Hendricks Regional Health Community Health Needs Assessment & Implementation Strategy 2013

Our Mission: To improve the health of our region through the provision of high quality health care in a compassionate, technologically advanced and efficient environment. The following materials are intended to comply with the community health needs assessment and implementation strategy requirements under section 501(r)(3) of the Internal Revenue Code, as added by the Patient Protection and Affordable Care Act.

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Table of Contents SECTION Page Introductory Material…………………………………………………3 Obesity and Associated Conditions……………………………….. …6 Diabetes………………………………………………………………11 Chronic Diseases……………………………………………………..16 Tobacco and Policy to Control Its Use……………………………….20 Access to Affordable Healthcare……………………………………..22 Prenatal Care/Infant Mortality………………………………………..25 Population of Elders…………………………………………………..28 Appendix A (CHNA Resources)……………………………………...30 Appendix B (HRH Support Groups)………………………………….31

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INTRODUCTORY MATERIAL At the core of our mission, we at Hendricks Regional Health (HRH) are dedicated to improving the health of the community that surrounds our facilities. While HRH has a long standing reputation of supporting healthy activities and the many agencies and organizations that promote health, we have intensified our efforts to focus on wellness and health improvement in the last few years. This enhanced focus on health and wellness is easy to identify. Perhaps most obvious is the collaborative effort with the YMCA which became manifest to the public in 2011 with the opening of the 117,000 SF hospital outpatient/YMCA facility in Avon. This facility provides access to fitness and family-based activities for people at all income levels based upon the YMCA’s sliding scale membership programs. In addition, HRH provides multiple services in our portion of the building that support health and wellness. These services include free dietician visits for YMCA members, nurse wellness coaches to work with people at risk for or already plagued by chronic diseases and weight loss programs (Lifesteps ®). However, HRH’s efforts to address community health needs to extend to other arenas as well. In the last 2-3 years, multiple employers in the area have reached out to HRH to help promote health and wellness for their associates and to help decrease health insurance costs. Details within the report that follows reveal that HRH’s health risk assessments have reached thousands of area residents and helped them understand their risks for cardiovascular disease, diabetes and cancer. In addition, HRH has partnered with local employers to provide on-site employee clinics since 2010. These clinics help make healthcare accessible and cost less (to both employers and employees). To support these and other wellness offerings, HRH has gone from a single full-time worker in wellness and health promotion (in 2008) to a group of nine people (working about eight and ½ full-time equivalents). This group consists of a clinical staff of nurses, an exercise physiologist, a dietician, and a medical assistant. As HRH takes on progressively more responsibility in the coordination and management of chronic illness and in prevention, this group will continue to grow to meet these needs. The fact that HRH is out-in-front of the health needs in the community has been realized by patients. In our 2012 Consumer Survey conducted by Healthstream with a random, blinded sample of 301 area residents, HRH was statistically ahead of all other hospitals (p<0.05) when consumers were asked which hospital was “most supportive of health and wellness” in the community. Thirty one percent (31%) of respondents named HRH. Similarly, consumers found us to be “the most supportive of the needs of the community” by a statistically significant amount over any other hospital with 32% of respondents naming HRH.

What members of the public may not realize is that the health and wellness leadership they perceive is supported by a detailed 3-year strategic plan to progressively increase HRH’s ability to impact health and wellness in our community: for our own associates,

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other corporations and organizations, and for the population at large. This plan is a portion of the HRH’s overall strategic plan and was separately approved by the board of trustees in 2012. This high level commitment demonstrates HRH’s long-term intention to achieve its mission.

1. Community Defined.

HRH serves a multi-county area, but the majority of its patients, both inpatient and outpatient, come from Hendricks County. In 2012, 70.1% of patients lived in zip codes that are associated with Hendricks County, so this best defines our “community” relative to this report.

2. Process and Methods.

During 2010 and 2011, HRH representatives collaborated with the Hendricks County Health Department (HCHD) and multiple other agencies to evaluate the top health needs for the population which encompasses most of HRH’s primary service area. HRH supported the process in a number of ways including providing input and expert advice, financial support, and even by distributing links to the survey that the group presented to the public. The results of this comprehensive survey were published by the HCHD in 2011. This rigorous assessment of the health needs of the community that HRH serves provides an excellent template for planning. We believe the nature of the assessment itself and the broad coalition involved in the development of the report (including the assessment of priority areas) match the requirements for hospitals as required under Section 9007 of the Patient Protection and Affordability Act. An electronic link to this survey is listed in the Appendix A. In addition to the 2011 report, HRH also participated in another CHNA developed by the United Way of Central Indiana (UWCI). This assessment covered multiple counties, but did provide much of the data on a county-by-county basis, making it helpful to augment the 2011 findings locally. This survey had many similar findings as those of the 2011 HCHD-led evaluation despite its broader geographic view. Lastly, HRH has used multiple available web-based resources to evaluate other data pertinent to health needs in Hendricks County. Some of these references are listed in Appendix A.

3. Community Input. As described above, the CHNA conducted in conjunction with the HCHD included input from a variety of sources, including Children’s Bureau, Inc,, Hendricks College Network, Hendricks County Health Department, Hendricks County Parks and Recreation, Hendricks Regional Health YMCA, IU West Hospital, Kingsway Community Care Center, Mental Health America Hendricks County, Hendricks County Senior Services,

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and Tobacco Free Hendricks County. In addition, members of medically underserved, low-income, and minority populations in the community were represented through the public survey conducted by HCHD and supported by HRH.

4. Significant Health Needs. As part of the CHNA process, HRH developed a prioritized list of identified needs in partnership with the HCHD and participating agencies. The multi-agency group and HRH decided on 3 broad areas of priority/action based upon the results:

• Obesity and it’s attendant morbidities • Tobacco use and policy to decrease its use • Affordable health care

Several other areas of concern were identified as well, and these, too are addressed within this report. For example, diabetes is addressed specifically as a case study in chronic disease. Access to prenatal care is discussed fully as a sub-category of access to affordable health care.

5. Resources Identified. During the CHNA process, HRH identified a number of resources that are available to address the health needs identified, many of which are already being utilized. A discussion of the health needs identified and the resources that are being, or will be, used to address the needs is contained in the sections that follow. RESOURCES AND IMPLEMENTATION STRATEGY In conjunction with the preparation and completion of the CHNA, HRH has closely reviewed the resources available at HRH and in the community that can be used to address the health needs identified. In many cases, HRH has already been pro-active in developing or supporting interventions in the community to enhance health. In some cases, this assessment has helped highlight needs that either require additional budgeted dollars for HRH or emphasize the need to continue a valuable service. Rather than re-stating the findings in the HCHD CHNA or those in the UWCI’s Health Assessment, this report will review HRH’s work to help address the areas of concern: both current and planned interventions. Furthermore, this report serves as HRH's Implementation Strategy in accordance with the requirements under section 501(r)(3) of the Internal Revenue Code, as added by the Patient Protection and Affordable Care Act. Each section of this report is divided into three parts:

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• Leading By Example—this sub-section reviews HRH’s current efforts to impact people who directly interact with HRH: its patients, visitors, and its employees and their families.

• Community Advocacy and Support—this sub-section provides detail of HRH’s activities on a local, regional and/or state level that are aimed to improve outcomes or health status in the priority area.

• Gaps and Future Activities—this sub-section provides goals and actions that are likely to come to fruition in the next 3 years.

The reader should, therefore, understand HRH’s recent and current activities as well as future plans relative to the given priority area. HRH will regularly monitor and evaluate the impact of the strategies discussed and incorporate such information into future reports.   

OBESITY & ASSOCIATED CHRONIC CONDITIONS In the past 30 years, adult obesity rates have more than doubled and the average American adult is 24 pounds heavier today than in 1960. The latest annual report from the Robert Wood Johnson Foundation (RWJF) and Trust for America’s Health (TFAH) shows that adult obesity rates remained level in every state except for one: Arkansas. Thirteen states now have adult obesity rates above 30 percent, 41 states have rates of at least 25 percent, and every state is above 20 percent, according to the report. Key Findings of the 2013 “F as in Fat” report (RWJF) are as follows:

• Rates vary by region: Of the states with the 20 highest adult obesity rates, only Pennsylvania is not in the South or Midwest. For the first time in eight years, Mississippi no longer has the highest rate—Louisiana at 34.7 percent is the highest, followed closely by Mississippi at 34.6 percent. Colorado had the lowest rate at 20.5 percent.

• Rates vary by age: Obesity rates for Baby Boomers (45-to 64-year-olds) have reached 40 percent in two states (Alabama and Louisiana) and are 30 percent or higher in 41 states. By comparison, obesity rates for seniors (65+ years old) exceed 30 percent in only one state (Louisiana). Obesity rates for young adults (18-to 25-year-olds) are below 28 percent in every state.

• Rates vary by education: More than 35 percent of adults ages 26 and older who did not graduate high school are obese, compared with 21.3 percent of those who graduated from college or technical college.

• Rates vary by income: More than 31 percent of adults ages 18 and older who earn less than $25,000 per year were obese, compared with 25.4 percent of those who earn at least $50,000 per year.

While many county residents take a proactive approach and focus efforts on eating well and being active, many of our residents still need to adopt healthier lifestyles. Hendricks County is not immune from the obesity “epidemic.”

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Leading by Example HRH has a multi-pronged approach to encouraging and coaching our patients and community toward a healthier future. HRH YMCA Partnership The Hendricks Regional Health YMCA is a destination where people can learn, plan and take action to improve their health. Visitors experience seamless transitions, making it easy and convenient to access everything they need for prevention, treatment, and maintenance of a healthy life. The goal of the Hendricks Regional Health YMCA is to break down barriers to a healthy lifestyle by forming a complete circle of care. It combines traditional healthcare services with fitness and wellness activities in the same facility. Staffs of both organizations combine efforts to offer diabetes prevention and care, nutrition counseling, weight management, health screenings, and more. Lifesteps ®Adult Weight Management Lifesteps® weight management program has been offered to our community since 2010. Lifesteps® is for people who are ready to change behaviors that prevent weight loss, want to realize a slimmer version of themselves, and want to know how to successfully deal with setbacks. This unique program meets people where they are and tailors the program steps to fit each individual’s lifestyle. Lifesteps® is a 16-week course that is offered twice a year. Over 90 individuals have enrolled and over 70 persons have completed the Lifesteps® program in the past three years. STOP Pediatric Weight Management According to the latest U.S. government statistics, one in three children weighs too much. Our children and parents in Hendricks County also struggle with weight issues. Hendricks Regional Health and the HRH YMCA are offering STOP, a twelve (12) week comprehensive pediatric weight management programthat uses a family based approach for children who are overweight or at risk for becoming overweight. The STOP program curriculum focuses on how to help children and their families make permanent lifestyle changes by making healthy food choices, modifying eating behaviors and engaging in more physical activity. STOP is offered two times a year. Furthermore, HRH and the HRH YMCA have initiated fundraising efforts to eliminate financial barriers for our Hendricks county residents. Nutrition Services The opportunity to work with a registered dietitian is also available to our community. A nutrition consultation is often the first step to learn tips and strategies on how to improve a person’s diet or the diet for the whole family. Medical Nutrition Therapy is important in almost every diagnosis and disease category. Learning to eat well and stay healthy is an important preventative care measure and one that pays dividends in lower health care costs. Opportunities provided by the HRH dietitians include a range of services, purposes and situations. Registered dietitians may assist an individual or a family with meal planning

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to improve an emerging situation, a situation with a pre-existing medical condition, or a nutrient excess or deficiency. Individual sessions are designed to assist the patient with goal setting and removal of barriers that can empower individuals to improve their health. Initial consultation will include a nutrition assessment and education regarding specific benefits and potential risks of certain eating habits and lifestyle behaviors designed to maximize health benefits. Through our partnership, members of the YMCA can access up to two (2) free visits with an HRH dietician annually, improving access to sound advice on healthy eating. Great Shape (with Lifesteps ®) & Fresh Start Great Shape is a one-on-one, six-month intensive program that is customized to help promote healthy behavior changes. It includes dietitian appointments utilizing the Lifesteps® program, fitness center membership, fitness classes, personalized activity plans, and regular bio-metric testing. There is no cost to participants, as the program is funded by employers. The program provides weekly group meetings, stress reduction tips, and a blogging community for additional support.

Great Shape Case Study The Great Shape wellness program helped a local employer lower health costs and improve the health of some high risk employees. Participants became less reliant on medications and become role models for fellow employees working towards healthier habits. Program results included: 78% of participants maintained their weight loss at 6 months (some as long as two years after the program) 36% reduced their reliance on medications to control blood pressure or diabetes 80% reported increased energy 64% reported their doctor noticed improvement in chronic condition management 73% are more physically active than before beginning the program 100% recommend Great Shape to others

While Great Shape produces excellent results for a high risk cohort of 10-15 individuals at a time, the intensity of the program prevents broad application. To provide a scalable solution for employers, HRH developed Fresh Start, a 12-week program that promotes weight loss through educational sessions and regular weigh-ins. Fresh Start can be provided for up to 100 people at a time. Community and Employer Outreach: Education Dietitians offer a wide variety of nutrition related programming. Virtual grocery store tours, glycemic index education, and feeding babies and toddlers are just a few of the programs that have been available to our community. Dietitians are also frequent speakers for the HRH Speakers Bureau and welcome the opportunity to educate and help increase the nutrition IQ of our community. In 2012 HRH dietitians offered over 25 speaking programs to our community.

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HRH offers a variety of classes, programs and expert speakers that can be tailored to help motivate people to begin or maintain healthy life choices. In addition to nutrition topics, other options include mini-marathon training programs, tobacco cessation classes, and stress reduction course. Fitness/Exercise Classes HRH's fitness classes offer a wide variety of options for all levels, from the beginner interested in fitness to the seasoned fitness aficionado! Classes are offered at the Danville campus with convenient times for associates and their spouses. The classes are also open to the public on a space-available basis. These are typically low-cost and do not require membership fees. In 2012, over 2000 people were served at the Danville site. Wellness Coaching Certified ACSM wellness coaches work with employees and their family members to help take care of the Big Three: moving more, making wise choices, and stressing less. Participants work with registered nurses, a registered dietitian, and an exercise physiologist in creating new plans and habits for healthier living in partnership with their family physician. Wellness Coach visits are via referral from healthcare providers. Sleep Disorders Clinic Many overweight individuals have co-morbidities that adversely impact their health. One of the most insidious of these associated conditions is obstructive sleep apnea. The Hendricks Regional Health Sleep Disorders Center offers a full-service department led by board-certified sleep medicine specialists. Our Center is accredited by the American Academy of Sleep Medicine. The standards for accreditation ensure the highest quality of medical care for those with a problem related to sleep or daytime alertness. Certified sleep technicians also regularly provide free public education sessions to help educate community members about the dangers related to sleep apnea and to provide suggestions for better rest and recovery. Community Advocacy and Support As a community partner for over 50 years, HRH has been active locally and regionally to help reduce obesity and to control chronic diseases. Below is but a partial list of efforts that HRH has been (or continues to be) involved in that advocate healthier lifestyles.

• Hendricks Health Partnership—members serve on work teams and on the advisory board.

• Top 10 by 2025—community-based coalition sponsored by the YMCA of Greater Indianapolis which seeks to improve multiple health metrics in the Indianapolis metropolitan service area.

• Sponsorship of community-based sports leagues, the HRH YMCA, and other programs and organizations that encourage activity for people of all ages (e.g., Hendricks County Senior Services, running/walking events).

Gaps and Future Activities National and local data indicate that the prevalence of obesity and its associated chronic diseases continue to increase. The reasons for this epidemic are many but easy access to

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calorically dense foods and reduced physical activity (both at work and at home) are key contributors. These effects are compounded by demography: the largest generation in American history (the “Baby Boomers”) is reaching age 65 at the rate of 10,000 per year. Because the occurrence of chronic disease increases with age, obesity and its attendant morbidities are expected to increase over the next decade. As discussed in segments above, HRH has developed multiple programs geared toward increasing physical activity, reducing obesity, and control of chronic disease. In addition to utilizing existing programs, HRH has also developed an entire department (Wellness and Population Health) dedicated to working with its associates, employers, and the community at-large. Despite the efforts described above to curb obesity and its associated conditions, HRH’s work to-date exists primarily within the framework of the “old” model of health commonly known as fee-for-service. This model rewards health care providers and hospitals directly for care provided to patients. In this model, more volume equates to more revenue. In this payment model, HRH and other providers are incentivized to “do more” tests and procedures, and are not as incentivized to control cost, encourage preventive services, or direct patients to the lowest cost options for care. This fee-for-service model remains the predominate paradigm in health care at present. This is expected to change over the next 3-5 years. In newer models and payment systems for healthcare, providers and hospitals will realize increased revenue by coordinating the care of patients and actively managing the health of large groups of patients. That is, the health care providers are rewarded by reducing costs and improve patient experience and clinical outcomes. This shift in paradigm will increase HRH’s (and, indeed, all healthcare providers’) efforts to support lifestyle change, compliance with medical care plans, and coordination of care. Beyond the healthcare system itself, HRH will continue to support programs which enhance our community’s health and wellness. HRH supports sports medicine programs at multiple schools in Hendricks and Putnam counties as well as making donations to band programs, youth sports, and parks & recreation activities. Via participation in the Hendricks County Health Partnership and the Top 10 group, HRH will work collaboratively with other agencies and governmental units to enhance the health of citizens in our service area. Specific Expansion of Programming over the next 3 years:

• Growth in the STOP pediatric weight loss program to 3 sessions/groups annually. • Bring additional wellness offerings to partnered organizations, such as the Avon

Community School Corporation. • Develop an intensive medical management model for patients with multiple

chronic illnesses, including obesity.

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DIABETES It is estimated that by the end of this decade, diabetes will likely affect 15 percent of American adults or around 39 million people (United Health, 2010). Lifestyle related choices and rising obesity rates are the prime drivers behind these numbers. Type 2 Diabetes has been associated with an increase in obesity in the previous generation. Obesity and being overweight is a result of an imbalance in food consumed and physical activity. National data has shown an increase in the calorie consumption of adults and no change in physical activity patterns. Obesity is a complex issue related to our lifestyles, environment and genes. Many underlying factors for obesity have been suggested, such as increasing standard portion sizes, eating out more often, increased consumption of sugar sweetened drinks, increasing “screen time” (in front of TV’s, computers and mobile devices), and even reduced outdoor exercise due to concern about crime (Indiana State Department of Health). People with diabetes are more likely to suffer from vascular diseases such as heart attack, stroke, high blood pressure, kidney failure, blindness, and amputations of feet and legs. Diabetes is the 7th leading cause of death in Indiana; over 470,000 Indiana adults (9.8 percent) have been diagnosed with diabetes. Not only are the costs associated with diabetes significant to the patient, but they are also significant to employers and health care plans. An estimated $4 billion dollars in health care costs associated with diabetes are spent annually in Indiana. A recent study in the American Journal of Preventative Medicine indicated that a person with type 2 diabetes may spend an average of $85,500 to treat the disease and its complications over his or her lifetime. The earlier the diagnosis, the greater the lifetime costs. Type 2 diabetes is increasingly diagnosed in adults over age 50. Over seventeen percent (17%) of Hoosier adults ages 55-64 and 21 percent of adults 65 years of age and older have been diagnosed with diabetes. But the onset of diabetes begins long before the age of 50. In Indiana, 35 percent of adults are estimated to be pre-diabetic, a condition that serves as a pre-curser to diabetes and is diagnosed by a higher than normal blood sugar but not yet high enough to be classified as diabetes. If current trends continue, 1 in 3 Americans will develop diabetes sometime in their lifetime, and those with diabetes will lose, on average, 10–15 years of life (Centers for Disease Control). At HRH, 79 percent of persons seen in the Center for Diabetes Excellence are age 45 or older. In 2012, 538 diabetes related consults were completed by the certified diabetes educators at Hendricks Regional Health, but we know we have many more people in our service area that have not yet benefited from diabetes education. Prevalence in Adult Population Health Costs Attributable to Diabetes

(in billions)

 2007  2010

(estimate)2020 (estimate)

2007 2010 (estimate)

2011‐2020    (projection)

People with pre‐diabetes  26.30%  28.4% 36.8% $27 $34 $585 People with undiagnosed  2.90% 3.10% 4.10% $12 $15 $253

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diabetes People with type 1 diabetes  0.20% 0.02% 0.20% $4 $5 $73 People with type 2 diabetes 7.60% 8.20% 10.80% $110 $120 $2,439 Total 37% 39.9% 51.90% $153 $194 $3,351 Source: UnitedHealth Group modeling, 2010 Leading by Example Significant challenges need to be tackled if we are to significantly improve management of those diagnosed with diabetes and to increase screening and diagnosis of pre-diabetes. Living with diabetes can be overwhelming without guidance and education. The Certified Diabetes Educators at Hendricks Regional Health have received extensive training in diabetes education and management and work with individuals to tailor a diabetes management program to engage and encourage individuals to manage their diabetes. Hendricks Regional Health’s Center for Diabetes Excellence has been a Recognized Education Program since 2002. HRH’s educational efforts are based upon the National Standards for Diabetes Education and are endorsed by the diabetes community. HRH’s Center for Diabetes Excellence must meet specific and rigorous standards that assure high-quality education to help develop and improve patient self-care skills that essential to effective diabetes management. HRH’s Center for Diabetes Excellence operates under the advice of the Diabetes Advisory Council. The council is comprised of four physicians, four community members, and the HRH associates that comprise the Center for Diabetes Excellence. The council meets once a year and assists in guiding educational efforts in our community. The American Diabetes Association provides statistics relative to how persons with diabetes manage their disease. National statistics regarding persons with diabetes: ° 74.3 percent have seen a health professional at least two times in the past 12 months ° 25.5 percent are currently taking medicine for their high blood pressure ° 68.8 percent had a health professional check their feet for any sores or irritations in the past 12 months ° 65.6 percent had an eye exam in which the pupils were dilated in the past 12 months ° 64.6 percent check their blood-glucose level at least once per day ° 59.5 percent have ever taken a course or class in how to self-manage their diabetes Specific to clients seen in HRH’s Center for Diabetes Excellence: ° 93 percent indicate they have made dietary changes as a result of their educational session. ° 94 percent indicated they monitor their blood sugars at home ° 56 percent indicated they have had their feet examined in the last year by a health care provider

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° 88 percent of gestational diabetics indicate they have made dietary changes to lower their blood sugars ° 71 percent of patients referred to our center were seen by one or both the RN and RD educators ° 60 percent of patients that signed up to attend diabetes classes attended the classes The Center for Diabetes Excellence has 4 RD’s, 3 RN’s, 1 FNP-C, 1 secretary and 1 coordinator. Six of our educators are Certified Diabetes Educators and one of our nurses is a Certified Family Nurse Practitioner. The diabetes team is well seasoned and well positioned to help educate and lower the rates of diabetes in our county and service area. The HRH YMCA offers the Diabetes Prevention Program (DPP) to community residents. The program has demonstrated the clinical effectiveness of preventing or delaying the onset of type 2 diabetes through dietary change, moderate-intensity exercise, and modest weight loss. Losing just 5 percent of body weight reduces the incidence of type 2 diabetes. The YMCA’s DPP uses a group model with a 16-session core program that is delivered over 20 weeks. Healthy eating, structured physical activity, and behavior modification are key components to the program. The DPP has achieved a 58 percent risk reduction in progressing from pre-diabetes to diabetes (UnitedHealth, 2010) Additionally, Hendricks Regional Health offers a Diabetes Support Group to our community. The group meets the third Monday of each month at the HRH YMCA. A member of the Center for Diabetes Excellence attends the meetings and usually offers a brief educational program with the rest of the time spent with group directed conversation and support. Furthermore, Hendricks Regional Health offers the support of a nurse practitioner with advanced training specific to diabetes. Angi Thompson, MSN, RN, FNP-C, CDE, accepts Medicare assignment and is accepting new patients that need assistance with primary care management. The diabetes educators with HRH are equipped to provide 1:1 as well as group training, and insulin pump and glucose meter training. Continuous glucose monitoring is also available in the Center for Diabetes Excellence. Employer health screenings and community health screenings provide additional opportunities to reach staff members that may not normally have screenings performed, especially with the increasing number of employees covered by high deductible health plans. By the third quarter of 2013, over 25 different screening dates had been offered around the community, with the majority screening for risk factors associated with diabetes. As of December 2013, HRH has provided over 2,300 community residents with health screenings in just 11 months. These screenings include a survey instrument, biometric and lab testing. . After a screening is completed, HRH Wellness staff nurses will follow-up with any participant that has an abnormal result. They will document the results in the patient’s electronic medical record, send a hard copy of the results to the patient, and call each individual person to provide additional education about the results. Wellness team members focus on changing health behaviors that lead to chronic disease

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by encouraging more activity, getting the patient exposed to additional nutrition resources and emphasizing stress management best practices. Bariatric Services HRH has teamed with St. Vincent to offer bariatric support group classes at the HRH YMCA and initial lab and radiology testing for those interested in bariatric surgery. While bariatric surgery is not right for all diabetics, it can improve control and potentially “cure” type II diabetes in some patients. Community Advocacy and Support HRH continues a high level of commitment and support with promotion of the HRH YMCA’s Diabetes Prevention Program and HRH’s Diabetes Education Program. The group classes are offered free of charge to those who have met with a diabetes educator for a 1:1. In addition, HRH has collaborated with the YMCA of Greater Indianapolis to identify patients who could benefit from enrollment in the YMCA’s DPP program. Many patients are eligible to participate at no cost due to federal grants that the YMCA has received. Weight management is key to managing type 2 diabetes. HRH offers the Lifesteps® program to our community. Typically, persons with diabetes make up 25-30% of our class participants. Classes start in August and January each year. In addition to Lifesteps ®, HRH diabetes nurses and nurse practitioner host a program called Diabetes Volunteer Health Aide. This program is open to folks that are designated to serve in the role of “Diabetes Volunteer Health Aide”. The class is designed to prepare volunteers with the education, skills and training necessary to carie for a child with diabetes in the school setting. The class is offered free of charge to our community. This class is in accordance with legislation in Indiana that requires schools to have volunteers assist school nurses with caring for children with diabetes and that such training be provided annually. We provide this as a free service and have done so since 2008 to Putnam and Hendricks counties. In 2012, sixty persons receive this training. The educators are working with the HRH Wellness Department to encourage those with elevated glucose levels to schedule an appointment for diabetes education or, if appropriate, the YMCA’s DPP. HRH is also collaborating with the Central Indiana Council on Aging (CICOA) to host Dining with Diabetes. CICOA offers this program in conjunction with our Hendricks County Purdue Extension. The program is for persons with diabetes, pre-diabetes and caregivers of those with diabetes 60 years of age or older. Four2-hour sessions include information on making healthy food choices that assist in good glucose control and information to help persons adopt positive lifestyle changes. Diabetes Day at the HRH YMCA was held in the fall of 2013. The no cost event was a targeted effort to screen and educate those with diabetes and pre-diabetes. Community

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members were invited to participate in a screening that provided lab results specific to diabetes management (A1C, fasting blood sugar and a lipid panel). Also provided was an educational session that consisted of a panel discussion between an endocrinologist, diabetes educators, and an HRH YMCA staff member. HRH’s diabetes educators provide ongoing community support via the Speakers Bureau. We offer programs for a variety of situations. Programming is available for businesses, community groups as well as interested groups. Topics can include, but are not limited to, eating for health, healthy snacking, nutrition, carbohydrate counting, living well with diabetes, managing stress as well as diabetes, label reading and nutrition, exercise, virtual grocery store tour, and healthy eating for the holidays. Gaps and Future Activities Diagnosis and Education While physicians do a good job of diagnosing pre-diabetes and diabetes, more needs to be done to improve the percentage of those diagnosed that receive diabetes education. Diabetes self-management starts and continues with high quality, clinically sound education. Patients with diabetes that are encouraged to receive education and counseling are better prepared to understand and work to manage their diabetes. Patients often encounter barriers to self-care such as the financial costs of meter strips and lancets, as well as access to healthy, minimally processed foods and low cost or supervised activity options. Tactics which help both patients and healthcare providers recognize gaps or lapses in ongoing education must be developed. Ongoing and regular communication from a person’s physician or other health care provider is important to those with diabetes. To address this concern, in 2013, a coordinated effort among HRH Wellness staff, the Center for Diabetes Excellence and physician offices, identified people with diabetics that carry HRH insurance who had not had recent education. These individuals were contacted via both letters and personal phone calls to encourage them to schedule follow-up appointments and education. If this is an effective tactic, it will be generalized to other employers who utilize HRH wellness services. Another issue faced by employers and employees alike is that people with diabetes have higher absenteeism than those without diabetes. The rate of absences is estimated to be 1.9 workdays per worker higher than those without diabetes (UnitedHealth, 2010). Employer based clinics and diabetes self-management classes are two methods to break barriers and bring diabetes education to persons in their work setting. Employees would benefit from becoming more knowledgeable about their diagnosis and better methods to control their diabetes. Employers would benefit by having employees that are prepared to manage their diabetes and that would hopefully translate to less sick time and lower related health costs.

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Specific Expansion of Programming over the next 3 years: • Diabetes Clinic offering to HRH Employer Clinic partners—a trial of this disease

management clinic will begin with Avon Community Schools in early 2014. • Support of the YMCA’s effort to publicize the DPP. Since results with HRH

patients have shown that the average participant loses 6.5% of his/her body weight, HRH will communicate these results within our physician network.

• Work with employers to expand access to diabetes treatment and monitoring equipment via employer based clinics.

CHRONIC DISEASES As people live longer, their burden of chronic disease generally increases. While HRH is rapidly working to expand its capabilities to keep people healthy and to reduce the onset of chronic illness, meeting the healthcare and psychosocial needs of those who do develop diseases remains a priority. Those with long-term illness often have reduced quality of life as well as reduced longevity. Leading by Example PROGRAMS TARGETING SPECIFIC CHRONIC DISEASES Breast Cancer Patient Navigation— Studies have shown that cancer patients who have access to a nurse navigator soon after a diagnosis report feeling that they had better emotional support and were better informed, and they were more involved in their care. These studies further support the importance of a navigation program within the hospital setting, with reports of those patients receiving navigation assistance noting a significantly better assessment of their chronic illness care with significantly fewer problems or complications from treatment. Based upon the improvements in patient care and experience that can be realized via Cancer Patient Navigation services, HRH provides these services to help lead the patient through her journey from the time of diagnosis throughout the continuum of care. Cancer Navigation services are offered to newly diagnosed breast cancer patients on-site, free-of-charge and are generally initiated at the time of the diagnostic procedure or biopsy. The focuses are on psychosocial support, care coordination, and acute/chronic illness education. In 2013, a study conducted by the Cancer Care Committee (the over-arching group that works to improve the processes of care for oncology patients) revealed that the timeliness of diagnosis and the time from diagnosis to first physician visit have both been improved since the navigator program began. Cancer Screening—Primary care and obstetrics/gynecology physicians provide the first line in cancer detection and prevention. Physicians and other providers help ensure that patients receive appropriate screening services. These offices routinely provide clinical breast exams, pap smears, digital prostate examinations, and colo-rectal cancer screening via checks for occult (hidden) blood in the stool. They also provide referral to

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mammography, colonoscopy, or more specialized testing to prevent cancer or to find it during earlier, more curable stages. For those who do not see a physician regularly, HRH provides health risk appraisals at work-sites and for the community that encourage appropriate screening. Mammography is a key cancer screening tool. Accessibility and awareness have both been focuses for breast cancer detection. For example, mammography is offered at two sites (Danville and Plainfield) and can be scheduled via phone or online.. HRH also provides extended hours of testing both in the morning and evening. This is done to enable women who are working the flexibility to obtain screening mammograms during hours that are more convenient for them so they do not have to take time away from work. At various times, based on scheduling needs, weekend hours are offered. HRH enhances awareness by mailing annual reminders to appropriate patients during the month that they celebrate their birthdays. Cardiac Rehabilitation – After an individual experiences a cardiac event, our staff can provide education and medically supervised exercise to minimize the effects of heart disease and reduce the risk of future heart problems. Center for Diabetes Excellence – Certified diabetes educators teach patients how to manage and live well with diabetes. Education is provided one-on-one or in a group setting. Oncology Infusion Center – For many patients, chemotherapy is part of their treatment plan. The Hendricks Oncology Infusion Center provides chemotherapy through a partnership with board-certified hematologists-oncologists. Unlike many similar programs, this infusion center is staffed by a doctorate of pharmacy to ensure safe and effective dosing of cancer-fighting drugs and to help counsel patients on medication side effects and coping mechanisms.

Palliative Care--The goal of palliative care is to prevent and relieve suffering of all kinds and to support the best possible quality of life for patients and their families. Palliative care is both a philosophy of care and an organized system for delivering care. It expands traditional disease model medical treatments to include holistic values of enhancing quality of life, optimizing function, and helping with treatment and end-of-life decision making. It can be delivered concurrently with life prolonging or curative treatment or as the main focus of care. Pulmonary Rehabilitation--A comprehensive pulmonary rehabilitation program is available for those at risk for lung disease, or who have experienced lung problems such as chronic obstructive pulmonary disease (COPD), emphysema, asthma, pulmonary fibrosis and primary pulmonary hypertension. Participating in rehab can help patients improve their quality of life through breathing training, muscle strengthening and building endurance; and helps to prevent future problems or complications. Radiation Oncology Care– HRH uses the latest technology with intensity modulated

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radiation therapy (IMRT), Image Guided Radiation Therapy (IGRT), and Three-Dimensional Computerized Treatment Planning for any cancer treatment including specialized prostate treatment. Strokes and TIAs (“Mini-strokes”) HRH is accredited by the Healthcare Facilities Accreditation Program (HFAP) as a Primary Stroke Center. That means our stroke care is specially designed to quickly diagnose, effectively treat and manage patients with stroke. HRH is committed to teaching our community about stroke warning signs and prevention. Following a stroke, patients often need a great deal of specialized care and follow-up. Scheduling and tracking multiple appointments can be overwhelming for someone who is simply trying to restore themselves or adjust to a new normal. To make stroke recovery more manageable, HRH offers clinic dedicated to patients recovering from a stroke or TIA. The clinic brings multiple professionals together in one place at one time surrounding patients and their families with the care and resources they need. Services offered in the “one stop shop” include neurology, speech therapy, physical and/or occupational therapy, nutritionists, diabetes educators (if appropriate), and social workers. A visit to the stroke clinic occurs within 2 weeks of discharge from HRH. Patients who utilize the stroke clinic have demonstrated a substantially lower risk for re-admission to the hospital. Community Advocacy and Support American Cancer Society—HRH has been actively engaged with the American Cancer Society (ACS) for many years. In addition to annual donations to the cause, HRH has fielded teams in multiple Relay for Life events. In 2012, the county’s first Making Strides Against Breast Cancer was held on the grounds of the Hendricks YMCA. This highly successful event was led by two HRH staff members. In addition to support to the ACS via monetary contributions and volunteer time, an ACS representative attends all HRH Cancer Care Committee meetings to help better coordinate services for all cancer patients in the region. Chaplain Services and Support Groups--The chaplains at HRH provide ongoing support to our inpatients and community members. Chaplains are trained to assist with advanced directive and end of life decision making as well as the grieving process. Support groups are offered for a variety of audiences and situations (Appendix B).

Tobacco and Policy to Control Its Use—Reducing the use of tobacco is critical to preventing myriad chronic diseases. This is in more detail in the section immediately following this one (page 19). Gaps and Future Activities HRH embraces the opportunity to serve those with chronic diseases: a few of our plans are discussed below.

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Improving Access to Mammography--In the recently completed community survey by the Komen Foundation (which included Hendricks County), it was clear that there are still significant barriers for women in obtaining mammograms. The most significant reason identified by women was that their own healthcare was not a priority. This reason crossed all socioeconomic levels, age groups, and ethnicities. For working poor or un/underinsured women, transportation and non-work time appointments were also cited a significant barriers to scheduling a mammogram. There was also fear of actually finding an abnormality, not only due to the quality of life impact, but due to the cost of then obtaining treatment.

The Komen study also reported that among minority populations there is a significant mistrust of the medical community and misunderstandings about mammography. In fact, some feared that mammograms are painful and/or that medical personnel will mistreat them. HRH is actively trying to address these issues by:

• Providing extended hours beyond work hours for screening mammograms • Actively working with organizations such as IBCAT and Komen Foundation and

Little Red Door to obtain grants for screening mammograms and funding for further diagnostic evaluation for patients with positive findings.

• Working with Partners in Care, Kingsway Community Care Center, and the Rockville Family Health & Help Center to encourage and engage low income and minority women in being pro-active in their own healthcare.

• Continuing to provide community education regarding the importance of regular mammography.

• Continuing outreach efforts via our own associates and through others in the community to identify and address barriers delaying and impeding care

Support for Cancer Survivors—During 2014 and 2015, HRH will financially and clinically support the “LIVESTRONG at the YMCA” program offered onsite at the HRH YMCA. For patients who have received diagnosis or treatment at an HRH facility, the program is offered free of charge. For those in the community who have had diagnosis or treatment, it is available at low cost.

LIVESTRONG at the Y is a twelve-week, small group program designed as both a support group and an exercise program for adult cancer survivors. This program fulfills the important need of supporting the increasing number of cancer survivors who find themselves in the transitional period between completing their cancer treatment and the shift to feeling physically and emotionally strong enough to attain their "new normal". Our goal is to help participants build muscle mass and muscle strength, increase flexibility and endurance and improve functional ability. Additional goals include reducing the severity of therapy side effects, preventing unwanted weight changes and improving energy levels and self esteem. A final goal of the program is to assist participants in developing their own physical fitness program so they can continue to

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practice a healthy lifestyle, not only as part of their recovery, but as a way of life. In addition to the physical benefits, the program provides participants a supportive environment and a feeling of community with their fellow survivors, HRH YMCA staff and members.

HRH YMCA fitness instructors work with each participant to fit the program to their individual needs. The instructors are trained in the elements of cancer, post rehab exercise and supportive cancer care. Support for Improving Lifestyles and Increasing Healthy Behaviors—HRH has invested substantially in primary and specialty care medical practices as well as, in programs & staff dedicated to helping people be healthier or, at least, to adapt to living with chronic disease. Many of these opportunities are discussed throughout this report in the Leading by Example sections. HRH intends to build upon this strong foundation in a number of ways, including:

• Enhancing awareness in the medical community and the public at-large about existing programs.

• Delivering individualized support and program content in innovative ways, such as on-site for employers or within primary care offices.

• Scaling current programs to meet expanded needs in the community.

TOBACCO AND POLICY TO CONTROL ITS USE Leading by Example In the mid-1990s, tobacco control was identified as a leading healthcare initiative that could positively impact the cost of treatment for chronic heart and lung diseases as well as improve the lives of those that decide to quit. As part of the Federal Tobacco Settlement in 1998, the State of Indiana developed a grassroots working model that would allow counties to apply for grant money to be used in their communities to start the change in public perception on tobacco use and highlight the benefits that control efforts could bring to the community and future generations. HRH was approached by the Hendricks County Health Department (HCHD) to become a founding member of our local coalition to use our name and reputation in the community upon which to build. In response to this request, hospital administration designated the Director of Cardio-pulmonary as the liaison to help build this coalition in the county. Now, fourteen years and seven grant cycles into this ever growing and changing initiative, HRH continues to be a leader in the coalition. In 2005, HRH replaced the HCHD as the fiscal agent for the coalition responsible for managing the grant money, acting as the direct report for the coalition coordinator and reporting our quarterly fiscal accounting to the State. In 2011, the Chief Therapist - now the Director of Cardio-pulmonary – was elected as the Chair of the Coalition responsible for the day to day activities of the coalition and stop smoking advocacy initiative. While the Coalition

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Coordinator is the face of Smoke Free Hendricks County (SFHC), HRH continues to provide the quiet support that creates the needed unity to accomplish our goals.

Another area where HRH has led within the community is via support for smoking free ordinances in the towns of Avon and Plainfield. The immediate past HRH CEO (recently retired) spoke at an Avon town hall meeting on the importance of the ordinance as a way to enhance the public welfare. The HRH Chief Therapist spoke at a Plainfield town hall meeting, debunking proposed “solutions,” such as the maintenance of separate smoke free rooms or increased ventilation system requirements. These interventions are not adequate mitigation of exposure to second hand smoke. Both town ordinances passed, and both are stronger than the recently passed state law.

Internally, HRH has offered support to its associates for years. While simultaneously creating a tobacco-free work environment, HRH also began offering smoking cessation classes and medications at no cost. More recently, HRH has also begun offering health insurance premium discounts to associates and their spouses who become or remain tobacco free. Annually, those who smoke can become eligible for the premium reduction by completing a certified tobacco cessation program. In this manner, current users are encouraged to attempt tobacco cessation at least once per year.

Community Advocacy and Support One of the spin-off efforts created by the work of the Smoke Free Hendricks County coalition is the Hendricks County Asthma Coalition (HCAC). This coalition was formed in collaboration with IU Health West (IUW) and the HCHD to focus on the county’s asthmatic population – reported by 12% of respondents in the 2010 HC CHNA. HCAC was set-up to follow the Indianapolis Joint Asthma Coalition (InJac) that required a Respiratory Therapist chair the coalition. To that end, a foundation, co-chaired by HRH and IUW, was developed to meet this requirement and to nurture collaborative, aligned efforts on this important public health topic.

HRH has also supported a proposed nonsmoking workplace ordinance promulgated by the HCHD. This healthcare ordinance is patterned after a similar ordinance adopted in Hancock County through its County Commissioners. The immediate past HRH CEO and the Vice President of Medical Affairs have met with County Commissioners to express support for this ordinance. This ordinance was tabled in 2012.

HRH has worked with the Indiana State Department of Health to promote the 1-800-QUIT-NOW tobaccos cessation line. All venues of care at HRH now refer tobacco users to this free service.

Gaps and Future Activities Both the SFHC and HCAC coalitions share common board members. This overlap permits coordinated activities, but diminishes impact as the board members can, at times, be over-tasked. In addition, HCAC does not have a revenue source like the grant funding that SFHC receives. Thus, these groups will need to define and address these issues in the next 3 years.

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The campaign for a county-wide smoke-free workplace ordinance will continue, and it has gained support from the American Lung Association and the American Cancer Society Indianapolis chapters. HCAC is making efforts to be a more active support organization with the aim to provide expert help to community organizations including, schools, daycare centers, and other private businesses.

ACCESS TO AFFORDABLE HEALTHCARE Leading by Example Community Benefit For over half a century, Hendricks Regional Health has provided quality care and the latest medical technology for our community. We have grown into a multi-specialty healthcare organization-proudly independent, non-profit and community-based. Part of our mission is providing healthcare services to all, regardless of ability to pay. Patients are not turned away from services based upon their inability to pay for services, either in our hospital-based services or physician offices of the HRH Medical Group. Likewise, contracted physician groups like anesthesia and emergency physicians, agree to follow HRH’s charity guidelines when working with un-insured or under-insured individuals. Reflective HRH’s desire to meet the needs of our community, $4.2 Million in charitable care was provided in 2012 alone, representing a direct cost to the organization of $1.8 Million. HRH also provides services to patients who receive government sponsored health insurance, like Medicaid, which often reimburse for care at a rate lower than the cost of delivering that care. In 2012, HRH incurred costs in excess of revenues for Medicare patients of $25.5 Million. For Medicaid, which represents a smaller portion of HRH’s patient volumes, the un-covered costs of care amounted to $4.4 Million. Partners in Care Clinic Understanding the need for affordable care in the community, HRH established the Partners In Care Clinic (PIC) in 1993. PIC provides a vital access point for uninsured and Medicaid patients in Hendricks and surrounding counties. PIC is comprised of two components: a Primary Care Clinic that is staffed by a family nurse practitioner and an OB/GYN Clinic that is staffed by a nurse practitioner and two midwives. In 2012 PIC had nearly 4,000 visits from uninsured, underinsured and Medicaid patients. Of this total amount, the Primary Care Clinic comprised 1,588 total visits-798 were adults and 790 were pediatric visits. The OB/GYN clinic had the remainder of the visits (2,387). OB patients accounted for 1,434 visits and GYN accounted for 953 visits. There were also 53 newborn visits. Together the two midwives in PIC clinic delivered 107 babies in 2012. HRH subsidizes PIC in order to keep this vital service in the community. IN 2012, HRH provided almost $418,000 to cover shortfalls in PIC’s operations.

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Through the free and reduced cost hospital care charity plans for the HRH Medical Group physicians, and PIC, HRH is providing direct access to affordable care in the community. HRH also assists in providing access to affordable care in other less direct ways that are described below: Health Screenings and Low Cost Wellness Activities HRH wellness staff regularly partners with not-for-profit community organizations to provide free health screenings which are open to the public. HRH is actively involved in the Hendricks County 4H Fair- providing health screening opportunities. HRH works with local churches to provide health education and screenings for members of their congregations and the general public. In addition, quarterly health risk assessments are performed at no cost at the Hendricks County Senior Services center. Substance Abuse: Drug Court HRH Wellness staff member’s partner with members of the Hendricks County Drug Court to offer wellness education and support for program participants, many of whom are financially vulnerable. Primary areas of focus are tobacco cessation, nutrition, stress management and building activity as a coping mechanism. Staff members encourage program participants to engage in healthy behaviors and other coping strategies that will help replace unhealthy choices and habits. Community Advocacy and Support In addition to the direct and indirect access to affordable health and wellness care that HRH provides to our community, HRH provides significant assistance to organizations that ultimately benefit the health of our community. Below is a brief description of the many ways that HRH helps to subsidize programs to keep the community healthy: Hendricks County Health Foundation’s Women, Infants and Children Clinic (WIC) HRH consistently supports this not-for-profit entity that sponsors the local Women, Infants and Children (WIC) clinic for our community. Three HRH associates are active on the board and one associate serves as the President of the board. HRH has financially supported the organization with seed monies and temporary cash flow when needed to continue the operations between grant cycles or when shortfalls have occurred. Meals on Wheels Meals on Wheels (MOW) is a non-profit organization that promotes good health, independence and eases loneliness for homebound seniors in our community. HRH serves as the foodservice contractor and provides office space, computers and a phone line for this valuable community service. Volunteers deliver meals to those who cannot prepare meals for themselves due to illness, disability or age. A team of registered dietitians and food service staff plan and prepare the meals. Over 22,400 meals were served to this homebound population in 2012.

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HRH underwrites MOW in the amount of $60,785 per year. In addition, HRH hosts the annual MOW Volunteer luncheon to recognize the 150+ county residents that delivery the meals all over our county. This is an additional donation of $1,500. Hendricks County Senior Center HRH serves as the foodservice contractor for the Hendricks County Senior Center. Meals use a 7-week cycle menu and are prepared in the HRH kitchen then transported to the Senior Center by volunteers. Over 7,700 meals were provided to our senior citizens in 2012. HRH underwrites $9,191 of the cost to support this program. Central Indiana Council on Aging’s Meals and More The Central Indiana Council on Aging (CICOA) sponsors Meals and More. HRH serves as the foodservice contractor for this program. Vouchers for Meals and More are available at the Hendricks County Senior Center and are redeemed at the Copper Grill inside HRH. The meal requires the participant to mail in a suggested donation and provides 1/3 of the daily nutritional requirement for seniors. HRH underwrites an additional cost of $1,503 annually to support this program. Sheltering Wings Sheltering Wings serves our county and surrounding area with crisis management and intervention as well as a safe and secure shelter for women and children. HRH continues to support the mission of Sheltering Wings throughout each year through subsidized rent, material and monetary contributions. HRH YMCA HRH has contributed at least $10,000 annually to the “Y for All” campaign to support the financial assistance program offered to individuals and families that find the cost of membership and programs the Hendricks YMCA to be a financial hardship. Gaps and Future Activities To ensure access to affordable health care in Hendricks County there are several issues to be addressed: Uninsured Hendricks County Residents According to the State of Indiana’s five year access plan entitled, “unlocking Access to Health care in Indiana”, Hendricks County has 17,757 uninsured resident. This represents 12% of the county’s population. Access to Affordable care is not only a priority for these citizens but also to those who are underinsured and paying high co-payments and deductibles. HRH will continue its charitable commitment to the uninsured and underinsured patients it serves. In addition, HRH will make more widely available information about the Patient Assistance Program (charity care) available at the Hospital for patients needing medically necessary and emergency care.

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Consistent with the Patient Portability and Affordable Care Act (ACA), HRH will be offering new ways of accessing affordable health care through the Healthcare Marketplace. HRH plans to be a State of Indiana Application Organization and will also offer the services of Indiana certified Healthcare Marketplace Navigators to patients and the greater community who need assistance enrolling in the Healthcare Marketplace. HRH will be publicizing information about its Healthcare Marketplace Navigator program through HRH physicians’ offices and immediate care clinics as well as the hospital and community partners. Only residents at 100% of poverty or above are eligible to purchase health insurance on the Marketplace. Thus, the Marketplace does not address all the un-insured people in the service area. After open enrollment on the Marketplace closes on March 31, 2014, HRH will review Marketplace enrollment in the community and evaluate the new needs of the uninsured and underinsured in the community. HRH will also examine its primary care access. For example, primary care in the Emergency Department is one of the most expensive and least efficient sites of care. Understanding the barriers to appropriate primary care access for the uninsured, underinsured and the newly insured will be examined by HRH. Through education, HRH will work to effectuate more appropriate utilization of primary care. In addition, new models of care that increase geographic access as well as additional office-specific access will develop over the next three (3) years. Transportation Some Hendricks county residents experience difficulty attending appointments or obtaining needed healthcare services due to a lack of transportation. Our county does not have a system of alternative transportation in both our towns and rural parts of our county. In order for some residents to successfully access health and wellness care, transportation will need to be addressed. LINK of Hendricks County is usually at capacity and the need is beyond the ability of this one identified service. Transportation will need to be addressed holistically by the community and HRH will be a partner in this important issue. PRENATAL CARE/INFANT MORTALITY Indiana ranks 45th among the 50 states for infant mortality. Recently, Dr. Van Ness, State Health Commissioner, has stated that reducing infant mortality is a top priority. With the leading cause/contributor to infant mortality being premature birth, perhaps the best way to improve the US’s rank is to focus in reducing premature births. Overall, Hendricks County does well when compared to national averages. Hendricks County is below the national rate for

• teen births, • infant mortality, • preterm births,

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• low birth weight infants, and • mothers who smoke.

The County also has a higher than average rate of mothers seeking prenatal care. However, there is still more to be done, including work to expand access into surrounding counties that do not have access to prenatal care. Leading by Example HRH delivers approximately 1100 babies annually and provides a full scope of obstetric, pediatric and gynecological services. There are 3 separate physician practices with a total of 9 OB/GYN physicians in addition to our 2 Certified Nurse Midwives who practice in our Partners in Care Clinic (PIC). PIC, which has been in operation since 1993, provides care to patients who are either un-insured or Medicaid/Medicaid Pending. PIC primarily serves obstetric patients from Hendricks County, but also accepts patients from neighboring counties which do not have obstetric physicians. Prenatal classes are offered at a nominal fee of $20 and range from natural childbirth, lactation, parenting, and sibling classes to infant massage and cesarean birth. On-line classes are also available for patients who may desire this method of learning. The fee for classes may be waived for those who demonstrate financial hardship. Recognizing that not all pregnancies end in a positive outcome, select HRH Childbirth Center staff members provide perinatal bereavement services for any mother experiencing a miscarriage, stillbirth, or infant loss. A special perinatal bereavement support group meets on a regular basis, and our certified counselors offer phone support up to a year after a loss. Nationally, there is a push to reduce infant mortality by increasing the duration of breastfeeding. HRH is proud to state that 76% of our new mothers choose to breastfeed. We have 8 nurses who are certified as either Lactation Counselors or International Board of Certified Lactation Consultants. These nurses provide 1:1 couplet care to assist with the initiation and continuation of breastfeeding. Breastfeeding support group is offered every Wednesday at 1pm for any lactating mother regardless of delivery site, and this is free of charge. Private outpatient lactation consultations are also available upon request. As part of comprehensive Women’s/Children’s services, HRH offers speakers to community groups and local schools with topics as diverse as teen pregnancy, adoption, domestic violence (including teen dating violence), and drugs/alcohol education. Community Advocacy and Support In partnership with agencies such as WIC, Healthy Families, First Steps, and the Department of Child Services, HRH offers services to all cultures and residents of Hendricks County. Staff of HRH participate and collaborate with other resource services

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such as Susie’s Place, a center for abused children, and “Sheltering Wings, a local domestic violence center. HRH has recently entered into an agreement with Danville Community Schools to provide a free DVD (Period of Purple Crying) with education for new parents regarding “Shaken Baby Syndrome”, why babies cry and how to comfort them. This project began in the fall of 2013 and funding will be provided for 12 months. Our associates volunteer time and resources to help support reading programs in local day cares, food to pantries, and fund raising activities (March of Dimes, United Way, etc.). Gaps and Future Activities Access to for non-Hendricks County Residents for Obstetrical and Newborn Services While access to pre-natal and post-natal care is good in Hendricks County, HRH is aware that there is a significant need for similar services in Putnam County. Putnam County hospital no longer offers OB services and therefore access to pre- and post-natal care is difficult. HRH has agreed to work alongside Putnam County Hospital and the public health community to identify sustainable models that can help address this problematic access issue. Other Pre and Post Natal Care Gaps HRH plans to implement a no cost Postpartum Depression Support Group and “Warm” Line for those patients suffering from a perinatal mood disorder. HRH has 8 newly certified nurses trained to help patients with these issues, and the warm line will be answered within a 24-hour timeframe (as opposed to a hot line which is answered immediately). HRH also plans to increase the number of prenatal classes that are offered as they are frequently full and available times are not conducive for some community members. This should increase the number of patients and families that are receiving vital education prior to delivery. Education can reduce the number of false labor checks and increase our efficiency in transitioning patients through our system. Teen pregnancy classes will be offered again in 2014. Although we have seen a decrease in our county for teenage pregnancies, this problem has not gone away. In collaboration with Healthy Families, HRH will also re-start a teen support group that helps to teach life skills and parenting. Participation in Statewide Efforts to Improve Perinatal Care—HRH fully supports the efforts of Indiana Perinatal Network (IPN) to promulgate care guidelines for pregnant women and for neonates. If successful, the IPN will help be certain that all Indiana-based obstetrical units and nurseries are unified by common standards of care. This will build a critical foundation for reducing infant mortality in the state.

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POPULATION OF ELDERS According to CHNA, Hendricks County will experience a 29% growth in residents 65 years and older between 2010 and 2015. Nationwide, people over the age of 85 years represent the fastest growing segment of the population. Leading by Example HRH has supported the Meals on Wheels programs since 1973, providing a base of operations for the service out of our Danville hospital as well as cooking and packaging the meals themselves. Additionally, HRH staff members have served frequently as drivers for the service and on the Meals on Wheels Board. HRH has budgeted to continue this commitment for 2014 and beyond. HRH Nutrition and Dietetics has provided lunch at Hendricks County Senior Services (HCSS) Center since 2000. This service feeds approximately 140 seniors on a weekly basis. This is planned to continue over the next 3 year period as well. HRH’s relationship with HCSS extends back many years. In fact, HRH built the current HCSS building at a cost of over $1M. This building is leased for 50 years and is located on a parcel owned by the Hospital. This building is the administrative hub of the agency, and it also houses multiple services for seniors, including a fitness center, computer lab, and meeting spaces for activities and educational offerings. HRH supports the annual Hendricks County Food Pantry luncheon. This event focuses attention on the many volunteers in our county that work and maintain our local food pantries. HRH has budgeted to continue this commitment in 2013 and to continue this effort in the future. HRH donates gently used assistive devices to the HCSS loaner program on a regular basis. This loaner program allows seniors to borrow medical equipment such as canes, walkers, bedside commodes and other similar items at no cost. Community Advocacy and Support In partnership with HCSS, HRH and IU West Hospital are teaming up to improve transportation for seniors. In 2012, both health care organizations pledged $10,000 each in matching grant funds to support the operation of another van dedicated to transporting seniors to their healthcare-related appointments. This support is in addition to donations provided to subsidize the HCSS annual health fair (Prime Time Expo) which targets seniors. A member of HRH’s Management Council has served as a board member for HCSS since 2010 to provide medical and health care input to the agency’s leadership. Gaps and Future Activities Low cost and/or public transportation for seniors has been identified as a need. As mentioned above, HRH and IU West have collaborated to help address this need via the

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HCSS Link Transportation system. However, this issue is broader than what can be reasonably addressed by the healthcare providers in the area. HRH will support actions by local agencies and governmental units that increase access to transportation for this group. Recognizing the difficulties that seniors often face returning home after hospital inpatient stays, HRH is forming plans to help ease the transition back home after a hospital stay. These efforts focus on two areas: timely physician follow-up visits and increased post-discharge activity whereby the hospital “reaches beyond its walls” to decrease the risk of a re-admission to the hospital. One innovative approach to this transition was trialed in late 2012 and early 2013: Stroke/TIA Follow-up Clinic. To help coordinate care, patients who are discharged with the diagnosis of stroke or TIA (“Mini-stroke”) attend a special office visit within 2 weeks. During this single visit, the patient sees a neurologist, speech pathologist, physical therapists, and a nutritionist. These medical professionals then collaborate in the development and coordination of a follow-up plan that is shared both with the patient and the patient’s primary care physician. This program reduced the re-admission rate for stroke/TIA patients from 12.7% to 6.9%. HRH will continue this clinic in the future. In addition, HRH has placed a priority upon timely physician visits (within 2 weeks) for all seniors after a hospital stay as data suggests this also decreases the risk of re-admission. In 2014, HRH will also pilot a program that includes more intensive follow-up to certain high risk seniors after discharge from the hospital. This will include phone calls to the seniors and, in some cases, free home visits to make certain that the seniors are thriving upon discharge. This program will reduce the number of people who are re-admitted to the hospital, and help streamline the resolution of issues that often occur post discharge (such as, medication side effects or newly discovered needs for assistive devices). Submitted for Approval of the Board of Trustees in December 2013

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Appendix A CHNA Assessment Resources

• Hendricks County 2011 Community Health Needs Assessment http://www.co.hendricks.in.us/departmentwebfiles/Health/CHA_Hendricks%20County.pdf

• United Way of Central Indiana Health Assessment April 2012 www.uwci.org/programs/community-assessments

• County Health Rankings & Roadmaps sponsored by the Robert Wood Johnson Foundation

www.countyhealthrankings.org/app/indiana/2013

• INdicators maintained by the Indiana Business Research Center at IU’s Kelley School of Business and sponsored by the Indiana State Department of Health and the Indiana Hospital Association

www.indianaindicators.org

• American Fitness Index 2012 from the American College of Sports Medicine http://www.americanfitnessindex.org/docs/reports/2012_afi_report_final.pdf

• Centers for Disease Control and Prevention www.cdc.gove/datastatistics

• Community Benefit Issue Brief detailing the requirements under the Affordable

Care Act for the CHNA. http://www.healthcare.gov/prevention/nphpphc/advisorygrp/gw-community-benefit-issue-brief.pdf

• Commission on Cancer Program Standards 2012

www.facs.org/cancer

• National Accreditation Program for Breast Centers

www.napbc-breast.org

• Cancer Facts and Figures 2012 http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-031941.pdf

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APPENDIX B Support Groups  Hendricks Regional Health is proud to facilitate and host a variety of support groups for the community. Groups are designed to provide a supportive environment with opportunities to come together for sharing and learning. All meetings are free to participants, and registration is not required unless specified. Offerings include: Alzheimer's Support Group Gives support to caregivers, family and friends of those who suffer from Alzheimer's disease. Bariatric Weight Loss Support Group Offered in conjunction with our partners at St. Vincent Bariatric Center of Excellence. Designed for anyone who has had, or is considering, bariatric surgery. This support groups meets at the Hendricks Regional Health YMCA. Bereavement Support Group – Emerging This group is especially tailored to those ready to express their grief in a comforting group environment. Participants may be relatively new in their grief, or may feel they are ready to deal with a loss that is not so recent. Bereavement Support Group – Comfort Zone (Suicide Support) Intended for those who have experienced the loss of a loved one due to suicide. The goal of the group is to help members face the emotions that come with the painful realities of suicide. Bereavement Support Group – Common Ground (Perinatal / Infant Loss) Provides support for families that have experienced a loss during pregnancy or in the first weeks following childbirth. Bereavement Support Group – Maintaining Help provide ongoing support for those experiencing grief. While the group has many widowed persons whose losses occurred over the past several years, new members are very welcome. Breast Cancer Peer Support Group Created by women with breast cancer for patients and survivors alike this group gathers regularly at HRH. This group compassionately serves the newly diagnosed, those in treatment and also those in their survivorship journey. Breastfeeding Support Group This is a fun group for breastfeeding moms and their babies. This group focuses on topics such as breastfeeding while working and other concerns.

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Cancer Support Group Designed for patients and caregivers needing support after a diagnosis of cancer this group is very active and encouraging. Group attendees include those with a variety of different types of cancer diagnoses. A new specific head and neck cancer support group has been formed and is available at HRH’s Cancer Center. Diabetes Support Group Designed for any adult living with diabetes, this group is facilitated by a diabetes educator from our Center for Diabetes Excellence. Living well with diabetes can be overwhelming and this group provides support to live healthy. Fibromyalgia & Chronic Pain/Fatigue Support Group Educates, encourages, and empowers those living with chronic pain, Fibromyalgia or Chronic Fatigue Syndrome. Kidney Disease Support Group Supportive friends and family can make a huge difference in the lives of men and women dealing with kidney disease, but sometimes their support isn’t enough. Talking with others going through similar experiences can be a much-needed opportunity to share information, get advice and receive and provide support. Lifesteps® Support Group Offered to graduates of the Lifesteps® program who would like to continue making positive changes in their eating habits, activity and daily behaviors. This group is intended to provide the support that is needed to maintain the positive changes that were learned through the Lifesteps® program. Multiple Sclerosis Support Group Provides support to anyone whose life has been touched by multiple sclerosis. The group utilizes guest speakers and sharing of resources. Parkinson's Support Group Provides support to caregivers, family, and friends of those who suffer from Parkinson's Disease. The group utilizes guest speakers and sharing of resources, and meets at the Senior Center. Young Mother Support Group This group is tailored for pregnant teens, young moms (up to age 23) and their children and offers a non-judgmental, supportive atmosphere. Participants share snacks and good conversation while they share ideas and support. Any young mom is welcome, regardless of if they plan to have their baby (or have already delivered) at Hendricks Regional Health. Also, educational opportunities with the group enable participants to earn “mommy money” to spend in the Mommy Store.    

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Vision Support Group This group provides support to caregivers, family, and friends of those who suffer from vision loss. The group utilizes guest speakers and sharing of resources, and meets at the Senior Center.