescribetheiremploymentstatus.Mostparticipantswereemployedfull-orpart-time(68.8%,n=348)and2.8%(n=14)describedthemselvesasunemployed.Others(16.4%,n=83)wereretired,7.3%were“homemakers,”and2.9%reportedbeingstudents.Participants’PerceptionsofHealthandWell-BeingParticipantswereaskedtorespondtofourquestionsthatsoughttocapturetheirperceptionsoftheircurrenthealthstatus.Participantswereaskedtoprovideanassessmentoftheiroverallhealth,theirphysicalhealth,theirmentalhealth,andtheirsocialwell-being.Additionally,participantswereaskedabouttheiroveralllifesatisfactionandtheirlevelofstress.Whileresponsestoeachareaassessedaredescribedbelow,Figures6,7,and8provideasummaryoftheparticipantresponses.

1.7 2.3 2.7

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11.1

16.8

27.328.3

0.0

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10.0

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Lessthan$15,000

$15,000-$24,999

$25,000-$34,999

$35,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000-$149,999

$150,000orMore

Percen

tofP

arpcipants

TotalHouseholdIncome,%(n=488)

OverallHealth.Participantswereasked“Wouldyousaythatingeneral,youroverallhealthis-”withfiveresponseoptionsrangingfrompoortoexcellent.Mostparticipantsratedtheiroverallhealthasverygood(41.7%,n=211),excellent(24.2%,n=122),orgood(24.4%,n=123).Theremainderassessedtheiroverallhealthasbeingfair(6.7%,n=34)orpoor(1.0%,n=5).PhysicalHealth.Participantswereasked“Wouldyousaythatingeneral,yourphysicalhealthis…”withfiveresponseoptionsrangingfrompoortoexcellent.Despitethevastmajoritywhoreportedtheiroverallhealthasbeingpositive,participantsdifferentiatedtheirlevelofhealthmorewhenbeingspecifictotheirphysicalhealth.Lessthanone-quarterofindividualscollectivelyratedtheirphysicalhealthasverygood(8.8%,n=45)orexcellent(1.3%,n=6).Largerproportionsofparticipantsratedtheirhealthasgood(32.0%,n=162),orfair(38.3%,n=193),withtheremainderratingtheirphysicalhealthaspoor(19.5%,n=98).MentalHealth.Participantswereasked“Wouldyousaythatingeneral,yourmentalhealthis…”withfiveresponseoptionsrangingfrompoortoexcellent.Themajorityofparticipantsratedtheiroverallhealthasverygood(40.9%,n=206),excellent(35.0%,n=117),orgood(19.5%,n=98).Theremainderassessedtheiroverallhealthasbeingfair(4.5%,n=23)orpoor(0.2%,n=1).SocialWell-Being.Participantswereasked“Wouldyousaythatingeneral,yoursocialwell-beingis…”withfiveresponseoptionsrangingfrompoortoexcellent.Themajorityofparticipantsperceivedtheiroverallsocialwell-beingtobelessthangood,withthelargestproportionofallparticipantsrespondingfair(41.2%,n=208)and36.1%(n=182)respondingwithpoor.Remainingparticipantsratedtheirsocialwell-beingasgood(19.4%,n=98),withtheremainderrespondingwithverygood(2.9%,n=14)orexcellent(0.4%,n=2).

Figure6.Participants’PerceptionsofHealthandWell-Being

7.7

90.4

57.8

42.1

4.7

95.3

77.3

22.6

0

20

40

60

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100

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Poor-Fair Good-Excellent

Poor-Fair Good-Excellent

Poor-Fair Good-Excellent

Poor-Fair Good-Excellent

OverallHealth PhysicalHealth MentalHealth SocialWell-Being

PercentofParticipants

PerceptionsofPersonalHealthandWell-Being,%(n=505)

OverallLifeSatisfaction.Participantswereaskedtorespondtoasinglequestion“overallIamsatisfiedwithmylife”withfiveresponseoptionsrangingfromstronglydisagreetostronglyagree.Figure7providesanoverviewofresponsestothisitem.LevelofLifeStress.Participantswereaskedtoranktheircurrentleveloflifestressbyrespondingtoasingleitem“Pleaserankyourselfonascaleof1to10where1meansyouhave“littleornostress”and10meansyouhave“agreatdealofstress.”Figure8providesthepercentageofrespondentswhorankedthemselvesonthismeasure.

Participantsintheconveniencesampletendedtoreporthigherlevelsofstress,with29.9%describingtheirstressasbeinginthetoplevels(greaterthan8onscaleof1-10).Regardinglifesatisfaction,20.2%ofthoseintheconveniencesampledisagreedwiththestatement“overallI

amsatisfiedwithmylife.”

Figure7.ParticipantsAgreementwithLifeSatisfactionItem

11.4

2.9

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0

10

20

30

40

50

60

70

80

90

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Disagree Neutral Agree

PercentofPaticipants

Overall,IamSatisfiedwithMyLife,%,(n=505)

Figure8.RankingofLevelofLifeStressHealthCareAccessandEngagementParticipantswereaskedtorespondtoarangeofquestionsrelatedtotheircurrentlevelofhealth-carecoverageandalsoaskedtodescribethetypesofengagementtheyhadwiththehealthcaresystemintheircommunitywithinthe12monthspriortothesurvey.Alsoassessedwaswhetherparticipantshadfoundthemselvesinsituationswithinthepastyearthatmadeitnecessarytoforegosomelevelofhealthcarebasedonalackoffinancialresourcesorbecausetheyhadtoprioritizeothermatters. InsuranceorHealthCareCoverage.Participantswereasked“doyoucurrentlyhaveinsuranceorcoveragethathelpswithyourhealthcarecosts?”Oftheparticipants,thevastmajority(96.3%n=486)reportedthattheydidhavesuchcoverageorinsurance,while3.2%(n=16)responded“no.”Theremainingthreepercenteitherdidnotknowwhethertheyhadcoverageordidnotrespondtothisquestion. CurrentPersonalProvider.Participantswereasked“doyoucurrentlyhavesomeonethatyouthinkofasyourpersonaldoctororpersonalhealthcareprovider?”Mostparticipantsindicatedthattheydidhavesuchapersonalprovider(84.0%,n=424),while15.5%(n=78)responded“no.”Figure9providesanoverviewoftheresponsestothequestionsaboutinsuranceorhealthcarecoverageandthepresenceofapersonalhealthcareprovider.

0

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1 2 3 4 5 6 7 8 9 10

PercentofParticipants

Little orNoStress GreatDealofStress

LevelofLifeStress,%(n=505)

Figure9.Participants’ReportedInsuranceandPersonalProviderCharacteristicsHealthcareEngagement.Participantswereprovidedwithalistof14health-relatedservicesandtypesofhealthcareengagementandaskedwhethertheyhadreceivedorutilizedeachofthosewithinthepast12months.Table12providesasummaryoftheparticipants’responsestothisquestion,orderedfromthehighesttolowestlevelsofcareengagement.Table12.Participants’ReportedTypesofHealthCareEngagement(n=505)

TypeofHealthcareEngagement ReceivedPast12Months(%)

DidNotReceivePast12Months(%)

FilledPrescription 73.2 26.8DentalCare 70.2 29.8PhysicalExam 67.6 32.4ImmunizationsorPreventiveCare 51.3 48.7AcuteCare 31.0 69.0ChronicCare 17.4 82.6UrgentCare 16.3 83.7CareatEmergencyRoom 10.6 89.4PrenatalCare 9.9 90.1ScreenedforAnxietyorDepression 8.6 91.4

HospitalInpatientCare 8.4 91.6MentalHealthTreatment 7.3 92.7FamilyPlanningCare 5.5 94.5AddictionTreatment 1.4 98.6

96.3

84

76 78 80 82 84 86 88 90 92 94 96 98

Yes,HaveInsuranceorCoverage

Yes,HavePersonalHealthCareProvider

Percent ofParticipants Indicating"Yes"

HealthCareCharacteristics,%,(n=502)

ResourcesandHealthcareEngagement.Participantswereprovidedalistofthreetypesofhealthcareengagementneedsincludingseeingaprovider,fillingaprescription,andfindingtransportationforcareandaskedtoindicatewhethertherehadbeenatimewithinthepast12monthsthattheycouldnotactuponthatneedbecause“theycouldn’tafforditorhadtoprioritizespendingmoneyonsomethingelse.”Lessthan20%ofparticipantsindicatedthatithadbeenthecasethattheyprioritizedsomethingovertheirhealthcareacrossthethreetypesassessed.Figure10presentsthisdata.Regardingseeingamedicalprovider,10.8%ofparticipants(n=55)indicatedthattheyhadaneedtoseeaproviderbutdidnotduetootherneeds.Regardingneedingtofillaprescription,11.8%,(n=60)indicatedthatthattheyhadaneedtoavoidfillingaprescriptionduetootherneeds.Regardingneedingtransportationforhealthcare,lessthanonepercentofparticipantsindicatedthattheyhadnotbeenabletoaccesstransportationduetootherneeds.

Figure9.Participants’ReportsofResourceChallengesandHealthCare

10.8

11.8

0.70

2

4

6

8

10

12

14

SeeingaMedicalProvider FillingaPrescription SecuringTransportation forHealthCare

PrioritizedSomethingOverMyHealthCare,PastYear,%(n=492)

SeeingaMedicalProvider

FillingaPrescription

SecuringTransportationforHealthCare

DuringPast12Months,INeeded (oneofthefollowing)ButCouldn'tAffordItor

HadtoPrioritizeOtherThings

PersonalHealth-RelatedBehaviorsOfinterestwasunderstandingtheextenttowhichparticipantshadparticipatedincertainbehaviorswithinthepast30days.Consideredwerebehaviorsthatwereconceptualizedashealthpromoting(e.g.,behaviorsperceivedbythehospitaltobesupportiveofone’shealthandwell-being)orhealthchallenging(e.g.,behaviorsperceivedbythehospitaltobechallengingtoone’shealthandwell-being).Table13providesasummaryofparticipants’self-reportedbehaviors.Table13.Participants’Self-ReportedHealthBehaviorsPast30Days(n=505)

HealthPromotingBehaviors %ReportingBehavior

CheckedBloodPressure 38.2GettingPlentyofSleep 56.1BeingPhysicallyActive 58.1EatingBalancedDiet 64.9TriedtoReduceStress 26.9TookPrescriptionforMentalHealth 15.5

HealthChallengingBehaviors %ReportingBehavior

UsedTobacco 3.9TookOpioidPrescribedtoMe 4.6TookOpioidNotPrescribedtoMe 0.3DrivingIntoxicated 0.7 SocialDeterminantsofHealthThoseconductingtheCHNAwereparticularlyinterestedinabetterunderstandingofwhetherparticipantsperceivedthatcertainsocialissues(oftenconsideredtobedeterminantofhealthstatus)wereimpactingtheirlives.Participantswereprovidedwithalistof10statementsandaskedtoreporttheextenttowhichthatstatementappliedtothem.Eachstatementreflectedaparticularsocialdeterminantofhealth.Thepurposeoftheseitemswastoassesstheextenttowhichparticipants“felt”specificcharacteristicsofsocialfactorsknowntoinfluencehealthoutcomes.Toassessthese,someitemswerewordedpositively.Forexample,“IfeelsafeintheplacewhereIlive”isapositivelywordeditemandthosereporting“never”or“seldom”tothatitemareamongthosewhohaveidentifiedasocialfactorthatcouldbeacteduponinthehealthandsocialservicesinfrastructuretoworkwithanindividualtohasconcernsabouthisorherhousingsituation.Negativelywordeditemslike“Iworryaboutbeingabletopaymyrentormortgage”areconsideredattheotherendoftheresponseoptions,withthoseresponding“sometimes,”

“often,”or“always”beingamongthosewhomightbenefitfromeconomicoremploymentassistanceinwaystoreducetheimpactonhealth.Consistentlyacrosstheseitems,thereweresixparticipantswhodidnotrespondtoeachitemandthoseparticipantswerenotincludedinthesummaryprovided.Table14providesanoverviewoftheextenttowhichparticipantsperceivedthosestatementstobeamongthosethatappliedtothem.Highlightedinthistablearethesocialdeterminantswithendorsementof10%orgreaterthat,inatypicalsocialservicesetting,wouldindicateaneedforfurtherconsideration,discussion,ortriage.Table14.Participants’ReportsofFeltSocialDeterminants(n=501)

ImportanceofCommunity-BasedHealthandSocialServiceProgramsParticipantswereaskedtoprovidetheperspectivesontheextenttowhichhealthandsocialserviceprogramsareimportanttotheirlocalcommunity.Duringthesurvey,participantswereprovidedwithalistof20differentprogramsthatareoftenpresentinmanycommunities.Participantswereinconsistentwithregardtotheextenttowhichtheyprovidedanassessmentofeachprogramtype.Asaresult,resultsfromparticipantswereusedtocalculaterankingsofprogramendorsement.Ofthetwentyprograms,approximatelytwo-thirdswererankedasbeingeithermoderatelyorveryimportantbymorethan50%ofparticipants.Whiletheseresultsdoprovidesomeinsightintothetypesofprogramsperceivedasmostimportantintheirlocalcommunity,acrosstheboardthesedatadosuggestthatingeneralmostcommunitymembersperceivethegeneralnetworkofhealthandsocialserviceprogramstobeimportantonthewhole.

SocialDeterminant ItemAssessed TotalSampleResponses

PositivelyWordedSocialDeterminantItems PercentReporting"Never"or"Seldom"AppliestoMe

SocialEcology Ifeelthosearoundmearehealthy 0.9Education Iamsatisfiedwithmyeducation 4.4CommunityCohesion Imakeeffortstogetinvolvedinmycommunity 28.6Policy Ivotewhenthereisanelectioninmytown 11.0Environment Ifeelthatmytown'senvironmentishealthy(air,water,etc) 1.7Housing IfeelsafeintheplacewhereIlive 3.1Psychosocial Itrytospendtimewithothersoutsideofwork 10.2Transportation Ihaveaccesstosafeandreliabletransportation 0.7

NegativelyWordedSocialDeterminantItems PercentReporting"Sometimes,""Often"or"Always"AppliestoMe

Economy Iworryaboutmyutilitiesbeingturnedofffornon-payment 3.4Employment Iworryaboutbeingabletopaymyrentormortgage 7.9

However,consideringthesedataintermsofthoseservicesthatparticipantsrankedas“very”importantdoesprovidevaluableinsightsintothosemostvalued.Table15providesalistoftheextenttowhichparticipantsratedaprogramtypeas“moderately”or“very”important,presentedinorderofhighesttolowestendorsement.Inthistable,highlightedseparatelyarethoseservicesrankedas“very”importantbymorethan50%or60%.

Table15.EndorsementofImportanceofCommunityPrograms(n=505)

CommunityPrograms Moderately/VeryImportant% Moderately

Important%

VeryImportant

%PhysicalActivity 93.2 41.1 52.1WalkingTrails/OutdoorSpace 88.4 27.8 60.6AgingServices 86.0 45.6 40.4MentalHealthCounseling 84.9 45.2 39.7SubstanceAbusePrevention&Treatment 79.9 35.8 44.1NutritionEducation 75.6 52.8 22.8GunSafetyEducation 69.8 34.6 35.2Free/EmergencyChildcare 56.5 33.3 23.2FamilyPlanning 55.4 35.2 20.2JobTraining/EmploymentAssistance 55.2 42.5 12.7ServicesforWomen,Infants,Children 52.3 31.1 21.2FoodPantries 52.1 34.3 17.8HealthInsuranceAssistance 50.5 34.2 16.3TransportationAssistance 40.4 33.2 7.2PrescriptionAssistance 38.7 31.6 7.1LegalAssistance 35.6 28.2 7.4FinancialAssistance 34.2 25.6 8.6HousingAssistance 32.5 25.3 7.2FoodStamps/SNAP 31.0 22.5 8.5NeedleExchange 29.9 18.3 11.6CommunityPerceptionsofPriorityHealthNeedsImportanttothedevelopmentoftheCHNAanditssubsequentImplementationPlanwastoassessthelocalhealthissueswhichcommunitymembersperceivedtobeofimportance.Thehospitaldevelopedalistof21differenthealthneedsthatarecommoninmanycommunitiessimilartothoseinHamiltonCounty.Surveyparticipantswereaskedtoselectfiveofthosecommunityhealthissuesthattheyperceivedtobeamongthemostimportantforthehospitalanditspartnerstoaddress.Accompanyingthelistofhealthissueswasastatementthatguidedsurveyparticipantsintheirselection.Thestatementread“Belowisalistofhealthissuespresentinmanycommunities.Pleasepickthefivethatyouthinkposethegreatesthealthconcernforpeoplelivinginyour

community.”Table16providesasummaryoftheextenttowhicheachhealthissuewasselectedasoneofthetopfiveissuesbysurveyparticipants.Table16.PriorityHealthIssuesSelectedbyParticipantsasBeingAmongtheTop5MostInNeedofAttentionintheServicePopulation(n=505)

HealthIssue %SelectingIssueasOneofTop5NeedingAttention

Obesity 69.7Chronicdiseaseslikediabetes,cancer,andheartdisease 56.8

Mentalhealth 54.9Substanceuseorabuse 52.4Agingandolderadultneeds 43.2Alcoholuseorabuse 32.5Injuriesandaccidents 24.5Tobaccouse 19.6Suicide 18.9Reproductivehealthandfamilyplanning 15.6Disabilityneeds 15.4Environmentalissues 14.0Foodaccess,affordability,andsafety 13.2Childneglectandabuse 10.6Assault,violentcrime,anddomesticviolence 8.9Sexualviolence,assault,rape,orhumantrafficking 7.8

Poverty 7.6Dentalcare 5.9InfectiousdiseaseslikeHIV,STDs,andhepatitis 3.0Homelessness 2.1Infantmortality 1.7

Whileparticipantswereabletoselectfromthefulllistof21healthissuesduringthesurvey,itwasdecidedtonarrowdownthepriorityissuestothetop50%duringthecommunityprioritizationsession.Figure11providesagraphicalpresentationofthetophealthissuessharedduringcommunitymeetingsforpurposesofinformingfutureinitiatives.

Figure11.MostFrequentlyEndorsedHealthIssuesasPriorityforActionCommunityPerceptionsofHealthIssuesNeedingPriorityResourceAllocationInadditiontoassessingtheextenttowhichparticipantsperceivedspecificneedsasbeingamongthemostimportantforactionintheircommunity,participantswerealsoaskedtoprovidetheirperceptionsoftheextenttowhichthosesame21issueswerealsoprioritiesfortheallocationofresourcesinthelocalcommunity.Participantsweregivenastatementtoconsiderpriortoindicatingtheirperceptions.Thestatementread“Previouslyyouwereaskedtopickissuesthatposethegreatesthealthconcerninyourcommunity.Ifyouhad$3andcouldgive$1tohelpsolvesomeofthese,whicharethethreetowhichyouwouldgive$1?”

69.7

56.8

54.9

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43.2

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Obesity

Chronicdiseaseslikediabetes,cancer,andheartdisease

Mentalhealth

Substanceuseorabuse

Agingandolderadultneeds

Alcoholuseorabuse

Injuriesandaccidents

Tobaccouse

Suicide

Reproductivehealthandfamilyplanning

Disabilityneeds

PercentofParticipants SelectingTopic asTop5Priority

LocalCommunityHealthNeedsSelectedasaTop5Issue,%(n=505)

Belowaresomeissuespresentinmanycommunities.PleasepickFIVE thatyouthinkposethegreatesthealthconcernforpeoplewholiveinyourcommunity.

DataReflectsTop11issuesfromtotallistof21possible.

Aswasthecasewiththehealthissuesselectedasprioritiesforaction,itwasdecidedtonarrowdownthepriorityissuestothetop50%duringthecommunityprioritizationsession.Figure12providesagraphicalpresentationofthetoprankedissuesthatsurveyparticipantsselectedasprioritiesfortheallocationofresources.

Figure12.MostFrequentlyEndorsedHealthIssuesasPriorityforResourceAllocation

35.0

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28.5

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9.9

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Chronicdiseaseslikediabetes,cancer,andheartdisease

Substanceuseorabuse

Obesity

Agingandolderadultneeds

Childneglectandabuse

Foodaccess,affordability,andsafety

Suicide

Sexualviolence,assault,rape,orhumantrafficking

Alcoholuseorabuse

Disabilityneeds

Percent ofParticipants IndicatingWouldGive$1ToIssues

Top10HealthIssuesSelectedAsPriorityforResourceAllocation,%(n=505)

Previously youwereaskedtopickissuesthatpose thegreatesthealthconcern inyourcommunity.

Ifyouhad$3andcould give$1tohelpsolvesomeofthese,whicharetheTHREEtowhichyouwould give$1?

ComparisonofNeedsandResourcePriorities

Whileparticipantswereaskedtoprovideanassessmentofpriorityneedsandprioritiesforresourceallocationasseparatesurveyitems,acomparisonofthosepriorityrankingsprovideshelpfulinsightsintotheextenttowhichthereisconsistencybetweenthetwo.Figure13providessuchacomparisonandhighlightssomeinconsistencybetweenhealthissuesthatcommunitymembersbelievedwereapriorityneedingaddressedandthosethattheybelieveshouldbeapriorityfortheallocationofresources.

Figure13.ComparisonofPriorityNeedsandResourcePriorities

69.7

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54.9

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9.9

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Obesity

Chronicdiseaseslikediabetes,cancer,andheartdisease

Mentalhealth

Substanceuseorabuse

Agingandolderadultneeds

Alcoholuseorabuse

Injuriesandaccidents

Tobaccouse

Suicide

Reproductivehealthandfamilyplanning

Disabilityneeds

TopHealthIssues ComparedtoPrioritizationforResourceAllocation(n=505)

%PriorityResourceAllocation %PriorityNeed

5.COMMUNITYCHNAFOCUSGROUPDISCUSSIONSToprovideforadditionalopportunitiesforcommunitymemberstoprovidevaluableinsightsintothedecisionsmadeduringthe2018CHNAprocess,thehospital,incollaborationwithpartnerorganizationsandotherhospitals,heldaseriesoffocusgroupdiscussions.Thesefocusgroupdiscussionsprovidedopportunitiestogathercommunitymembers,providersoflocalhealthandsocialservices,andotherstakeholderstoreviewinformation,haveopenconversationsaboutlocalhealthneeds,andtooffersuggestionsforpriorityhealthtopicsthatshouldbeconsideredasthehospitalsmakedecisionsabouttheirprioritiesandsubsequentimplementationplan.Thissectionofthereportprovidesanoverviewofthefocusgroupdiscussionsandtherecommendationsemergingfromthosediscussions.AppendixBincludesalistingofthoseparticipatinginthefocusgroupsandasummaryoftheprocessandoutcomesofeachfocusgroup.FocusGroupsInApril2018,threefocusgroupdiscussionswereheld.ThosediscussionsincludedparticipantsfromawiderangeofparticipantsfromHamiltonCounty.ParticipantsAtotalof38communitymembersparticipatedinthefocusgroupdiscussions.Tobetterfacilitatediscussion,participantsweredividedintothreeseparategroups.Belowisasummaryofthenumberofparticipantsforeachfocusgroupdiscussion.FocusGroups #ofCommunityMembersParticipatingGroupOne 11 GroupTwo 15 GroupThree 12 Avarietyoforganizationtypes,includingschoolsystems,healthsystems,behavioralhealthorganizations,housing,socialservices,communityhealthcenters,seniorservices,thebusinesscommunity,andlocalpolicymakers,wererepresentedinthefocusgroups.Inthedetailedfocusgroupsummaries(AppendixB)asummaryoftheorganizationsrepresentedineachfocusgroupispresented.

MethodsToconductthefocusgroupdiscussions,thefacilitatorsappliedagreatdealofconsistencyinboththeapproach,process,andtypesofinformationsharedwiththecommunitymembers.Theprocessforthefocusgroupdiscussionsincludedthefollowingactivities:

• Introductions

• Adescriptionofthepurposeofthediscussionandgroundrules

• Twoprimaryquestionsguidedthediscussions,including:

o Whatisthemostimportantunmetneedaffectingthehealthofyourcommunity?

o Consideringtheunmetneedyouindicated,whichofthefollowingtypesofindividualsaremostvulnerableinyourcommunity?

• Topicsemergingfromthesediscussionswerewrittenonlargesheetsofpaperandplacedonthewall.Eachparticipantwasprovidedagreensticker(indicatingtheir#1priority)andpinksticker(indicatingtheir2ndpriority)inordertoendorsethetopicsbasedoneachoftheprimaryquestions.

• Endorsementsforfirstandsecondprioritiesweretalliedanddiscussedfurtherforclarification

OutcomesEachfocusgroupselectedpriorityissuesandprioritypopulations.Collectively,acrossthethreegroups,afinallistofprioritieswasproduced.Figure14providesasummaryofthehighlyrankedprioritiesemergingfromeachgroupandasummaryofthefinaloutcomesacrossthethreegroups.Detailedsummariesoftheseoutcomesareprovidedinthefocusgroupnotes(AppendixB).

Figure14.FocusGroupPriorities

HighPriorityIssues* HighPriorityPopulations*

Transportation IndividualsfacingMentalHealthDiagnosisAccesstoHealthServices IndividualswithSubstanceAbuseHistory

Housing IndividualsfacingMentalHealthDiagnosisTransportation ChildrenAccesstoHealthServices SeniorsChronicDiseaseManagement IndividualswithChronicConditions

IndividualswithSubstanceAbuseHistory

AccesstoHealthServices UninsuredandUnderinsuredTransportation IndividualsFacingMentalHealthDiagnosis

IndividualswithSubstanceAbuseHistoryChildren

**Inrankorder

CollectivePrioritiesAcrossGroupsPrioritiesbyFocusGroup

Housing

IndividualsFacingMentalHealthDiagnosis

IndividualswithSubstanceAbuseHistory

UninsuredandUnderinsured

Children

FocusGroupOne

FocusGroupTwo

FocusGroupThree

*Highpriorityissuesinrankorderbasedonparticipantendorsements.

FinalPriorityIssues** FinalPriorityPopulations**

Transportation

AccesstoHealthServices

5.PRIORITIZATIONPROCESSToconsidertheCHNAdataandtoidentifythemosturgenthealthissuesthatwouldguidethehospital’sfuturepriorityareas,acomprehensiveprioritizationprocesswasconducted.RepresentativesofcommunityhealthorganizationsintheserviceareaandhospitalstaffparticipatedinameetingtoreviewdatacollectedfortheCHNA.Alistofcommunitypartnerorganizationsfromwhicharepresentativeparticipatedisincludedlaterinthissection.AcopyoftheslidesusedduringthepresentationofdataisincludedasAppendixC.Thesessionincludedthefollowingactivities:• AreviewofthepurposeofconductingtheCHNAandreflectionsondecisionsandactions

takeninresponsetothe2016CHNA.

• AreviewofdatawaspresentedbyarepresentativeofMeasuresMatter,LLC.ThatdatareviewincludedasummaryoftheexistinghealthindicatorsanddatafromtheCHNAsurvey.

• AnominalgroupprocessfacilitatedbyMeasuresMatter,LLCtofacilitatethegroup’s

selectionofpriorityhealthissuesforthe2018CHNA.Thatprocesswasconductedinthefollowingway:

o Participantswereprovidedwiththelistofhealthtopicsthatemergedasamong

thosehavingthemostsupportfrombothexistingdataandtheCHNAsurvey.ThatlistofhealthtopicsisprovidedinFigure14.Additionally,participantswereprovidedasummaryoftheoutcomesofthefocusgroupsaspresentedinFigure13intheprevioussectionofthisreport.

o Participantsweregiventheopportunitytoaddadditionaltopics.

o Participantswereeachprovidedwith5“stickydots”andaskedtoplacetheirdotsontheissuesthattheyeachfeltweremostinneedofprioritization.

o The“dots”oneachtopicweretalliedandadiscussionaboutthetopicsandany

specialconsiderationsforeachwasheld.ResultingPrioritiesAsaresultofbothphasesoftheprioritizationprocess,XissuesreceivedendorsementforprioritizationforRiverviewHealth.Thoseissuesincluded:

• ToBeAdded

AlistofavailablecommunityhealthresourceswasalsoreviewedaspartoftheprocessandthepotentialpartnersforaddressingtheseneedsisincludedasAppendixD.

Figure14.OverlappinghealthissuesthatemergedfromsecondarydataandtheCHNAsurvey.