Table of Contents - Center for Rural Health · 2018-06-08 · Towner County Public Health District...

Table of Contents

Executive Summary ......................................................................................................................................... 3

Overview and Community Resources ....................................................................................................... 6

Assessment Process ........................................................................................................................................ 11

Demographic Information ............................................................................................................................ 15

Health Conditions, Behaviors, and Outcomes ....................................................................................... 16

Survey Results.................................................................................................................................................... 22

Findings from Focus Group and Key Informant Interviews .............................................................. 41

Priority of Health Needs ................................................................................................................................ 44

Appendix A1 – Paper Survey Instrument ................................................................................................. 46

Appendix A2 – Online Survey Instrument ............................................................................................... 51

Appendix B – County Health Rankings Model ...................................................................................... 58

Appendix C – Prioritization of Community’s Health Needs .............................................................. 59

Appendix D – Response to Previous Assessment ............................................................................... 61

This project was supported, in part, by the Federal Office of Rural Health, Health Resources and Services Administration (HRSA) of the U.S.

Department of Health and Human Services (HHS), Medicare Rural Flexibility Hospital Grant program. This information or content and conclusions

are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or

the U.S. Government.

_____________________________________________________________________________________________ Community Health Needs Assessment 3

Executive Summary

To help inform future decisions and strategic planning, Towner County Medical Center in

Cando and Towner County Public Health District conducted a community health needs

assessment in Towner County and the surrounding area. The assessment sought input

from area community members and health care professionals as well as analysis of

community health-related data.

To gather feedback from the community, residents of the Cando area and surrounding

region were provided the opportunity to participate in a survey. Approximately 198

residents took the survey. Additional information was collected through a focus group

and key informant interviews with community members. The input from all of these

residents represented the broad interests of the community. Together with secondary

data gathered from a wide range of sources, the information gathered presents a

snapshot of health needs and concerns in the community.

The demographics of Towner County reflect the overall makeup of North Dakota in

many respects, but residents tend to be older than the state as a whole and there are

considerably more children living in poverty. Additionally, residents are less likely to

have completed a four-year degree, which can have health care workforce implications.

Data compiled by County Health Rankings show that as compared to North Dakota

generally, Towner County is in the “middle of the pack” on measures of health outcomes

and health factors. The county ranked 21st of all North Dakota counties on health

outcomes and 22nd on health factors. There is room for improvement on certain

individual factors that influence health. Factors on which Towner County was performing

poorly relative to the rest of the state included:

• Premature death

• Diabetics

• Adult obesity

• Food environment index

• Physical inactivity

• Access to exercise

opportunities

• Alcohol-impaired driving

deaths

• Uninsured residents

• Dentists

• Preventable hospital stays

• Unemployment

• Children in poverty

• Income inequality

• Children in single-parent

households

• Injury deaths


Of 78 potential community and health needs listed in the survey, residents who took the

survey chose ten needs as the most important:

Ability to retain doctors

and nurses in the area

Availability of dental care

Cancer

Cost of health insurance

Attracting and retaining

young families

Adequate childcare services

Jobs with livable wages

Obesity/overweight

Availability of resources to help

the elderly stay in their homes

Youth alcohol use and abuse

The survey also revealed that the biggest barriers to receiving health care as perceived

by community members were not enough doctors and the inability to see the same

provider over time.

When asked what the good aspects of the area were, respondents indicated that the top

community assets were:

Family-friendly; good place to raise kids

Safe place to live, little/no crime

Friendly, helpful, and supportive people

Quality health care

Input from community leaders provided via key informant interviews and a focus group

echoed many of the concerns raised by survey respondents. Thematic concerns

emerging from these sessions were:

Cost of health care services


Attracting and retaining young families


Cancer


Dementia/Alzheimer’s disease


Following careful consideration of the results and findings of this assessment,

Community Group members determined that, in their estimation, the significant health

needs or issues in the community are:



Ability to meet needs of older population

Ability to retain doctors and nurses in the area



Overview and Community Resources

The purpose of conducting a community health assessment is to describe the health of

local people, identify areas for health improvement, identify use of local health care

services, determine factors that contribute to health issues, identify and prioritize

community needs, and help health care and community leaders identify potential action

to address the community’s health needs. A health needs assessment benefits the

community by: 1) collecting timely input from the local community; 2) providing an

analysis of secondary data related to health-related behaviors, conditions, risks, and

outcomes; 3) compiling and organizing information to guide decision making, education,

and marketing efforts, and to facilitate the development of a strategic plan; and 4)

engaging community members about the future of health care. Completion of a health

assessment also is a requirement for public health departments seeking accreditation.

With assistance from Prairie Health Partners and the Center for Rural Health (CRH) at the

University of North Dakota School of Medicine and Health Sciences, Towner County

Medical Center (TCMC) and Towner County Public Health District (TCPHD) completed a

community health assessment in Towner County. Many community members and

stakeholders worked together on the assessment.

Cando, located in northeastern North Dakota, is the county seat of Towner County, the

largest durum wheat-producing county in the world. Access to major cities is within

reasonable driving distance of Cando. Winnipeg, Manitoba, is less than three hours

away, while access to major shopping and medical facilities in North Dakota is within 40

miles. Figure 1 shows the location of Towner County. In addition to Cando, other

communities in Towner County include Bisbee, Egeland, Hansboro, Perth, and Rocklake.


Figure 1: Towner County, North Dakota

Towner County Medical Center

Towner County Medical Center is a 20-bed, critical access hospital located in

Cando, North Dakota. As a hospital and accredited level V trauma center, TCMC

provides comprehensive care for wide range of medical and emergency situations.

TCMC offers many services, including inpatient and outpatient treatment facility,

retirement housing, and childcare. With approximately 130 employees, TCMC is

one of the largest employers in the region.

The original Towner County Memorial Hospital was a 26-bed hospital built in 1952

with funds raised by the people of Towner County and the Order of the Sisters of


St. Francis. The hospital nearly doubled in size in 1968 with an addition that

included new patient rooms, an ambulance garage, an emergency room, a new

laboratory, and a radiology room. In 1992, the ownership and direction of the

hospital changed based on a community initiative, and physical changes to the

facility were made in 1995 to ensure handicapped accessibility. Also added were a

new medical clinic, dental clinic, emergency room, a drive-through emergency

garage, x-ray suite, physical therapy room, nursing station, laboratory, medical

records area, and birthing room.

TCMC defines its mission as follows:

Towner County Medical Center provides: total quality comprehensive healthcare;

caring and compassionate health services for patients, residents, families and

healthcare workers; medical care for all life stages delivered by a professional and

expert healthcare team; and a commitment to our communities to maintain and

ensure the ongoing provision of quality health services.

Specific services provided locally by Towner County Medical Center are:

General and Acute Services

Cardiology (visiting physician)

Clinic

Emergency room

Gynecology (visiting physician)

Hospital (acute care)

Independent senior housing

Nutrition counseling

Obstetrics (visiting physician)

Ophthalmology evaluation and surgery services (visiting physician)

Orthopedics (visiting physician)

Pharmacy

Surgical services

Swing bed services

Screening/Therapy Services

Chiropractic services

Chronic disease

management

Holter monitoring

Laboratory services

Lower extremity circulatory assessment

Massage therapy

Occupational physicals

Occupational therapy

Pediatric services

Physical therapy

Respiratory care

Sleep studies

Social services


Radiology Services

CT scan

Digital mammography

General x-ray

Nuclear medicine (mobile unit)

MRI (mobile unit)

Ultrasound (mobile unit)

In addition to the rural health clinic and the hospital, TCMC also includes senior

independent living housing, basic care residential service, and skilled nursing residential

service in Cando.

Towner County Public Health District

Towner County Public Health District provides public health services that include

environmental health, nursing services, the WIC (women, infants, and children) program,

health screenings and education services. Each of these programs provides a wide

variety of services in order to accomplish the mission of public health, which is to assure

that North Dakota is a healthy place to live and each person has an equal opportunity to

enjoy good health. To accomplish this mission, TCPHD is committed to the promotion of

healthy lifestyles, protection and enhancement of the environment, and provision of

quality health care services for the people of North Dakota.

Specific services that TCPHD provides are:

Bicycle helmet safety education

resources

Blood pressure checks

Breastfeeding resources

Car seat program

Child health

Blood sugar testing

Emergency response and

preparedness program

Health Tracks (child health

screening)

Home visits

Immunizations

Office visits and consults

Preschool education programs

Assist with preschool screening

Radon testing kits

School health (vision screening, school

immunizations)

Tobacco Prevention and Control

Tuberculosis testing and management

West Nile program—surveillance and

education

WIC (Women, Infants & Children)

Program


Community Resources

Numerous recreational activities are available for residents of Cando with its city parks,

participatory and observational sports, athletic

fields, a swimming pool and nine-hole golf

course. Its city parks include facilities for tennis,

baseball, volleyball, basketball, and horseshoes.

The Cando All Seasons Arena offers skating and

hockey. Some of the state’s best fishing may be

found within 40 miles, and the area is abundant

with waterfowl, geese, and deer. The Cando

public school system prepares students for

vocational and post-secondary training.

Health care facilities and services in the area include those in the following list. While

some are outside of Towner County, in neighboring Ramsey and Benson counties, they

are accessible to many Towner County residents.

Basic care facilities

Cando – 5-bed basic care facility

Devils Lake – 43-bed, 13-bed, and 7-bed basic care facilities

Edmore – 15-bed basic care facility

Maddock – 21-bed basic care facility

Nursing homes

Cando – 30-bed nursing home

Devils Lake – 82-bed and 48-bed nursing homes

Rural health clinics

Cando

Maddock


Pharmacies

Cando – one retail pharmacy in addition to the TCMC pharmacy

Devils Lake – three retail pharmacies in addition to the hospital and clinic pharmacies

Maddock

Assessment Process

Prairie Health Partners, a Grand Forks-based consulting firm, working closely with the

CRH, provided substantial support to TCMC and TCPHD in conducting this needs

assessment. Professionals from Prairie Health Partners have conducted dozens of

comprehensive community health needs assessments and community development

activities in a wide variety of communities, including many rural communities. The CRH is

one of the nation’s most experienced organizations

committed to providing leadership in rural health. Its

mission is to connect resources and knowledge to

strengthen the health of people in rural communities. As

the federally designated State Office of Rural Health (SORH)

for the state and the home to the North Dakota Medicare

Rural Hospital Flexibility (Flex) program, the Center

connects the School of Medicine and Health Sciences and

the university to rural communities and their health

institutions to facilitate developing and maintaining rural

health delivery systems. In this capacity the Center works

both at a national level and at state and community levels.

The assessment process was collaborative. Professionals from both TCMC and TCPHD

were heavily involved in planning and implementing the process. They met regularly by

telephone conference and via email with representatives from Prairie Health Partners.

The process closely followed a model used during the last community health needs

assessment cycle. Towner County Medical Center did not receive any written comments

from the public on the previous community health needs assessment or its most recent

implementation strategy. In response to the previous assessment findings, TCMC

implemented a number of programs and initiatives, as detailed in Appendix D.

As part of the assessment’s overall collaborative process, Prairie Health Partners

spearheaded efforts to collect data for the assessment in a variety of ways:

• A survey solicited feedback from area residents;

• Community leaders representing the broad interests of the community took part

in one-on-one key informant interviews;


• The Community Group, comprised of community leaders and area residents, was

convened to discuss area health needs and inform the assessment process; and

• A wide range of secondary sources of data was examined, providing information

on a multitude of measures including demographics; health conditions, indicators,

and outcomes; rates of preventive measures; rates of disease; and at-risk

behaviors.

Detailed below are the methods undertaken to gather data for this assessment by

convening a Community Group, conducting key informant interviews, soliciting feedback

about health needs via a survey, and researching secondary data.

Community Group

A Community Group consisting of 10 community members was convened and first met

on April 11, 2016. During this first Community Group meeting, group members were

introduced to the needs assessment process, reviewed basic demographic information

about Towner County, and served as a focus group. Focus group topics included

community assets and challenges, the general health needs of the community,

community concerns, and suggestions for improving the community’s health.

The Community Group met again on June 6, 2016 with 25 community members in

attendance. At this second meeting the Community Group was presented with survey

results, findings from key informant interviews and the focus group, and a wide range of

secondary data relating to the general health of the population in Towner County. The

group was then tasked with identifying and prioritizing the community’s health needs.

Members of the Community Group represented the broad interests of the community

served by TCMC and TCPHD. They included representatives of the health community,

business community, political bodies, law enforcement, education, faith community,

social service agencies, and public health. Not all members of the group were present at

both meetings.

Interviews

One-on-one interviews with five key informants were conducted in person in Cando on

April 11, 2016. Representatives from Prairie Health Partners conducted the interviews.

Interviews were held with selected members of the Community Group as well as other

key informants who could provide insights into the community’s health needs. Included

among the informants were a public health professional with special knowledge in public

health acquired through several years of direct experience in the community, including

working with medically underserved, low income, and minority populations, as well as

with populations with chronic diseases.


Topics covered during the interviews included the general health of the community,

community concerns, delivery of health care by local providers, awareness of health

services offered locally, barriers to receiving health services, and suggestions for

improving collaboration within the community.

Survey

A survey was distributed to gather feedback from the community. The survey was not

intended to be a scientific or statistically valid sampling of the population. Rather, it was

designed to be an additional tool for collecting qualitative data from the community at

large – specifically, information related to community-perceived health needs and assets.

The survey was distributed to various residents of Towner County and the surrounding

area. The survey tool was designed to:

Learn of the good things in the community and the community’s concerns;

Understand perceptions and attitudes about the health of the community, and

hear suggestions for improvement; and

Learn more about how local health services are used by residents.

Specifically, the survey covered the following topics:

Residents’ perceptions about community assets

Broad areas of community and health concerns

Awareness of local health services

Barriers to using local health care

Potential financial support for the hospital from the community

Basic demographic information

Suggestions to improve the delivery of local health care

Approximately 600 community member surveys were available for distribution. To

promote awareness of the assessment process, press releases led to published articles in

three newspapers in Towner and Rolette counties including in the communities of Rolla,

Bisbee, Starkweather, Minnewauken, and Leeds. Additionally, information was published

on TCMC’s Facebook page and on its website.

The surveys were distributed by Community Group members and at TCMC, TCPH, and

area businesses. To help ensure anonymity, each survey included a postage-paid return

envelope to the CRH. In addition, to help make the survey as widely available as possible,

residents also could request a survey by calling TCMC or TCPHD. Area residents also

were given the option of completing an online version of the survey, which was

publicized in local newspapers and on the websites of both TCMC and TCPH.


The survey period ran from March 1 to April 8, 2016, and 101 paper surveys were

returned, while 97 online electronic surveys were taken. In total, counting both paper and

online surveys, 198 community member surveys were submitted. The response rate is on

par for this type of unsolicited survey methodology and indicates an engaged

community.

Secondary Data

Secondary data was collected and analyzed to provide descriptions of: (1) population

demographics, (2) general health issues (including any population groups with particular

health issues), and (3) contributing causes of community health issues. Data were

collected from a variety of sources including the U.S. Census Bureau; the Robert Wood

Johnson Foundation’s County Health Rankings (which pulls data from more than 20

primary data sources); the National Survey of Children’s Health Data Resource Center;

the Centers for Disease Control and Prevention; the North Dakota Behavioral Risk Factor

Surveillance System; and the National Center for Health Statistics.


Demographic Information

Table 1 summarizes general demographic and geographic data about Towner County.

TABLE 1: TOWNER COUNTY - INFORMATION AND DEMOGRAPHICS

(From 2010 Census/2014 American Community Survey; more recent estimates used where available)

Towner County

North Dakota

Population.) 2,310 739,482

Population change (2010-2014) 2.8% 9.9%

People per square mile (2010) 2.2 9.7

Persons 65 years or older (2014 est.) 23.5% 14.2%

Persons under 18 years (2014 est.) 21.7% 22.8%

Median age (2014 est.) 48.8 35.9

White persons (2014 est.) 94.4% 89.1%

Non-English speaking (2014 est.) 0.6% 5.4%

High school graduates (2014 est.) 92.2% 91.3%

Bachelor’s degree or higher (2014 est.) 18.8% 27.3%

Live below poverty line 10.9% 11.5%

Children under 18 in poverty (2013) 21.5% 14.1%

While the population of North Dakota has grown in recent years, the population of

Towner County has seen more modest growth between 2010 and 2014. The data show

that the area is rural and that its residents are considerably older than the state as a

whole. Nearly one in four residents is aged 65 or older, and the median age is

approximately 13 years older than the state median age. Area residents also are less

likely to have completed a four-year degree, which can have health care workforce

implications. While overall poverty in Towner County is slightly less than the state rate,

the rate of children in poverty is substantially higher that the state average, with more

than one in five children in the county living in poverty.


Health Conditions, Behaviors, and Outcomes As noted above, several sources of secondary data were reviewed to inform this

assessment. The data are presented below in two categories: County Health Rankings

and children’s health.

County Health Rankings

The Robert Wood Johnson Foundation, in collaboration with the University of Wisconsin

Population Health Institute, has developed County Health Rankings to illustrate

community health needs and provide guidance for actions toward improved health. In

this report, Towner County is compared to North Dakota rates and national benchmarks

on various topics ranging from individual health behaviors to the quality of health care.

The data used in the 2016 County Health Rankings are pulled from more than 20 data

sources and then are compiled to create county rankings. Counties in each of the 50

states are ranked according to summaries of a variety of health measures. Those having

high ranks, such as 1 or 2, are considered to be the “healthiest.” Counties are ranked on

both health outcomes and health factors. As shown in Table 2 below, Towner County

ranks 21st out of 49 ranked counties in North Dakota on health outcomes and 22nd on

health factors.

Below is a breakdown of the variables that influence a county’s rank. A model of the

2016 County Health Rankings – a flow chart of how a county’s rank is determined – may

be found in Appendix B. For further information, visit the County Health Rankings

website at www.countyhealthrankings.org.

http://www.countyhealthrankings.org/


Table 2 summarizes the pertinent information gathered by County Health Rankings as it

relates to Towner County. It is important to note that these statistics describe the

population of a county regardless of where county residents choose to receive their

medical care. In other words, all of the following statistics are based on the health

behaviors and conditions of the county’s residents, not necessarily the patients and

clients of Towner County Medical Center, Towner County Public Health District, or of any

other particular medical facilities.

For most of the measures included in the rankings, the County Health Rankings’ authors

have calculated the “Top U.S. Performers” for 2016. The Top Performer number marks

the point at which only 10% of counties in the nation do better, i.e., the 90th percentile

or 10th percentile, depending on whether the measure is framed positively (such as high

school graduation) or negatively (such as adult smoking).

As shown in the key below, the measures listed in Table 2 marked with a red checkmark

() are those where a county is not measuring up to the state rate/percentage; a blue

checkmark () indicates that the county may be faring better than the North Dakota

average, but is not meeting the U.S. Top 10% rate on that measure. Measures marked

with a smiling icon () indicate that the county is in the U.S. Top 10% of counties on that

measure.


TABLE 2: SELECTED MEASURES FROM 2016 COUNTY HEALTH RANKINGS

Towner County

U.S. Top 10% North Dakota

Ranking: Outcomes 21st (of 49)

Premature death 7,000 5,200 6,600

Poor or fair health 12% 12% 14%

Poor physical health days (in past 30 days) 2.6 2.9 2.9

Poor mental health days (in past 30 days) 2.6 2.8 2.9

% Diabetic 11% 9% 8% Ranking: Factors 22nd (of 49)

Health Behaviors

Adult smoking 16% 14% 20% Adult obesity 31% 25% 30%

Food environment index 6.5 8.3 8.4

Physical inactivity 29% 20% 25%

Access to exercise opportunities 52% 91% 66%

Excessive drinking 20% 12% 25% Alcohol-impaired driving deaths 100% 14% 47% Sexually transmitted infections 258.8 134.1 419.1 Teen birth rate 25 19 28

Clinical Care

Uninsured 14% 11% 12%

Primary care physicians - 1,040:1 1,260:1

Dentists 2,310:0 1,340:1 1,690:1

Mental health providers 390:1 370:1 610:1

Preventable hospital stays 76 38 51

Diabetic monitoring 88% 90% 86%

Mammography screening 71% 71% 68%

Social and Economic Factors Unemployment 3.9% 3.5% 2.8%

Children in poverty 17% 13% 14% Income inequality 5.1 3.7 4.4 Children in single-parent households 28% 21% 27% Violent crime 0 59 240 Injury deaths 88 51 63

Physical Environment Air pollution – particulate matter 9.6 9.5 10.0 Drinking water violations No No Severe housing problems 5% 9% 11%

= County is worse than the state average

= County is not meeting the Top 10% nationally

= County in Top 10% nationally


The data from County Health Rankings show that Towner County is in top 10% of

counties nationally on a number of studied measures:

• Self-reported poor or fair health

• Self-reported poor physical health

days

• Self-reported poor mental health days

• Mammography screening

• Violent crime

• Severe housing problems

The data revealed, however, that Towner County is faring worse than North Dakota

averages on the following measures:

• Premature death

• Diabetics

• Adult obesity

• Food environment index

• Physical inactivity

• Access to exercise opportunities

• Alcohol-impaired driving deaths

• Uninsured residents

• Dentists

• Preventable hospital stays

• Unemployment

• Children in poverty

• Income inequality

• Children in single-parent households

• Injury deaths

Other measures where Towner County tended to do better than the state overall, but was

not performing in the top 10% of counties nationally were:

• Adult smoking

• Excessive drinking

• Sexually transmitted infections

• Teen birth rate

• Mental health providers

• Diabetic monitoring

• Air pollution – particulate matter

Children’s Health

The National Survey of Children’s Health touches on multiple intersecting aspects of

children’s lives. Data is not available at the county level; listed below is information about

children’s health in North Dakota. The full survey includes physical and mental health

status, access to quality health care, and information on the child’s family, neighborhood,

and social context. Data are from 2011-12. More information about the survey may be

found at: www.childhealthdata.org/learn/NSCH.

Key measures of the statewide data are summarized below. The rates highlighted in red

signify that the state is faring worse on that measure than the national average.


TABLE 3: SELECTED MEASURES REGARDING CHILDREN’S HEALTH (For children aged 0-17 unless noted otherwise)

Health Status North

Dakota National

Children born premature (3 or more weeks early) 10.8% 11.6%

Children 10-17 overweight or obese 35.8% 31.3%

Children 0-5 who were ever breastfed 79.4% 79.2%

Children 6-17 who missed 11 or more days of school 4.6% 6.2%

Health Care

Children currently insured 93.5% 94.5%

Children who had preventive medical visit in past year 78.6% 84.4%

Children who had preventive dental visit in past year 74.6% 77.2%

Young children (10 mos.-5 yrs.) receiving standardized screening for developmental or behavioral problems

20.7% 30.8%

Children aged 2-17 with problems requiring counseling who received needed mental health care

86.3% 61.0%

Family Life

Children whose families eat meals together 4 or more times per week 83.0% 78.4%

Children who live in households where someone smokes 29.8% 24.1%

Neighborhood

Children who live in neighborhood with a park, sidewalks, a library, and a community center

58.9% 54.1%

Children living in neighborhoods with poorly kept or rundown housing 12.7% 16.2%

Children living in neighborhood that’s usually or always safe 94.0% 86.6%

The data on children’s health and conditions reveal that while North Dakota is doing

better than the national averages on some measures, it is not measuring up to the

national averages with respect to:

Obese or overweight children

Children with health insurance

Preventive primary care and dentist visits

Developmental/behavioral screening

Children in smoking households

Table 4 includes selected county-level measures regarding children’s health in North

Dakota. The data come from North Dakota KIDS COUNT, a national and state-by-state

effort to track the status of children, sponsored by the Annie E. Casey Foundation. KIDS

COUNT data focus on main components of children’s well-being; more information

about KIDS COUNT is available at www.ndkidscount.org. The measures highlighted in

red in the table are those in which that county is doing worse than the state average.

The year of the most recent data is noted.


The data show that Towner suffers from higher rates of uninsured children and a lack of

licensed childcare services. Notably, the number of uninsured children living in

households below 200% of the poverty rate is nearly 15 points higher than the state rate.

TABLE 4: SELECTED COUNTY-LEVEL MEASURES REGARDING CHILDREN’S HEALTH

Towner County

North Dakota

Uninsured children (% of population age 0-18), 2014 8.3% 7.0%

Uninsured children below 200% of poverty (% of population), 2013

60.5% 45.8%

Medicaid recipient (% of population age 0-20), 2015 28.3% 27.9%

Children enrolled in Healthy Steps (% of population age 0-18), 2013

2.9% 2.5%

Supplemental Nutrition Assistance Program (SNAP) recipients (% of population age 0-18), 2015

15.3% 20.7%

Licensed childcare capacity (% of population age 0-13), 2016 37.0% 44.5%


Survey Results

As noted above, 198 community members took the survey in communities throughout

the assessment area. Survey results are reported below in five categories:

Demographics/health insurance status

Community assets

Community concerns

Delivery of health care

Potential financial support for TCMC

Throughout this report, numbers (N) instead of percentages (%) are reported because

percentages can be misleading with smaller numbers. Survey respondents were not

required to answer all survey questions; they were free to skip any questions they

wished. Because the intent of the survey was to gather as much information as possible,

responses from incomplete surveys were not excluded from the final results.

Demographics/Health Insurance Status

To better understand the perspectives being offered by survey respondents, survey-

takers were asked a few demographic questions. With respect to demographics of those

who chose to take the survey:

The survey attracted a fairly even distribution of ages. The most represented

groups were those aged 55 to 64 and 45 to 54, with 47 and 35 respondents,

respectively.

The large majority were female, with a ratio of female-to-male of nearly two-to-

one.

A majority (N=98) worked full-time, with retirees (N=44) being the next largest

group.

More than half of respondents (N=101) had an associate’s degrees or higher,

with a plurality of respondents (N=49) having bachelor’s degrees.

Of respondents who chose to provide household income, the two most

represented groups (N=40 for each) were those reporting income in the ranges

of $25,000 to $49,999 and $50,000 to $74,999.

Figure 2 shows these demographic characteristics. It illustrates the wide range of

community members’ household income and indicates how this assessment took into

account input from parties who represent the varied interests of the community served,

including wide age ranges, those in diverse work situations, and lower-income

community members. Of those who provided a household income, 13 community

members reported a household income of less than $25,000, with three of those


indicating a household income of less than $15,000. Of survey-takers who chose to

identify their race or ethnicity, 169 were white and two were American Indian.

Figure 2: Demographics of Survey Respondents

2

277

35

47

30

25

118 to 24 years

25 to 34 years

35 to 44 years

45 to 54 years

55 to 64 years

65 to 74 years

75 years and older

Less than 18 years

Age

110

59

1Gender

Female

Male

Transgender

98

203

100

44

Full time

Part time

Homemaker

Multiple job holder

Unemployed

Retired

Employment status2

28

45

32

49

20

Less than high school

High school diploma orGED

Some college/technicaldegree

Associate's degree

Bachelor's degree

Graduate orprofessional degree

Highest Education

3

10

40

40

26

12

11

27

0 25 50

Less than $15,000

$15,000 to $24,999

$25,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $149,999

$150,000 and over

Prefer not to answer

Household income


Survey takers were asked whether they worked for the hospital, clinic, or public health unit.

As shown in Figure 3, 144 responded they did not work for these health organizations,

while 32 said they did.

Figure 3: Work for Hospital, Clinic or Public Health?

Community members were asked about their health insurance status. Health insurance

status often is associated with whether people have access to health care. A large majority

of respondents (N=132) reported having insurance that was self-purchased or through

their employer. Fifty-five reported having Medicare. Three respondents said they had no

insurance or were underinsured.

Figure 4: Insurance Status

32

144

Yes No

1

1

2

7

12

16

55

132

0 20 40 60 80 100 120 140

No insurance

Indian Health Service (IHS)

Not enough insurance

Medicaid

Veteran’s Health Care Benefits

Other

Medicare

Insurance through employer or self-purchased


Community Assets

Survey-takers were asked what they perceived as the best things about their community

in four categories: people, services and resources, quality of life, and activities. In each

category, respondents were given a list of choices and asked to pick the three best

things. Respondents occasionally chose less than three or more than three choices within

each category. The results indicate there is consensus (with 120 or more respondents

agreeing) that community assets include:

Family-friendly; good place to raise kids (N=149)

Safe place to live, little/no crime (N=145)

Friendly, helpful, and supportive people (N=137)

Quality health care (N=122)

Figures 5 to 8 illustrate the results of these questions.

Figure 5: Best Things about the PEOPLE in Your Community

11

11

22

29

44

89

116

137

0 50 100 150

People are tolerant, inclusive and open-minded

Other

Sense that you can make a difference through civicengagement

Government is accessible

Community is socially and culturally diverse orbecoming more diverse

Feeling connected to people who live here

People who live here are involved in their community

People are friendly, helpful, supportive


Figure 6: Best Things about the SERVICES AND RESOURCES in Your Community

Figure 7: Best Things about the QUALITY OF LIFE in Your Community

Figure 8: Best Thing about the ACTIVITIES in Your Community

2

9

20

25

30

31

41

93

112

122

0 50 100 150

Opportunities for advanced education

Other

Business district (restaurants, availability of goods)

Access to healthy food

Community groups and organizations

Programs for youth

Public transportation

Active faith community

Quality school systems

Health care

6

14

72

104

145

149

0 50 100 150

Other

Job opportunities or economic opportunities

Informal, simple, laidback lifestyle

Closeness to work and activities

Safe place to live, little/no crime

Family-friendly; good place to raise kids

9

52

60

79

84

113

0 50 100 150

Other

Local events and festivals

Year-round access to fitness opportunities

Arts and cultural activities

Activities for families and youth

Recreational and sports activities


Community Concerns

At the heart of this community health assessment was a section on the survey asking

survey-takers to review a wide array of potential community and health concerns in

seven categories and asked to pick the top three concerns. The seven categories of

potential concerns were:

Community health

Availability of health services

Safety/environmental health

Delivery of health services

Physical health

Mental health and substance abuse

Senior population

The three most highly voiced concerns, chosen by at least 100 respondents, were:

Ability to retain doctors and nurses in the area (N=111)

Availability of dental care (N=101)

Cancer (N=100)

The other issues that were chosen by at least 80 survey-takers were:

Cost of health insurance (N=95)

Attracting and retaining young families (N=92)

Adequate childcare services (N=87)

Jobs with livable wages (N=87)

Obesity/overweight (N=87)

Availability of resources to help the elderly stay in their homes (N=82)

Youth alcohol use and abuse (N=80)

Examining the survey responses from those who indicated they worked for a health care

organization reveals that health care professionals generally share the same concerns as

community members. One exception was that health care professionals ranked as a

lower concern the ability to retain doctors and nurses in the area. While all respondents

ranked that as the most important concern, health care professionals ranked it as the

12th most important concern. Both groups ranked highly the availability of dental care,

cancer, and the cost of health insurance. Top concerns of health care professionals (those

chosen by at least 15 health care professionals) were:


Cost of health insurance (N=24)

Availability of dental care (N=23)

Adequate childcare services (N=18)

Cancer (N=18)

Obesity/overweight (N=17)

Attracting and retaining young families (N=16)

Jobs with livable wages (N=15)

Figures 9 through 15 illustrate these results.

Figure 9: Community Health Concerns – All Respondents

Figure 9A: Community Health Concerns – Health Care Professionals Only

7

18

27

31

35

35

35

87

87

92

0 50 100 150

Other

Poverty

Adequate youth activities

Change in population size (increase or decrease)

Affordable housing

Access to exercise and wellness activities

Adequate school resources




1

2

2

5

5

6

8

15

16

18

0 25

Other

Adequate youth activities

Adequate school resources

Poverty

Change in population size (increase or decrease)

Affordable housing

Access to exercise and wellness activities





Figure 10: Availability of Health Services Concerns – All Respondents

Figure 10A: Availability of Health Services Concerns – Health Care Professionals Only

9

10

17

20

21

38

54

69

71

101

0 50 100 150

Availability of substance abuse/treatment services

Other

Availability of public health professionals

Availability of wellness/disease prevention services

Ability to get appointments

Availability of mental health services

Availability of specialists

Availability doctors and nurses

Availability of vision care


0

0

1

1

3

5

9

11

13

23

0 25

Availability of public health professionals

Ability to get appointments

Availability of substance abuse/treatment services

Availability of wellness/disease prevention services

Other

Availability doctors and nurses

Availability of specialists

Availability of vision care

Availability of mental health services



Figure 11: Safety/Environmental Health Concerns – All Respondents

Figure 11A: Safety/Environmental Health Concerns – Health Care Professionals Only

2

11

13

20

23

26

34

36

37

45

61

0 50 100 150

Low graduation rates

Other

Air quality

Physical violence, domestic violence…

Land quality (litter, illegal dumping)

Prejudice, discrimination

Public transportation (options and cost)

Traffic safety (speeding, road safety,…

Crime and safety

Water quality (well water, lakes, rivers)

Emergency services (ambulance & 911) available 24/7

1

1

1

2

2

3

4

5

7

7

8

0 25

Low graduation rates

Physical violence, domestic violence…

Crime and safety

Air quality

Land quality (litter, illegal dumping)

Other

Public transportation (options and cost)

Water quality (well water, lakes, rivers)

Prejudice, discrimination

Traffic safety (speeding, road safety, drunk/distracted…

Emergency services (ambulance & 911) available 24/7


Figure 12: Delivery of Health Services Concerns – All Respondents

Figure 12A: Delivery of Health Services Concerns – Health Care Professionals Only

4

5

7

12

17

20

26

51

74

95

111

0 50 100 150

Adequacy of Indian Health or Tribal Health services

Other

Providers using electronic health records

Sharing of information between healthcare providers

Quality of care

Extra hours for appointments, such as evenings and…

Patient confidentiality

Cost of prescription drugs




0

1

1

1

2

3

8

9

13

14

24

0 50

Adequacy of Indian Health or Tribal Health services

Extra hours for appointments, such as evenings and…

Other

Providers using electronic health records

Quality of care

Sharing of information between healthcare providers

Patient confidentiality

Cost of prescription drugs





Figure 13: Physical Health Concerns – All Respondents

Figure 13A: Physical Health Concerns – Health Care Professionals Only

3

4

4

5

13

18

21

21

39

40

61

87

100

0 50 100 150

Sexual health (including sexually transmitted diseases/AIDS)

Teen pregnancy

Other

Youth sexual health (including sexually transmitted…

Lung disease (emphysema, COPD, asthma, etc.)

Youth hunger and poor nutrition

Wellness and disease prevention, including vaccine-…

Youth obesity

Heart disease

Poor nutrition, poor eating habits

Diabetes

Obesity/overweight

Cancer

0

0

0

2

2

2

3

5

6

6

14

17

18

0 25

Youth sexual health

Teen pregnancy

Sexual health (including sexually transmitted diseases/AIDS)

Other

Youth obesity

Youth hunger and poor nutrition

Lung disease (emphysema, COPD, asthma, etc.)

Poor nutrition, poor eating habits

Heart disease

Wellness and disease prevention, including vaccine-preventable diseases

Diabetes

Obesity/overweight

Cancer


Figure 14: Mental Health and Substance Abuse Concerns – All Respondents

Figure 14A: Mental Health and Substance Abuse Concerns – Health Care Professionals Only

0

1

4

15

20

21

27

38

42

52

52

71

80

0 50 100 150

Adult suicide

Other

Youth suicide

Youth mental health

Youth tobacco use (exposure to second-hand smoke, use of…

Adult tobacco use (exposure to second-hand smoke, use of…

Adult mental health

Adult drug use and abuse (including prescription drug abuse)

Stress

Depression

Youth drug use and abuse (including prescription drug abuse)

Adult alcohol use and abuse (including binge drinking)

Youth alcohol use and abuse (including binge drinking)

0

1

1

2

4

4

5

6

7

8

12

13

13

0 25

Adult suicide

Other

Youth suicide

Adult tobacco use (exposure to second-hand smoke, use ofalternate tobacco products such as e-cigarettes, vaping,…

Youth drug use and abuse (including prescription drug abuse)

Youth tobacco use (exposure to second-hand smoke, use ofalternate tobacco products such as e-cigarettes, vaping,…

Adult drug use and abuse (including prescription drug abuse)

Adult mental health

Youth mental health

Stress

Depression

Adult alcohol use and abuse (including binge drinking)

Youth alcohol use and abuse (including binge drinking)


Figure 15: Senior Population Concerns – All Respondents

Figure 15A: Senior Population Concerns – Health Care Professionals Only

4

8

21

31

44

45

49

57

78

82

0 50 100 150

Elder abuse

Other

Cost of activities for seniors

Long-term/nursing home care options

Availability of resources for family and friends caringfor elders

Availability of activities for seniors



Assisted living options

Availability of resources to help the elderly stay intheir homes

1

3

4

5

6

8

8

9

13

14

0 25

Elder abuse

Other

Cost of activities for seniors

Long-term/nursing home care options

Availability of activities for seniors


Availability of resources for family and friendscaring for elders


Assisted living options

Availability of resources to help the elderly stay intheir homes


In an open-ended question, residents were asked generally what are the challenges

facing their community. Seventy-nine survey-takers provided responses to this question.

The large majority of these comments (N=26) cited economic concerns, including the

lack of well-paying jobs, inadequate economic development, lack of economic diversity,

and poverty. The next most commonly listed concern (N=16) was the lack of community

amenities, especially restaurants and retail shopping. Other concerns noted by

community members were declining population and the inability to attract and retain

young people (N=10), lack of a full-time physician (N=9), challenges filling certain jobs

(N=6), the aging population (N=5), lack of daycare (N=4), and lack of affordable housing

(N=4).

In another open-ended question, residents were asked to further share other concerns

and suggestions to improve the delivery of local health care. Forty survey-takers

provided responses to this question. The most common comments concerned the desire

for physician services (mentioned by 11 respondents) and praise for the local hospital, its

staff, and services (mentioned by 10 respondents). Also cited was dissatisfaction with the

hospital’s billing services. Specific comments provide some insights into residents’

perception of these issues:

I think the health care availability is excellent for a rural county.

I am grateful TCMC is close enough and provides good care, with respect and compassion.

Thank you for the service you provide.

Overall quite happy, glad to have a hospital and clinic. Would like to see them get a doctor.

We have good nurse practitioners, chiropractors, and physical therapists, but need a doctor.

We have excellent care providers (PA's) but we do need a MD in the area to serve at will at

TCMC. When asked who my doctor is all I can say is "I don't have one." It's kind of sad to

have a great medical facility and no MD.

The clinic, hospital, nursing home, etc. are very important to the community and one of the

reasons older residents stay in the community as long as they are able.

Delivery of Health Care

The survey asked residents what they see as preventing them or others from receiving

health care locally. The most prevalent barrier perceived by residents was not enough

doctors (N=49), followed by the inability to see the same provider over time (N=41).

Figure 16 illustrates these results.


Figure 16: Perceptions about Barriers to Care

The survey revealed that, by a large margin, for trusted health information residents turn

to a primary care provider (doctor, nurse practitioner, physician assistant). Other

common sources of trusted health information are other health care professionals

(nurses, chiropractors, dentists, etc.) and web searches/Internet (WebMD, Mayo Clinic,

Healthline, etc.).

0

0

0

3

4

4

9

10

16

17

17

19

26

27

29

41

49

0 25 50

Limited access to telehealth technology

Lack of disability access

Don’t speak language or understand culture

Lack of services through Indian Health Service

Not able to get appointment/limited hours

Can’t get transportation services

Poor quality of care

Distance from health facility

Don’t know about local services

Other

Not enough evening or weekend hours

Not enough specialists

No insurance or limited insurance

Not affordable

Concerns about confidentiality

Not able to see same provider over time

Not enough doctors


Figure 17: Sources of Trusted Health Information

The survey asked community members whether they were aware of (or have used)

services offered locally by Towner County Medical Center. Among services offered by the

hospital, community members were most aware of:

Clinic (N=167)

General x-ray (N=139)

Laboratory services (N=136)

Chiropractic services (N=134)

Emergency room (N=131)

Community members were least aware of the following services:

Mental health services (N=11)

Dermatology services (N=13)

Speech therapy (N=21)

OB/Gyn services (N=26)

Surgical services (N=26)

These services with lower levels of awareness may present opportunities for further

marketing, greater utilization, and increased revenue. Figures 18 to 20 illustrate

community members’ awareness of services.

4

27

54

71

85

140

0 50 100 150

Other

Public health professional

Word of mouth, from others (friends, neighbors, co-workers, etc.)

Web searches/Internet (WebMD, Mayo Clinic,Healthline, etc.)

Other health care professionals (nurses, chiropractors,dentists, etc.)

Primary care provider (doctor, nurse practitioner,physician assistant)


Figure 18: Awareness of General and Acute Services

Figure 19: Awareness of Screening/Therapy Services

11

13

26

26

35

37

48

52

59

63

67

69

74

77

106

111

131

134

167

0 50 100 150 200

Mental health services

Dermatology services

OB/Gyn services

Surgical services

eEmergency

Telemedicine

Ophthalmology (eye/vision) (visiting specialist)

DOT physicals

Orthopedic (visiting specialist)

Joint injections

Oncology (visiting specialist)

Cardiology (visiting specialist)

Endoscopic surgery (colonoscopy, EGD)

Swing bed and respite care services

Hospital (acute care)

Vaccinations

Emergency room

Chiropractic services

Clinic

21

31

46

54

58

68

69

74

84

111

115

136

0 50 100 150 200

Speech therapy

Dietary consults

Social services

Sleep studies

Occupational therapy

Diabetes screening/treatment

Cancer screenings

Cardiac stress testing

Well-child/adult yearly physicals

Physical therapy

Massage therapy

Laboratory services


Figure 20: Awareness of Radiology Services

In an open-ended question, survey-takers were asked what specific health care services,

if any, should be added locally. Forty-five respondents provided suggestions. The most

common requests were: a dentist (N=11), a physician (N=10), education services, such

as nutrition and health counseling (N=4), and enhancement to fitness services, such as

additional equipment and classes (N=3).

52

60

71

78

84

92

111

139

0 50 100 150 200

Echocardiogram

DEXA scan (osteoporosis screening)

MRI

Ultrasound

EKG—Electrocardiography

CT scan

Mammography

General x-ray


Potential Financial Support for TCMC

The survey asked residents, “Which improvements to Towner County Medical Center would you

be willing to financially support through private donations or a sales tax (e.g., a 1-cent sales

tax)?” Residents were most likely to support an improved or expanded fitness facility (N=56) and

a security system (for both patients and staff) (N=49). Thirty-eight respondents said they would

be unwilling to support any of the proposed improvements. Figure 21 shows these results.

Figure 21: Which Improvements Would You Support?

18

23

24

32

38

49

56

0 25 50 75

Other

New wall treatments (wallpaper, paint, etc.) in clinicfacility

New furniture in clinic facility

New flooring in clinic facility

I would not support any of these

Security system (for both patients and staff)

Improved or expanded fitness facility


Findings from Focus Group and Key Informant Interviews

Questions about the health and well-being of the community, similar to those posed in

the survey, were explored during key informant interviews with community leaders and

health professionals. The themes that emerged from these sources were wide-ranging,

with some directly associated with health care and others more rooted in broader

community matters. Some issues were similar to those that emerged from the survey,

while others were not reflected in survey responses. Seven issues were raised:





Cancer



To provide context for these expressed needs, below are some of the comments that

interviewees made about these issues:


It’s a great convenience to have health care services here, but they’re really

expensive.

There is some perception in community that the hospital is for-profit.

It’s not just the cost, it’s that the hospital billing service is difficult to work with.

Expensive costs are exacerbated by many patients’ low wages.


There is a real need for quality childcare for children younger than school age.

Lack of daycare services has led some parents to quit jobs or move.

We need someone to take the lead and look at other communities who have tackled the

daycare issue with success.


Many baby boomers are retiring. We need to keep young people here.


Teachers often stay here only a year and then leave.

There is not a lot bringing young people here. Many need to have multiple jobs to earn

enough.

Unless you have ties here, there’s no real incentive to move here.


There’s no dentist in town.

We are in dire need of both a dentist and a doctor.

Cancer

There is lots of cancer here.

There is confusion about whether insurance covers cancer screenings.


A lot of people are opting not to have insurance and now have stopped filing tax returns to

avoid penalties.

Social services not outreaching to educate people about insurance options.

People are not getting care because they don’t have insurance.


We don’t have services for Alzheimer’s.

Caregivers are exhausted, especially the ones taking care of those with Alzheimer’s.

Focus group participants and key informants also were asked to weigh in on community

engagement and collaboration of various organizations and stakeholders in the

community. Specifically, participants were asked, “On a scale of 1 to 5, with 1 being no

collaboration/community engagement and 5 being excellent collaboration/community

engagement, how would you rate the collaboration/engagement in the community

among these various organizations?” They were then presented with a list of 12

organizations or community segments to rank. According to these participants, the

hospital, pharmacies, and schools are the most engaged in the community, while other

local health providers and human services/social services are viewed as having the most

room for improvement. The averages of these rankings (with 5 being “excellent”

engagement or collaboration) were:

Hospital (healthcare system) – 4.3

Pharmacies – 4.1


Schools – 4.1

Faith-based – 3.9

Public Health – 3.9

Law enforcement – 3.7

Economic development organizations – 3.6

Long term care, including nursing homes and assisted living – 3.6

Business and industry – 3.5

Emergency services, including ambulance and fire – 3.5

Human services/social services – 3.0

Other local health providers, such as dentists and chiropractors – 3.0


Priority of Health Needs

The Community Group met again on June 6, 2016. Twenty-five community members of

the group attended the meeting. Representatives from Prairie Health Partners presented

the group with a summary of this report’s findings, including background and

explanation about the secondary data, highlights from the survey results (including

perceived community assets and concerns, and barriers to care), and findings from the

focus group and key informant interviews.

Following the presentation of the assessment findings, and after consideration of and

discussion about the findings, all members of the group were asked to identify what they

perceived as the top four community health needs. All of the potential needs were listed

on large poster boards, and each member was given four stickers so they could place a

sticker next to each of the four needs they considered the most significant.

The results were totaled, and the concerns most often cited were:

Ability to meet needs of older population (13 votes)

Cost of health insurance (11 votes)

Attracting and retaining young families (9 votes)

Adequate childcare services (8 votes)

Ability to retain doctors and nurses in the area (7 votes)

In a second round of “voting,” each member of the group was then given one additional

red sticker to place next to the concern that they believed was the most important

priority of the top five highest ranked priorities. In this second round of voting, where

participants were asked to pick “the” most important concern, the group chose the cost

of health insurance as the most pressing concern. The order of the prioritized needs

changed slightly in this second round of voting:

Cost of health insurance (9 votes)

Attracting and retaining young families (6 votes)

Ability to meet needs of older population (4 votes)

Ability to retain doctors and nurses in the area (3 votes)

Adequate childcare services (1 vote)

A summary of this prioritization may be found in Appendix C. Table 5 shows the

currently prioritized needs along with those prioritized by the community in the previous


community health needs assessment. While concerns about health care workforce and

health care insurance were prioritized in both assessments, the current assessment

revealed additional emerging concerns of the community.

TABLE 5: COMPARISON OF PRIORITIZED NEEDS FROM PREVIOUS ASSESSMENT

CURRENT CHNA PREVIOUS CHNA


Attracting and retaining young

families

Ability to meet needs of older

population

Ability to retain doctors and

nurses in the area


Access to needed

equipment/facility update

Chronic disease management

Financial viability of hospital

Health care workforce

shortage

Uninsured adults


Appendix A1 – Paper Survey Instrument


Appendix A2 – Online Survey Instrument


Appendix B – County Health Rankings Model


Appendix C – Prioritization of Community’s Health Needs

Community Health Needs Assessment

Cando, North Dakota

Ranking of Concerns

The top four concerns for each of seven topic areas, based on the community survey results, along with other concerns

from other data sources, were listed on flipcharts. The numbers below indicate the total number of votes (indicated by

placement of dots on the flipcharts) by participating Community Group members. The “Priorities” column lists the number

of yellow/green/blue dots placed on the concerns indicating which areas were perceived to be priorities. Each participant

was given four dots to place on the items they felt were priorities. After the first round of voting, the top five priorities were

selected based on the highest number of votes. Each person was then given one dot to place on the item they viewed as

the most important priority of those top five highest ranked priorities. The “’Red Dot’ Round” column lists the number of

red dots placed on the flipcharts.

Priorities “Red Dot” Round

DELIVERY OF HEALTH SERVICES

Ability to retain doctors and nurses in the area Cost of health insurance Cost of health care services Cost of prescription drugs

7 11 1

3 9

AVAILABILITY OF HEALTH SERVICES

Availability of dental care Availability of vision care Availability of doctors and nurses Availability of specialists

3 1 3

MENTAL HEALTH AND SUBSTANCES ABUSE

Youth alcohol use and abuse Adult alcohol use and abuse Youth drug use and abuse Depression

3

3 1

SAFETY/ENVIRONMENTAL HEALTH

Emergency services (ambulance & 911) available 24/7 Water quality (well water, lakes, rivers) Crime and safety Traffic safety

4

2

SENIOR POPULATION

Availability of resources to help the elderly stay in their homes Assisted living options

6 3


Ability to meet needs of older population Dementia/Alzheimer’s disease

13 2

4

COMMUNITY HEALTH

Attracting and retaining young families Jobs with livable wages Adequate childcare services

9 3 8

6

1

PHYSICAL HEALTH

Cancer Obesity/overweight Diabetes Poor nutrition, poor eating habits

2

1 1

OTHER CONCERNS

Food environment index Physical inactivity/access to exercise opportunities Uninsured residents Unemployment Children in poverty Income inequality Children in single-parent households Injury deaths

1 4

6


Appendix D – Response to Previous Assessment

Implementation Strategy Planning Report

Towner County Medical Center

Facilitated by

Ken Hall, JD

Karin Becker, PhD candidate

Center for Rural Health

The University of North Dakota School of Medicine and Health Sciences

Funded by

The Department of Health and Human Services,

Health Resources and Services Administration, Federal Office of Rural Health Policy, North Dakota Medicare

Rural Hospital Flexibility Grant Program


Introduction

Towner County Medical Center (TCMC), which includes a Critical Access Hospital (CAH), held

a strategic planning workshop in Cando, ND on October 17, 2013. Two representatives from the

Center for Rural Health at the University of North Dakota School of Medicine and Health

Sciences facilitated the meeting, which was attended by members of the hospital’s

administrative staff.

The strategic planning workshop was a continuation of the overall Community Health Needs

Assessment (CHNA) process, which is a requirement of the Affordable Care Act (ACA). The

legislation mandates that non-profit hospitals conduct a CHNA at least every three years,

examine input from community representatives, publicly disseminate the results, prioritize

community health needs, and develop a written implementation strategy (a health

improvement plan) to help meet the needs identified in the CHNA. With assistance from the

Center for Rural Health, TCMC conducted the needs assessment portion of the process earlier

in 2013.

The purpose of the workshop was to initiate a more formalized strategic planning process

resulting in a written implementation strategy to help address the identified significant

community health needs. Strategic planning is a technique to assist a group to analyze current

conditions and then develop strategies to address a set of issues and/or concerns. Workshop

facilitators used a logic model as a framework for evaluating, analyzing, and organizing ideas

to address the enumerated significant needs. Logic models are widely practiced in social science

research to state future goals, outline responsibilities and actions needed to achieve the goals,

and demonstrate a program’s progress.

To begin the strategic planning workshop, the facilitators from the Center for Rural Health

shared findings from the 2013 CHNA report with the workshop participants. Data analyzed

during the CHNA process included primary data (a community health survey and key

informant interviews) and secondary data (analysis of County Health Rankings and other data

sources). The corresponding PowerPoint presentation is attached as Appendix A.

Through an earlier community needs prioritization process, the CHNA in the Cando area

identified five significant needs:

Financial viability of the hospital

Access to needed technology and equipment

Elevated rate of diabetics


Elevated rate of uninsured residents

Lack of continuous, full-time physician

Survey results, specific community member comments, and secondary statistics about these

significant needs were presented to the group to contextualize the needs.

The workshop focused on generating ideas and strategies to address the identified significant

needs through a variety of approaches. To initiate the brainstorming process using the logic

model, participants were presented with one of the needs as the beginning point on a

continuum. The end point was the outcome, or a vision of what the future would look like if

that need was addressed. Participants were given sticky notes and asked to write down desired

outcomes, that is, goals or changes they would like to see related to this need. One facilitator

organized the sticky notes into thematic categories and read them to the group as the other

facilitator typed them into a laptop, and a table showing the logic model continuum was

projected onto a screen so all could see. The outcomes were reviewed collectively so

participants could discuss them.

Working backwards from the stated outcomes or goals, participants were then asked as a group

to brainstorm activities that could help achieve the outcomes. Once a list of activities was

produced and discussed, resources were identified to accomplish the activities, including

people, organizations, existing infrastructure and programs, and potential financial resources.

Finally, to complete the logic model, a list of outputs, or evidence that the activity was

accomplished, was discussed but not produced as the activity needs to be enacted first. The

output column in the table will be completed later. The brainstorming tables, in draft form, are

included in this report for informational purposes as Appendix B.

Through collaborative brainstorming, participants identified clear and measurable action steps

that can be taken to address the needs identified through the assessment. A further step of

delineating who will responsible for what activity and assigning a timeline to the tasks will help

convey ownership.


Priority Need #1: Financial Viability of the Hospital

Outcome Goals and Anticipated Impact

Hospital positioned to survive and thrive in the long term

Reduced reliance on contract staff for clinical care

Specific Actions and Activities

Reduce dependence on locum physicians through promotion and greater use of existing

mid-level providers

Reduce dependence on contract nursing staff

Enact strategic personnel changes to reduce human capital costs

Require CEO approval of all purchases

Refinance existing debt

Increase revenue through promotion of new CT scanner and chemotherapy services

Expand geographic service area by marketing new mid-level provider who recently

joined TCMC from nearby community

Resources to Commit

Senior level administrative personnel

Financial resources to market and promote new services and providers

Accountable Parties


Partnerships/Collaboration

Work with financial service provider/lender to refinance existing debt


Priority Need #2: Access to Needed Technology/Equipment


Hospital facilities and equipment are current and allow for continued excellent care of

patients

Level of technology and equipment inspires confidence in staff and patients


Acquire CT scanner

Alert local media to existence of new CT scanner and encourage local newspaper to

cover the event with article and photos

Update website to include information about new equipment and technology

acquisitions

Resources to Commit

Financial resources to acquire CT scanner

Administrative personnel time to promote and market new CT scanner

TCMC website

Accountable Parties


Website administrator


Work with local media to promote new equipment and technology acquisitions


Priority Need #3: Elevated Rates of Diabetics


Increased community awareness and education about diabetes

Increase diabetes prevention in community

Increase in screenings for diabetes in community


Provide space and equipment for fitness center

Expand screenings related to diabetes in community

Organize a community event related to physical activity and/or nutrition, such as

walk/run-a-thon, healthy food potluck, etc.

Organize speaker for community Senior Group to raise awareness of diabetes and serve

a healthy meal and distribute healthy eating recipes

Institute a wellness page on hospital website

Comply with and promote Blue Cross Blue Shield of ND MediQHome

Resources to Commit

Financial resources and facilities for community fitness center

Financial resources and hospital personnel for expanded diabetes screenings

Financial resources and hospital personnel to organize community events, such as event

promoting physical activity and/or nutrition, Senior Group speaker

TCMC website

Accountable Parties



Work with Public Health to promote community events

Senior Group

Blue Cross Blue Shield of North Dakota – MediQHome


Priority Need #4: Elevated Rates of Uninsured Adults


Decrease number of uninsured adults

Analysis of feasibility of TCMC/County insurance plan

Increase awareness of requirements of Affordable Care Act


Send TCMC financial counselor to training for guidance on helping residents navigate

the health insurance marketplace

Offer TCMC financial counselor’s services to residents to help navigate the health

insurance marketplace

Post requirements of Affordable Care Act on hospital website, along with resources

relating to meeting requirements

Distribute flyers in clinic about requirements of Affordable Care Act and availability of

TCMC financial counselor’s services

Organize a speaker for Senior Group about the requirements of the Affordable Care Act

Distribute flyers at Ag Day (March 2014) about requirements of Affordable Care Act and

availability of TCMC financial counselor’s services

Resources to Commit

Services of TCMC financial counselor

Financial resources to send financial counselor to training

Financial resources and hospital personnel to create and distribute educational materials

about ACA requirements and resources

TCMC website

Accountable Parties

TCMC financial counselor




Senior Group


Priority Need #5: Lack of Continuous, Full-Time Physician


Have long-term, stable access to primary care providers

Have succession plan in place to address anticipated provider turnover


Engage with local residents in medical school to encourage them to return to community

to practice medicine

Work with Center for Rural Health on physician recruitment

Work to build stable, well-liked staff of mid-level providers that includes both female

and male providers

Resources to Commit

TCMC staff time

TCMC financial resources for recruiting efforts

Accountable Parties



UND School of Medicine and Health Sciences

Center for Rural Health


The intervening time until the next CHNA is conducted provides the timeline for implementing

these activities. Since TCMC’s most recent assessment was conducted in 2013, the next

assessment will need to be completed no later than 2016. In the meantime, the activities set forth

in the implementation strategy will be undertaken.

Summary and Next Steps

The strategic planning session was the starting point to begin the CHNA implementation

strategy as required under the ACA. Participants met for nearly three hours and engaged in

thoughtful discussions related to the goals and future of TCMC. Specific outcomes, activities,

resources, and potential collaborators were generated from the previously prioritized needs as

identified in the CHNA. The strategic planning process being used by TCMC is a tool to foster

collaboration and increase the scope and reach of TCMC’s services. By identifying common

values and focusing on efforts and activities to build a healthier community, TCMC has the

opportunity to establish stronger relationships to benefit the communities served.

Table of Contents - Center for Rural Health · 2018-06-08 · Towner County Public Health District...

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