2012 Community Needs Health Assessment

March 2012

1330 Coshocton RoadMount Vernon Ohio 43050

www.KnoxCommHosp.org740.393.9000

2012 Community HealthNeeds Assessment

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Community Health Needs AssessmentKnox Community Hospital | Mount Vernon, OH

Table of Contents

Executive Summary .................................................................................................................... 1 • Project Objectives• Brief Overview of Community Health Needs Assessment• Financial Opportunity Summary

Approach ...................................................................................................................................... 4

Findings........................................................................................................................................ 7 • Defi nition of Area Served by the Hospital Facility• Demographic of the Community

Existing Health Care Facilities and Resources ..................................................................... 14 • Existing Health Care Facilities and Resources within the Community

that Are Available to Respond to the Health Needs of the Community • Overall Community Need Statement and Priority Ranking Score

Management Action Plan ........................................................................................................ 19

Appendix .................................................................................................................................... 25

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Community Health Needs AssessmentKnox Community Hospital | Mount Vernon, OH 1

Executive Summary

The Community Health Needs Assessment (CHNA) is part of the required hospital documentation of “Community Benefit” under the Affordable Care Act (ACA). In addition to completion of a CHNA and funding any needed improvement, the Hospital must document the following:

Financial Assistance policy and policies relating to emergency medical care;

Billing and collections; and

Charges for medical care.

Further explanation and specific regulations are available from Health and Human Services (HHS), the Internal Revenue Service (IRS) and the U.S. Department of the Treasury.

Project Objectives

Knox Community Hospital (KCH) partnered with QHR for the following:

Complete a Community Health Needs Assessment report, compliant with IRS – Treasury;

Provide the Hospital with information needed to complete the IRS – 990h schedule; and

Produce the information needed for the hospital to issue an assessment of community health

needs and document how it intends to respond to the needs.

Brief Overview of Community Health Needs Assessment

Typically, non-profit hospitals qualify for tax-exempt status as a Charitable Organization, as described in

Section 501(c) 3 of the Internal Revenue Code. However, the term “Charitable Organization” is

undefined. Prior to the passage of Medicare, charity was generally recognized as care provided to the

less fortunate without means to pay. With the introduction of Medicare, the government met the

burden of providing compensation for such care.

In response, IRS Revenue ruling 69-545 eliminated the Charitable Organization standard and established

the Community Benefit Standard as the basis for tax-exemption. Community Benefit determines if

hospitals promote the health of a broad class of individuals in the community, based on factors

including:

Emergency room open to all, regardless of ability to pay;

Surplus funds used to improve patient care, expand facilities, train, etc.;

Controlled by independent civic leaders; and

All available and qualified physicians are privileged.

Executive Summary

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Specifically, the IRS requires:

Effective on tax years beginning after March 23, 2012, each 501(c) (3) hospital facility is required to conduct a community health needs assessment at least once every three taxable years and adopt an implementation strategy to meet the community needs identified through such assessment;

The assessment may be based on current information collected by a public health agency or non-profit organizations and may be conducted together with one or more other organizations, including related organizations;

The assessment process must take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge or expertise of public health issues;

The hospital must disclose in its annual information report to the IRS (Form 990 and related schedules) how it is addressing the needs identified in the assessment and, if all identified needs are not addressed, the reasons why (e.g., lack of financial or human resources);

Each hospital facility is required to make the assessment widely available, and ideally downloadable from the hospital web site;

Failure to complete a community health needs assessment in any applicable three-year period results in a penalty on the organization equal to $50,000. For example, if a facility does not complete a community health needs assessment in taxable years one, two or three, it is subject to the penalty in year three. If it then fails to complete a community health needs assessment in year four, it is subject to another penalty in year four (for failing to satisfy the requirement during the three-year period beginning with taxable year two and ending with taxable year four); and

An organization that fails to disclose how it is meeting needs identified in the assessment is subject to existing incomplete return penalties.2

2 Section 6652

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Financial Opportunity Summary

KCH intends to devote approximately $104,500 annually3 in response to Community Benefit4 obligations

(See chart below). Specific annual allocations will be reported on the KCH 990 tax form, supported by its

financial statements and data entries to its Community Benefits Inventory for Social Accountability

(CBISA) System.

12 Months Ending October 2011

Net Revenue $118,108,807 Bad Debt $10,049,787

Total Net Revenue $108,059,020

Community Benefit target goal 5% Total Net Revenue $5,402,951

Current Charity $6,566,742 Response to community benefit $104,500

Total Provided Community Benefit $6,671,242

3 Response to Schedule H (Form 990) Part V B 6 f 4 The term “Community Benefit” is defined as the term is used in the Accountable Care Act and by the IRS 990 instructions. This term may be defined differently by the Hospital when complying with reporting requirements of “Community Benefit” or “Charity” as defined by the State. Amounts shown are for planning and budgetary purposes only. Actual dollar allocations will vary year to year and are documented on the Corporate 990 return.

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Approach

To complete a CHNA, the Hospital must:

Describe the process and methods used to conduct the assessment;

o Sources of data, and dates retrieved;

o Analytical methods applied;

o Information gaps impacting ability to assess the needs; and

o Identify with whom the Hospital collaborated.

Describe how the hospital gained input from community representatives;

o When and how the organization consulted with these individuals;

o Names, titles, and organizations of these individuals; and

o Any special knowledge or expertise in public health possessed by these individuals.

Describe the process and criteria used in prioritizing health needs;

Describe existing resources available to meet the community health needs;

Identify the programs and resources the hospital facility plans to commit to meeting each identified need and the anticipated impact of those programs and resources on the health need.

QHR takes a comprehensive approach to assess community health needs. We perform several independent data analyses, based on secondary source data, augment this with local survey data and then resolve any data inconsistency or discrepancies from the combined opinions formed from local experts. We rely on secondary source data and most secondary sources using the county as the smallest unit of analysis. Since the service area does not comprise the entire county, we asked local residents to note if they perceived the problems, or needs, identified by secondary sources to exist in their portion of the county.5

The data displays used in our analysis are presented in the Appendices. Data sources used include:6

www.countyhealthrankings.com – to assess the health needs of Knox County compared to all

Ohio counties;

www.Communityhealth.hhs.gov – to assess the health needs of Knox County compared to its

national set of “peer counties”;

Thomson Market Planner – to assess characteristics of the hospital’s primary service area, at a

zip code level, based on the classification of the population into various socio-economic groups,

determining the health and medical tendencies of each group, and, then creating an aggregate

5 Response to Schedule H (Form 990) Part V B 1 i 6 Response to Schedule H (Form 990) Part V B 1 d

Approach

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composition of the service area according to contribution each group makes to the entire area;

and, to access population size and socio-economic characteristics;

www.capa.org – to determine the availability of Palliative Care programs and services in the

area;

http//apps.nccd.gov – to determine the potential importance of stroke and heart attack

comorbidities, complications and death rates; and

http://www.healthmetricsandevaluation.org/tools/data-visualization - visualize comparative life

expectancy and diabetic relative incidence.

In addition we deployed a Community Health Need Assessment survey within the local population for any resident to complete. 7

956 area residents completed our opportunity to provide community input. Respondents

replied to the survey starting Friday July 22, 2011 at 6:20 AM with the last response on Thursday

September 29, 2011 at 9:18 AM.

The terms of gaining input stipulated each respondent would remain anonymous.

The administration of an internet-based survey was promoted through a paid advertisement in a

local newspaper and was distributed to local civic and health organizations with a request for

participation. Preliminary conclusions were presented to a local group of experts, which were

asked to validate prior assessments and to establish priority among various identified health and

medical issues8; and

Analyzing the information showing how Knox County related among its peers in terms of

primary and chronic needs and other issues of uninsured persons, low-income persons and

minority groups was augmented by local opinion from respondents commenting on whether or

not they believe certain population groups (or people with certain situations) need help to

improve their condition and if so who needs to do what.9

After analyzing the preceding data and information we put the information and summary conclusions before our local group of experts. Local Experts10 were asked to agree or disagree with the summary conclusions. They also were at liberty to augment potential conclusions with additional statements of need. New needs could, and did, emerge from this consultation.11 Consultation with our Local Experts occurred again via an internet based survey as explained below, during the period beginning Tuesday November 1, 2011 at 3:19 PM and ending Friday November 18 at 7:01 PM.

With the prior steps identifying potential community needs, the Local Experts participated in a Delphi method activity. This is a structured communication technique, originally developed as a systematic,

7 Response to Schedule H (Form 990) Part V B 1 h 8 Part response to Schedule H (Form 990) Part V B 3 9 Response to Schedule H (Form 990) Part V B 1 f 10 Part response to Schedule H (Form 990) Part V B 3 11 Response to Schedule H (Form 990) Part V B 1 e

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interactive forecasting method that relies on a panel of experts. The experts answer questionnaires in a series of rounds. We contemplated and implemented one round as referenced during the above dates. After each round, we provide an anonymous summary of the experts’ forecasts from the previous round as well as the reasons provided for their judgments. Thus, experts were encouraged to revise their earlier answers in light of the replies of other members of their panel. Typically this process decreases the range of answers with the expert opinions moving toward a consensus "correct" answer. This process stops when we achieve identification of the most pressing, highest priority community needs.

In the KCH process each Local Expert was asked to allocated 100 points among all identified needs, again having the opportunity to introduce needs previously unidentified and to challenge conclusions developed from the data analysis. This resulted in a rank order of priorities, with some needs not receiving virtually any support and some needs receiving identical point allocations.

We dichotomized the rank order into two groups; needs having high priority and needs having low priority. The determination of the break point, high as opposed to low, was a qualitative interpretation by QHR and by the KCH executive team of where there was a reasonable break point in rank, as indicated by the weight amount of points each potential need received. This dichotomized high priority need vs. low priority need rank order was presented to the KCH executive team to indicate which needs did the hospital considered they held high responsibility to respond vs. low responsibility to respond. This resulted in a matrix of needs and guided the hospital in developing its implementation response.12

Some conceptually similar needs were combined during the implementation discussion with the KCH executive team. The reason for need consolidation was an effort to facilitate implementation efforts. The contemplated implementation actions were not as discrete as the articulation of need, i.e. Need #10 “Diabetes” – the incident of disease is a moderate concern among area residents and #11 “Diabetic Screening – Knox residents do not take advantage of screening resources are best implemented by a Diabetic initiative responding to both the need statements.

This process of need consolidation did change the overall rank order of needs but it did not compromise the integrity of the opinions obtained from the Local Experts. KCH Board and Executive Staff met on January 10, 2012 to review the results of the Local Experts and the recommendations emerging from the above discussed process. It was determined the results from this process to be a fair depiction of the community health needs in the area. It formed the basis for the hospital’s response to community health needs.

12 Response to Schedule H (Form 990) Part V Section B 6 g, h and Part V B 1 g

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Findings

Definition of Area Served by the Hospital Facility13

Knox Community Hospital, in conjunction with QHR, has defined its service area as the

following ZIP codes:

43014 – Danville 43019 – Fredericktown 43022 – Gambier 43028 – Howard 43037 – Martinsburg 43050 – Mount Vernon 43843 – Walhonding

This service area comprises virtually all of Knox County, Ohio.

13 Responds to IRS Form 990 (h) Part V B 1 a

Service Area43014 Danville43019 Fredericktown43022 Gambier43028 Howard43037 Martinsburg43050 Mount Vernon43843 Walhonding

Findings

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Demographic of the Community14

The 2010 population for this area was estimated to be 59,98615, and is expected to grow at a rate of 3.4%, to achieve a 2015 population of 62,020. This growth rate is lower than the Ohio state average and lower than the national growth rate.

The 2015 Median age for the population is projected to be 37.6 years of age, younger than both the Ohio and national median ages. The 2010 Median Household Income is $46,993, lower than the Ohio median income and lower than the national median. The unemployment rate as of September 2011 was 8.3%16, just below the higher 8.5% Ohio rate, but almost a percent lower than the national rate of unemployment (9.1%).17

The portion of the population over 65 is 14.4%, and the population of women of childbearing age is higher than both the state and national rates. Additional demographic data is presented in Appendix F.

Findings

Upon completion of the CHNA, QHR identified several issues within the Knox Community

Hospital community, including:

BIRTHS TO WOMEN AGE 40 TO 54 - appears at a high rate;

BIRTHS TO UNMARRIED WOMEN - Knox performs better than peers and better than national

rate;

BREAST CANCER - occurs among women at a high rate;

CANCER - is among the leading causes of death and is a moderate area resident concern;

CANCER SCREENING - services are in low demand, impacting from 24% to 54% of the population,

although Cancer is a leading cause of death;

CHRONIC HIGH BLOOD PRESSURE - affects an estimated 30% of the population and occurs at

rates above the national average;

CHRONIC LOW BACK PAIN - affects an estimated 27% of the population;

COLON CANCER - occurs at a high rate;

CORONARY HEART DISEASE - occurs at a high rate, is the leading cause of death, but is among

the lower moderate Knox County resident concerns;

DIABETES - the incident of the disease is a moderate concern among area residents;

DIABETIC SCREENING (lacking) - Knox residents do not take advantage of screening resources;

14 Responds to IRS Form 990 (h) Part V B 1 b 15 All population information, unless otherwise cited, sourced from Thomson Market Planner 16 ODJFS Civilian Labor Force Estimates http://ohiolmi.com/laus/Ranking.pdf 17 November 17 data abstract – Bureau of Labor Statistics, US government

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DRINKING - excessive drinking (binge drinking or chronic consumption of alcoholic beverages) is

a Knox County health problem, recognized as a lower ranked moderate concern among County

residents;

HEALTH INSURANCE - some/many residents lack the ability to afford coverage. This is a

moderate concern to area residents;

INFANT MORTALITY - is an indicator where Knox performs better than peers and better than

national rates;

LOW BIRTH WEIGHT - is an indicator where Knox performs better than peers and better than

national rates;

LUNG CANCER - occurs at a high rate among peers but is below national average;

MENTAL HEALTH - is a lower ranked moderate concern among area residents;

MOTOR VEHICLE INJURY - occurs at a high rate;

NEONATAL INFANT MORTALITY - occurs at low rates compared to national and peer averages;

NO CARE IN THE FIRST TRIMESTER - occurs at a high rate;

OBESITY - impacts 29% of the population, is an underlying adverse health condition and is a

moderate resident concern;

POST-NEONATAL INFANT MORTALITY - occurs at a high rate among peers but below the national

average;

PREMATURE BIRTHS - presents as an indicator where Knox performs better than peers and

better than the national rate;

SMOKING - the rate of smoking in Knox County appears excessive and is the leading serious

concern among residents;

STROKE - occurs at a high rate compared to peer counties but appears either at or below

national occurrence levels;

SUICIDE - is at a low rate among peers and among national statistics;

TEEN BIRTH RATE - is a moderate resident concern but is not a statistically indicated concern;

UNHEALTHY FOOD CHOICES - are an underlying factor leading to obesity problems and is a

moderate resident concern;

UNINTENTIONAL INJURY - occurs at a high rate compared to peer counties;

VERY LOW BIRTH WEIGHT - occurs at a high rate among peers but does not excessive the

national average;

WHITE NON HISPANIC INFANT MORTALITY - is low in all comparisons; and

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SUBSTANCE ABUSE – including prescription and non-prescription drug abuse – brought forward

by a couple of Local Experts.

The above list results from a compilation of summary points derived from analysis of several data sets.

The data and information examined appears in the Appendices to this report. The Observations drawn

from each individual data examination appear below, followed by an overall summary of data analysis

conclusions submitted for Local Expert opinion.

Observation of Knox County Compared to a national set of “peer” counties,

Knox County appears Unfavorable compared to peers and to national averages in the following:

Births to Women age 45 to 54;

No Care in the first Trimester;

Breast Cancer (among females);

Colon Cancer;

Coronary Heart Disease;

Motor Vehicle Injury; and

Stroke.

Compared to the same “peer” counties, Knox County was observed to perform better than its peers but

inferior in comparison to national averages among none of examined metrics.

Comparing Knox County to better than national average performance, but unfavorable in comparison to

its peers in the following brought forward the following list of potential community needs:

Very low birthweight (<1,500 g);

Post neonatal infant mortality;

Lung Cancer; and

Unintentional Injury.

Compared the performance of Knox County to both its peers and to national averages generated

unfavorable findings in the following areas:

Low Birth weight (< 2,500 grams);

Premature Births (<37 weeks);

Births to Women under 18;

Births to Unmarried Women;

Infant Mortality;

White Non-Hispanic Infant Mortality;

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Neonatal Infant Mortality; and

Suicide.

In summary, the Knox County Peer Comparisons indicate:

Births to women age 40-54, no care prenatal care in the first trimester, breast cancer, colon

cancer, coronary heart disease, motor vehicle crashes and stroke are potential concerns

comparing Knox to its Peer Counties and to national rates;

Very low birth weight, post-neonatal infant mortality, lung cancer and unintentional injury are

conditions where Knox compares unfavorable to its peers;

Knox resident self rated health status is statistically significantly better than its peers; and

Environmental factors and infectious disease present as minor concerns, meeting most

standards.

Observations from public input to community health need assessment

Very positive about living in local society, many issues not expressed as being of any real

concern;

Prevalence of smoking is emphasized;

What items present as moderate concerns are (in descending order of concern);

o Health insurance;

o Unhealthy food choices & obesity;

o Cancer;

o Diabetes;

o Teen Birth rates;

o Mental health and substance abuse issues; and

o Heart disease.

Excepting mental health provider availability, the vast majority of residents have a medical

provider.

Observations from Knox County compared to all other Ohio counties, in terms of Community

Health Needs

Knox County health status generally compares favorably among Ohio counties, ranking 33

among the 88 ranked counties;

The high smoking rate in Knox County is the highest ranked adverse health status factor.

Smoking is higher in Knox County than in approximately 96% of Ohio counties;

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Excessive drinking is also an adverse finding. Excessive Drinking (persistent drinking more than 1

alcoholic beverage a day or consuming more than 4 drinks (women) or 5 drinks (men) on a

single occasion in the last 30 days) is higher than in about 93% of Ohio counties;

Diabetic Screening is inadequate. Screening rates in about 90% of Ohio Counties is better than

what occurs in Knox County;

The highest ranked POSITIVE influence among the health status factor is the lack of low birth

weight babies. Knox County performance is better than 91% of Ohio counties;

The low incident of Obesity also is a positive factor in Knox County. Knox County rate is about

better than 85% of Ohio Counties;

Other positive factors where Knox County performs better than about 80% of Ohio Counties

include:

o Sexually Transmitted Disease;

o Teen Birth Rate;

o Preventable hospital stays; and

o Unemployment.

Observations from the demographic analysis

The service area comprises of 22,801 households and 14.5% of the residents of the age 65 or

more in Knox County, Ohio. The elderly population is slightly higher than the percent of the

population the elderly comprise in the state or in the national population;

The population of the area is estimated to be 59,986 and by 2015 should be 62,020, a rate of

growth somewhat slower than the rate of growth in Ohio or the national growth rate;

The area is dominantly white; all minorities comprise only 3.8% of the population;

The population segment comprising “Women of childbearing age” is in line with the national

rate but 1% higher than the average in Ohio;

The indication of a High incident of chronic diabetes unfortunately agrees with the prior

observation of a low use of diabetic screening by Knox County residents. It appears this risk

factor is not an artifact of obese residents, rather it may relate, in part, to poor eating habits

what also occurs at an excessive rate among residents;

Chronic high blood pressure and heart disease along with a low rate of routinely taking

advantage of cardiac stress testing all agree with Heart disease as the leading cause of death;

Low demand for cancer screening agrees with Cancer being among the leading causes of death

in the County;

The high smoking rate again appears as a prevalent adverse health factor; and

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The population is reluctant to show responsibility for their own health and does not take

advantage of resources for obtaining health information.

Observations from the other statistical data examinations

Ranking the causes of death finds the leading causes to be the following:

o Heart Disease;

o Cancer;

o Stroke;

o Chronic Lower Respiratory Disease;

o Unintentional Injury; and

o Diabetes Mellitus.

The incident of stroke is close to the state average but it does exceed the national average rate.

Of significance, there is a very high incident of diabetic and hypertension comorbidities;

Heart disease rates place Knox County in the lowest quartile of Ohio Counties;

Knox County is not designated as a Medically Underserved Area; and

Knox County has a palliative care program and hospice program.

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Existing Health Care Facilities and Resources within the Community that Are

Available to Respond to the Health Needs of the Community

We used the priority ranking of area health needs to organize our search for locally available

resources.18 The following resource list identifies locally available resources corresponding to each

priority need.

In general, KCH is the major hospital in the service area. The next closest facilities are outside the service

area and include:

Licking Memorial Hospital – a 227 bed acute care facility located 28 miles away (45 minutes);

and

Morrow County Hospital – a critical access hospital in located 27 miles away (39 minutes).

In rank order of need, we identified the following local resources which could be available to respond to

the need.

9. CORONARY HEART DISEASE – Knox County Health Department, Jackie Fletcher 392.2200

extension 2245;

5. CANCER SCREENING – American Cancer Society/ Knox Community Hospital, Sandy Kollar

393.5578 or Becky Dangelo 393.5579;

21.OBESITY – Knox County Health Department; Knox County Head Start, Peg Tazwell 393.6972;

17.MENTAL HEALTH – Behavioral Health Care Partners of Central Ohio, Lynn Agapi-Gilligan

937.0442; Community Mental Health and Recovery Board of Licking and Knox Counties,

Wendy Williams 740.522.1234; Mental Health America of Knox County, Dodie Melvin

397.3088: Pathways of Central Ohio – 2 1 1, Kristin McCloud 740.345.6166 extension 211: The

Main Place, Glenn Hopkins 392.3431 ;

24.SMOKING – Knox County Health Department, Mike Whitaker 392.2200 extension 2233;

Alcohol and Drug Freedom Center, Jeff Williams or Mary Samuell 397.2660;

4. CANCER – American Cancer Society 800.227.2345;

12.DRINKING – Alcohol and Drug Freedom Center, Jeff Williams or Mary Samuell 397.2660;

28.UNHEALTHY FOOD CHOICES – Knox County Health Department; Knox County Head Start,

Peg Tazwell 393.6972;

11.DIABETIC SCREENING (lacking) – Knox Community Hospital; Knox County Health

Department, 392.2200 extension 2252; Central Ohio Diabetes Association of Central Ohio:

614.436.1917;

18 Response to IRS Form 990 h Part V B 1 c

Existing Health Care Facilities & Resources

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10.DIABETES - Knox Community Hospital; Knox County Health Department, 392.2200 extension

2252; Central Ohio Diabetes Association of Central Ohio, 614.436.1917;

3. BREAST CANCER - American Cancer Society 800.227.234;

13.HEALTH INSURANCE – No local resources available;

2. BIRTHS TO UNMARRIED WOMEN – Knox Community Hospital; Care Net Pregnancy Services,

Lois Carter 393..370; GRADS Program of Career Center, Tess Kinsey 397.5820; KNO-HO-CO

Health Service, Kelly Baldwin 740.622.9801;

20.NO CARE IN THE FIRST TRIMESTER Knox County Health Department, 392.2200 Extension

2242; Care Net Pregnancy Services, Lois Carter 393.0370; KNO-HO-CO Health Services, Kelly

Baldwin 740.622.9801;Knox County Head Start (Early Head Start), Peg Tazewell 393.6972;

32.SUBSTANCE ABUSE - Alcohol and Drug Freedom Center, Jeff Williams or Mary Samuell

397.2660;

16.LUNG CANCER - American Cancer Society 800.227.2345;

29.UNINTENTIONAL INJURY- Knox County Health Department, 392.2200 Extension 2242;

8. COLON CANCER American Cancer Society 800.227.2345;

25.STROKE – Knox Community Hospital, Knox County Health Department, Jackie Fletcher

392.2200 Extension 2245;

26.SUICIDE – Behavioral Health Care Partners of Central Ohio, Lynn Agapi-Gilligan 397.0442;

Community Mental Health and Recovery Board of Licking and Knox Counties, Wendy Williams

740.522.1234; Mental Health America of Knox County, Dodie Melvin 397.3088; Pathways of

Central Ohio 2-1-1,Kristin McCloud 740.345.6166 Extension 211; Hospice of Knox County, Kathy

Wantland 397.5188;

6. CHRONIC HIGH BLOOD PRESSURE - Knox Community Hospital, Knox County Health

Department, Jackie Fletcher 392.2200 Extension 2245;

27.TEEN BIRTH RATE - Knox County Health Department, 392.2200 Extension 2242; Care Net

Pregnancy Services, Lois Carter 393.0370; KNO-HO-CO Health Services, Kelly Baldwin

740.622.9801;Knox County Head Start (Early Head Start), Peg Tazewell 393.6972;

14.INFANT MORTALITY – Knox County Health Department, 392.2200 Extension 2242;

18.MOTOR VEHICLE INJURY – Knox County Sheriff’s Department, Sheriff Davis Barber 393.6800;

Knox County Health Department , 392-2200 Extension 2242;

15.LOW BIRTH WEIGHT - Knox County Health Department, 392.2200 Extension 2242; Care Net

Pregnancy Services, Lois Carter 393.0370; KNO-HO-CO Health Services, Kelly Baldwin


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23.PREMATURE BIRTHS – Knox County Health Department, 932.2200 Extension 2242; Care Net

Pregnancy Services, Lois Carter 393-0370;

19.NEONATAL INFANT MORTALITY - Knox County Health Department, 392.2200 Extension

2242;

22.POST-NEONATAL INFANT MORTALITY - Knox County Health Department, 392.2200 Extension



30.VERY LOW BIRTH WEIGHT - Knox County Health Department, 392.2200 Extension 2242; Care

Net Pregnancy Services, Lois Carter 393.0370; KNO-HO-CO Health Services, Kelly Baldwin


1. BIRTHS TO WOMEN AGE 40 TO 54 - Knox County Health Department, 392.2200 Extension



7. CHRONIC LOW BACK PAIN – Center for Pain Management Knox Community Hospital,

740.393.9000; Central Ohio Arthritis Foundation, Morgan Patten 614.876.8200; and

31.WHITE NON HISPANIC INFANT MORTALITY - Knox County Health Department, 392.2200 Ext.

2242.

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Overall Community Need Statement and Priority Ranking Score:

High Priority Issues where Hospital has High Implementation Responsibility

1. Cancer (cancer screening, cancer deaths, breast cancer, lung cancer, colon cancer) – Lower cancer

deaths.

Problem Statement: Disease rates should not exceed national incident rates while screening and

detection services should increase

4. Cardiovascular Health (Coronary heart disease, stroke, chronic high blood pressure) – Lower the

cardiovascular death rate.

Problem Statement: Incidents of heart disease and stroke need to decline while an increasing portion of

the population needs to achieve/maintain blood pressure control

Low Priority Issues where Hospital has High Implementation Responsibility

5. Maternal and Infant Care (Births to Unmarried Women, Teen Birth Rate, Infant Mortality, Low Birth

Weight, No Care in the First Trimester, Premature Births, Neonatal Infant Mortality, Post-neonatal

Infant Mortality, Very Low Birth Weight, White Non Hispanic Infant Mortality and Births to Women

Age 40 to 54) – Improve utilization of available resources (i.e. care during the first trimester)

Problem Statement: Enhance prenatal care and seek improvement in other underlying conditions

resulting in very low weight babies and infant mortality

7. Diabetes (Diabetic Screening and Diabetes rates) – Better manage the disease and its process

Problem Statement: Enhance diabetic awareness, problem identification and controls such that Knox

County no longer resides in the bottom 10% of Ohio Counties as well as achieving diabetes as being a less

frequent contributor to stroke comorbidities.

High Priority Issues where Hospital has Low Implementation Responsibility 2. Adverse Behavior Modification (Smoking, Drinking and Substance Abuse) – Improve indicator

values or rates.

Problem Statement: Incidents of smoking, alcohol consumption and abuse of legal and illegal pharmaceuticals all need to decline at least to State average rates

3. Obesity (Obesity rates and Unhealthy Food Choices) – Improve indicator values or rates

Problem Statement: The portion of the population meeting clinical obesity standards needs to decline

Low Priority Issues where Hospital has Low Implementation Responsibility 6. Mental Health (Mental Health and Suicide) – Seek a reduction in adverse measures.

Problem Statement: Seek improvement in the self reported poor mental health days experienced in service area population and achieve an enhance identification of individuals at risk of suicide

8. Health Insurance – Seek a reduction in adverse measures.

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Problem Statement: Reduce vulnerable populations service access problems

9. Injury – Seek a reduction in adverse measures.

Problem Statement: Improve accident response as actions to reduce the incident of accidents are

implemented

10. Chronic Low Back Pain – Seek a reduction in adverse measures.

Problem Statement: Enhance resources to manage the prevention, risk reduction and treatment of low back pain

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Management Action Plan

The following Management Action Plan (MAP) provides Hospital management with a standalone tool for

operationalizing its response to the Community Health Needs it identified.19

19 Response to Schedule H (Form 990) Part V B 6 a and b

Management Action Plan

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unit

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for

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Proprietary


By definition, generally, the needs identified as being of LOW Priority and which KCH holds LOW RESPONSIBILITY for implementation are needs to which the hospital will monitor but otherwise not address. The reason for this action is multifaceted:

Actions required are beyond the mission of KCH;

KCH can be more effective in applying its resources to higher priority needs;

The hospital does not possess the expertise needed to cause a substantive positive

improvement;

Actions contemplated as being appropriate for implementation fall more appropriately to the

responsibility of others;

Other than encouragement, implementation efforts for some needs require appropriate actions

by individuals modifying their personal habits rather than a response by an organization or the

Health System; and

The best use of KCH resources is to focus on resolving or improving the higher priority needs

rather than to attempt to respond to everything with small, perhaps ineffective, efforts.20

The exception to this is the lowest ranked priority, Low Back Pain. KCH has an existing programmatic

initiative to respond in this area. The management action plan does allocate a minor amount of funding

support for this initiative.

The intended resource allocation by priority is as follows

High Priority Community Health Needs where KCH holds high responsibility for implementation -

$40,000 in addition to funding development of a second cath lab;

High Priority Community Health Needs where KCH holds low responsibility for implementation -

$3,000;

Low Priority Community Health Needs where KCH holds high responsibility for implementation -

$60,000;

Low Priority Community Health Needs where KCH holds low responsibility for implementation -

$1,500; and

Total budget for provision of services that address the needs identified in the Needs Assessment

= $104,500.21

20 Reference Schedule H (Form 990) Part V Section B 7 21 Reference Schedule H (Form 990) Part V Section B 6. f

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Appendix A: 956 Community Responses to Community Health Need Survey

Questions

Participants responding to opinions about the community

Interpretation – Residents are very positive about living in Knox County

Appendix

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What is your opinion about the following health and mental health issues in your

community?

Interpretation – residents are not overly concerned about the listed health issues in Knox County

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During the last two years why were you unable to get a needed health service?

Interpretation – We asked survey participants to offer free text response to several questions. We

interpreted the responses by developing "Word Clouds". Word Clouds are analytical tools which give

greater visual prominence to words appearing more frequently in the source text. This information

visualization establishes a portrait of the aggregate responses, presenting the more frequently used

terms with greater text size and distinction in the visual depiction. Common article word (i.e. “a", "the",

etc.) non-contextual verbs (i.e. "is", "are", etc.) and similar words used when writing sentences are

suppressed by this application.

In the above visualization, survey participants responded to the question “During the last two years why

were you unable to get a needed health service.” Insurance coverage and service affordability were the

major reasons a needed service was not obtained. 85.5% of responses indicated there were NO

problems accessing needed service. The highest response rates for needed service not being available

was 3.3% citing a mental health need and 3.2% citing a dental need. 8%, (the highest response rate

among need categories) indicated their dental needs were not available because of payment issues.

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What specific concerns do you have about Knox County Health care?

Interpretation – The larger the text, the more frequent the term was used in an open ended response to a request to add detail about their health and mental concerns in Knox County. No disease entity emerges as a concern. People items (abuse, child care) do emerge as potential issues and there is articulation of concerns about smoking, dental, alcohol and educational issues.

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Behavioral Health Issues emerge as a “Moderate” concern

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Poverty and Bullying also are “Moderate” concerns

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956 Residents cite considerable concern about tobacco use but the concern is not

related to smoking in a confined area when non-smokers are present.

YES 38%

NO 62%

Anyone in household use tobacco

NO 85%

Anyone in household smoke in confined area when non-smokers present

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965 Residents express no real concern on the following topics

Conclusions from public input to community health need assessment 1. Very positive about living in local society, many issues not expressed as being of any real

concern; 2. Prevalence of smoking is emphasized; 3. What items present as moderate concerns are (in descending order of concern);

• Health insurance; • Unhealthy food choices & obesity; • Cancer; • Diabetes; • Teen Birth rates; • Mental health and substance abuse issues; and • Heart disease.

4. Excepting mental health provider availability, the vast majority of residents have a medical provider.

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Appendix B: Local Experts Providing Recommendations of Priority among

Identified Community Need22

Individuals providing commentary and participating in the priority setting process included:

Christine Mills - American Cancer Society - Income Development Director -

[email protected];

Kim Rose – KCH - Board Member - [email protected];

Julie Miller - Knox County Health Department - Health Commissioner -

[email protected];

Kelly Gardner, RN - Knox County Board of DD - Major Unusual Incident Manager -

[email protected];

Gordon Yance - First-Knox National Bank - Board Chairman - [email protected];

Teresa Bemiller - Knox County, Ohio - County Commissioner - [email protected];

Rick Schlegel - FREEDOM CENTER - AToD Counselor 3 - [email protected];

Jennifer Odenweller - United Way of Knox County Inc. - Executive Director - [email protected];

Richard K Mavis - City of Mount Vernon Ohio – Mayor - [email protected];

Wendy Williams - Community Mental Health and Recovery Board - Executive Director -

[email protected];

Bruce White - Knox Community Hospital – CEO - [email protected]; and

Jan Thomas – Kenyon College – Professor of Sociology – [email protected].

22 Reference Schedule H (Form 990) Part V Section B 3

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Appendix C: Final Rank Order for Priorities Developed by Local Experts with KCH

Responsibility Identified

Commentary on Community Need Statistical Conclusions 1. Knox County compared to all Ohio Counties

The high smoking rate in Knox County is the highest ranked adverse health status factor.

Smoking is higher in Knox County than in approximately 96% of Ohio Counties;

Excessive drinking is also an adverse finding. Excessive Drinking (persistent drinking more

than 1 alcohol beverage a day or consuming more than 4 drinks (women) or 5 drinks (men) on a

single occasion in the last 30 days) is higher than in about 93% of Ohio counties; and

Inadequate Diabetic Screening - the screening rate in about 90% of Ohio Counties is better

than what occurs in Knox County.

Agreeing with observation 12; Disagreeing with Observation 2

Clarifying reasons for opinions or additional needs which should be considered:

I do not have any statistics to back up my opinion, but based on demographics I would think the

first two health factors occur more in the eastern portion of the County. I also believe that

individuals in this area might not be utilizing health care options as much due to various reasons.

Those I hear about would be personal beliefs (Amish population), lack of transportation, lack of

knowledge regarding diseases and income/lack of health insurance or medical card; and

The data I have seen supports items 1 and 2. I can't speak to item 3. Additionally I would note

the rate of per capital narcotics prescribed to Knox residents is higher than the state average.

2. Knox County Compared to Peer Counties

UNFAVORABLE observations

1. BIRTHS TO WOMEN AGE 40 to 54 occurs at a rate higher than at peer counties and at

the national rate;

2. NO CARE IN THE FIRST TRIMESTER occurs at a rate higher than at peer counties and

at the national rate;

3. BREAST CANCER among women occurs at a rate higher than at peer counties and at

the national rate;

4. COLON CANCER occurs at a rate higher than at peer counties and at the national rate;

5. CORONARY HEART DISEASE occurs at a rate higher than at peer counties and at the

national rate;

6. MOTOR VEHICLE INJURY occurs at a rate higher than at peer counties and at the

national rate; and

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7. STROKE occurs at a rate higher than at peer counties and at the national rate.

SOMEWHAT A CONCERN observations:

A. VERY LOW BIRTH WEIGHT occurs at a rate higher than at peer counties;

B. POSTNEONATAL INFANT MORTALITY occurs at a rate higher than at peer counties;

C. LUNG CANCER occurs at a rate higher than at peer counties; and

D. UNINTENTIONAL INJURY occurs at a rate higher than at peer counties.

BETTER than Peers and National rates:

I. LOW BIRTH WEIGHT (<2500 grams) ; PREMATURE BIRTHS (<37 weeks) ; BIRTHS TO

WOMEN UNDER 18; BIRTHS TO UNMARRIED WOMEN; and INFANT MORTALITY, occurs

at a rate lower than at peer counties and at lower than at national rates;

II. WHITE NON HISPANIC INFANT MORTALITY and NEONATAL INFANT MORTALITY

occurs at a rate lower than at peer counties and at lower than at national rates; and

III. SUICIDE occurs at a rate lower than at peer counties and lower that at national rates.



Does unintentional injury include unintentional overdoes? If yes, that rate is rising. There were

11 completed suicides in 2009 and 7 in 2010. We have at least 7 so far this year. I believe that

puts us at or above the state and national per capita numbers;

Please consider recent local data regarding premature births and suicide, specifically over the

past 2-3 years;

Judging from the announcements in the local newspaper, it would appear that the vast majority

of births at KCH are to unmarried women. I am surprised that we are better than peer and

national rates in this category;

While the peer comparisons are quite concerning, I have no basis upon which to disagree; and

I have to admit that due to not being in a field where you have access to most of this

information I am at a loss to know if this information is factual. I do find it surprising that we

have so many unfavorable observations. I would agree that due to having mostly rural roads we

do have a high number of motor vehicle injuries. The one area I have heard about from our

coroner is that we do have a high number of suicides, which in this survey says we are at a lower

rate than peer counties.

3. Primary Service Area Population Characteristics

1. Chronic high blood pressure and heart disease findings agree with heart disease as the leading cause of death

2. Low demand for cancer screening agrees with Cancer being among the leading causes of death in the County

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25% or more of the population is: A. Obese (29% of population); B. Do not use cancer prevention services (24% to 54% of the population, depending upon the specific test); C. Have chronic low back pain (27% of population); and D. Have chronic high blood pressure (30% of the population).



Statement number 2 is a difficult statement the way it is worded, in that there are times

patients WANT tests done, yet a physician is not wanting to order it because an insurance

company may not be happy. Is this statement only for the "routine" cancer screenings like

mammograms, pap smears, and prostate checks?? Even getting a colonoscopy at age 49 was not

going to happen for me when I felt my symptoms warranted one and I wanted one done...; and

I can not dispute the above findings. I think these diseases are leading causes of death in most

counties and across the country. Also it appears likely the above percentage is reflective of the

County's population.

4. Area Resident Summary Opinions

Respondents were very positive about living in Knox County. Many issues are expressed as not being of any real concern. Responses noted their most serious concern was the high prevalence of smoking. Items presented as moderate concerns are (in descending order of concern, with the highest concern being listed first)

o Health Insurance (lack of affordable coverage);

o Unhealthy food choice and Obesity;

o Cancer;

o Diabetes;

o Teen Birth rates;

o Mental Health and Substance Abuse Issues; and

o Heart Disease.



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Not sure actual data supports concern about teen birth rates;

Was the high prevalence of smoking a serious concern related to health or general community

concerns/issues?

From a health perspective, you can certainly tie smoking in with cancer and heart disease.

Unhealthy food choices/obesity can certainly be tied in with diabetes and a host of other

medical issues including mental health. I feel that substance abuse should be higher on this list,

as it is an issue that crosses over into every socio-economic area and age group; and

I am surprised that the high prevalence of smoking is the most serious concern. I would not have

put health insurance as the first choice in the list. I would have listed mental health and

substance abuse issues as a high concern because it not only impacts an individual's health but

also contributes to suicides and higher crime rates. Individuals are committing crimes in order to

pay for the drugs they need. Obviously heart disease and cancer are diseases you hear a great

deal about and obesity can lead to serious health issues.

3. Additional Community Health Assessment Considerations

1. Palliative Care programs (programs focused not on curative actions but designed to relieve disease

symptoms pain and stress arising from serious illness) exist at Knox Community Hospital and several

Hospice programs are in the area.

2. Ranking the causes of death finds the leading causes to be the following (in descending order of

occurrence):

Heart Disease;

Cancer;

Stroke;

Chronic Lower Respiratory Disease;

Unintentional Injury; and

Diabetes Mellitus.

The incident of Stroke is close to the state average, but it does exceed the national average rate.

Probably of greater importance is the very high incident of diabetic and hypertension comorbidities

(disease conditions accompanying the main illness) associated with patients presenting with stroke

conditions.



It all boils down to unhealthy food choices and unhealthy life styles. Education needs to begin

with kids all the way up through their school years! Adults have already developed habits that

are hard to break, and older adults have already harmed their bodies in many instances. Most

adults are also not willing to be taught or "talked to" about changing!

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Combination of Community Need Priorities The Local Experts made the preceding comments and observations about the list of potential

community need. The Local Experts then allocated priority points. The observation of their collective

opinion was judged substantially internally consistent and hence no need for further inquiry as to the

relative problems being addressed or final need statement.

To aid implementation efforts and to enhance clarity as to what were the final set of identified

community need, QHR and the KCH executive team made the following need statement combinations:

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Community Health Need Categories

Rank Order of Uncombined Priorities Priority Point

Allocation

% of Total

Points

Cumulative Total Points

Priority Potential Decisions

1. Cancer

5. CANCER SCREENING 89 8.9%

21.7%

65.9%

Hig

h P

rior

ity

4. CANCER 73 7.3%

3. BREAST CANCER 29 2.9%

16.LUNG CANCER 14 1.4%

8. COLON CANCER 12 1.2%

2. Adverse Behavior

Modification

24.SMOKING 97 9.7%

18.5% 12.DRINKING 71 7.1%

32.Substance Abuse 17 1.7%

3. Obesity 21.OBESITY 100 10.0%

14.6% 28.UNHEALTHY FOOD CHOICES 46 4.6%

4. Cardiovascular

Health

9. CORONARY HEART DISEASE 93 9.3%

11.1% 25.STROKE 10 1.0%

6. CHRONIC HIGH BLOOD PRESSURE 8 0.8%

5. Maternal and Infant

Care

2. BIRTHS TO UNMARRIED WOMEN 19 1.9%

10.1%

34.1%

Low

Pri

orit

y

27.TEEN BIRTH RATE 8 0.8%

14.INFANT MORTALITY 7 0.7%

15.LOW BIRTH WEIGHT 6 0.6%

20.NO CARE IN THE FIRST TRIMESTER 38 3.8%

23.PREMATURE BIRTHS 6 0.6%

19.NEONATAL INFANT MORTALITY 4 0.4% 22.POST-NEONATAL INFANT MORTALITY

4 0.4%

30.VERY LOW BIRTH WEIGHT 4 0.4%

31.WHITE NON HISPANIC INFANT MORTALITY

2 0.2%

1. BIRTHS TO WOMEN AGE 40 TO 54 3 0.3%

6. Mental Health

17.MENTAL HEALTH 85 8.5% 9.4%

26.SUICIDE 9 0.9%

7. Diabetes 11.DIABETIC SCREENING (lacking) 44 4.4%

8.4% 10.DIABETES 40 4.0%

8. Health Insurance

13.HEALTH INSURANCE 41 4.1% 4.1%

9. Injury 29.UNINTENTIONAL INJURY 11 1.1%

1.8% 18.MOTOR VEHICLE INJURY 7 0.7%

10. Low Back Pain

7. CHRONIC LOW BACK PAIN 3 0.3% 0.3%

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Community Health Need Categories Problem Statements

1. Cancer – Disease rates should not exceed national incident rates while screening and detection

services should increase;

2. Adverse Behavior Modification – Incidents of smoking, alcohol consumption and abuse of legal

and illegal pharmaceuticals all need to decline at least to State average rates;

3. Obesity – The portion of the population meeting clinical obesity standards needs to decline;

4. Cardiovascular Health – Incidents of heart disease and stroke need to decline while an

increasing portion of the population needs to achieve/maintain blood pressure control;

5. Maternal and Infant Care – Enhance prenatal care and seek improvement in other underlying

conditions resulting in very low weight babies and infant mortality;

6. Mental Health – Seek improvement in the self reported poor mental health days experienced in

service area population and achieve an enhance identification of individuals at risk of suicide;

7. Diabetes – Enhance diabetic awareness, problem identification and controls such that Knox

County no longer resides in the bottom 10% of Ohio Counties as well as achieving diabetes as

being a less frequent contributor to stroke comorbidities;

8. Health Insurance – Reduce vulnerable populations service access problems;

9. Injury – Improve accident response as actions to reduce the incident of accidents are

implemented; and

10. Low Back Pain – Enhance resources to manage the prevention, risk reduction and treatment of

low back pain.

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Appendix D: Knox County Compared to Other Ohio Counties23

Health Outcomes

23 http://www.countyhealthrankings.org/Ohio/Knox produced by Robert Woods Johnson & U of WI Population Health Inst.

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Health Factors

Indicator Knox County

Goal Target

# 1 Ohio County

#88 Ohio County

Clinical Care

Uninsured Adults (% of population under 65 without insurance) 14% 13% 12% 14%

Primary Care Provider Rate (primary care physicians per 100,000) 1,142:1 631:1 652:1 1,791:1

Preventable Hospital Stays (ambulatory sensitive admissions/ 1000 Medicare Enrollees)

70 52 66 102

Diabetic Screenings (% diabetic Medicare patients HbA1c tested) 78% 89% 84% 80%

Mammography Screening (% of female Medicare enrollees that receive mammography screenings)

64% 74% 66% 53%

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Indicator Knox County

Goal Target

# 1 Ohio

County

#88 Ohio

County

Social & Economic Factors

High School Graduates (% of ninth graders graduating in 4 years) [2 times more influential in ranking than other factors]

85% 92% 90% 85%

Some college (% of adults 25 – 44 with some post secondary education) [2times more influential in ranking than other factors]

50% 68% 68% 50%

Unemployment (% 16+ adults unemployed and looking for work) [4 times more influential in ranking than other factors]

9.6% 5.3% 6.9% 8.1%

Children in Poverty (% of children <18 living in poverty) [4 times moreinfluential in ranking than other factors]

19% 11% 5% 27%

Inadequate Social Support 16% 14% 19% 25%

Children in single-parent households 25% 20% 5% 37%

Homicide Rate (deaths per 100,000, age adjusted) [2 times more influential in ranking than other factors]

--- 1 --- 6

Physical Environment

Air Pollution particulate matter days (Annual unhealthy days) 0 0 2 1

Air Pollution ozone days (Annual unhealthy days) 3 0 3 2

Access to Healthy Foods (Availability of food stores) 63% 92% 60% 56%

Access to recreational facilities (facilities per 100,000) 5 17 15 6

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Summary of Observations from Knox County compared to all other Ohio counties,

in terms of Community Health Needs

1. Knox County health status generally compares favorably among Ohio counties, ranking 33 among the 88 ranked counties;

2. The high smoking rate in Knox County is the highest ranked adverse health status factor. Smoking is higher in Knox County than in approximately 96% of Ohio counties;

3. Excessive drinking is also an adverse finding. Excessive Drinking (persistent drinking more than 1 alcoholic beverage a day or consuming more than 4 drinks (women) or 5 drinks (men) on a single occasion in the last 30 days) is higher than in about 93% of Ohio counties;

4. Diabetic Screening is inadequate. Screening rates in about 90% of Ohio Counties is better than what occurs in Knox County;

5. The highest ranked POSITIVE influence among the health status factor is the lack of low birth weight babies. Knox County performance is better than 91% of Ohio counties;

6. The low incident of Obesity also is a positive factor in Knox County. Knox County rate is about better than 85% of Ohio Counties;

7. Other positive factors where Knox County performs better than about 80% of Ohio Counties include:

o Sexually Transmitted Disease;

o Teen Birth Rate;

o Preventable hospital stays; and

o Unemployment.

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Appendix E: Knox County Compared to National Peer Counties24

24 http://communityhealth.hhs.gov

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Knox County Peer Group is #18

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Peer Counties

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Knox County Performance Compared to Peer Counties and National Averages

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Summary Measures of Health

Measures of Birth and Death

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Environmental Health Factors

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Preventative Service Use

http://communityhealth.hhs.gov/

Expected Cases based

on occurrence among peer

counties

Flue Vaccine – 10th to 50th percentilePneumonia Vaccine – 10th to 50th ptileMammography – 10th to 50th percentilePap Smears – 10th to 50th percentile

Sigmoidoscopy – 50th to 90th percentileHepatitis A – 10th to 50th percentileHepatitis B – 0 to 10th percentilePertussis – 10th to 50th percentile

1 CDC national Notifiable Disease Surveillance System 2003 – 20072 CDC Behavioral Risk Factor Surveillance System 2000 – 2006

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Risk Factors for Premature Death

Summary of observations from Knox County Peer Comparisons

1. Births to women age 40-54, no care prenatal care in the first trimester, breast cancer, colon cancer, coronary heart disease, motor vehicle crashes and stroke are potential concerns comparing Knox to its Peer Counties and to national rates;

2. Very low birth weight, post-neonatal infant mortality, lung cancer and unintentional injury are conditions where Knox compares unfavorable to its peers;

3. Knox resident self rated health status is statistically significantly better than its peers; and

4. Environmental factors and infectious disease present as minor concerns, meeting most standards.

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Appendix F: Knox Service Area Population Characteristics25

Population Characteristic Knox County USA

2010 Total Population 59,986 309,038,999

2015 Total Population Estimate 62,020 321,675,045

2010-2015 % Population Change 3.4% 4.1%

2015 Median Age 37.6 38.2

2010 Median Household Income $46,993 $55,993

Population 65+ % of Total Pop 14.5% 13.2%

% Proj. Change 1.0% 15.5%

Females 15-44 % of Total Pop 20.7% 20.1%

% Proj. Change -0.5% -0.7%

25 All population values obtained from Thomson Market Planner

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Demographics Expert 2.72010 Demographic Snapshot

Area: Knox CoLevel of Geography: ZIP Code

DEMOGRAPHIC CHARACTERISTICSSelected

Area USA 2010 2015 % Change55,572 281,421,906 Total Male Population 30,049 31,166 3.7%61,622 309,038,974 Total Female Population 31,573 32,692 3.5%63,858 321,675,005 Females, Child Bearing Age (15-44) 12,773 12,842 0.5%

3.6% 4.1%Average Household Income $57,551 $71,071

POPULATION DISTRIBUTION HOUSEHOLD INCOME DISTRIBUTION

Age Group 2010 % of Total 2015 % of TotalUSA 2010 % of Total HH Count % of Total

USA % of Total

0-14 11,743 19.1% 12,106 19.0% 20.1% <$15K 2,709 11.9% 12.1%15-17 2,519 4.1% 2,563 4.0% 4.2% $15-25K 2,735 12.0% 10.2%18-24 7,105 11.5% 7,602 11.9% 9.7% $25-50K 6,803 29.8% 25.5%25-34 8,143 13.2% 7,728 12.1% 13.3% $50-75K 5,046 22.1% 19.5%35-54 16,216 26.3% 15,887 24.9% 28.1% $75-100K 2,671 11.7% 12.5%55-64 7,035 11.4% 8,101 12.7% 11.5% Over $100K 2,837 12.4% 20.1%65+ 8,861 14.4% 9,871 15.5% 13.2%Total 61,622 100.0% 63,858 100.0% 100.0% Total 22,801 100.0% 100.0%

EDUCATION LEVEL RACE/ETHNICITY

2010 Adult Education Level Pop Age 25+ % of Total USA % of Total 2010 Pop % of Total

USA % of Total

Less than High School 1,599 4.0% 6.4% White Non-Hispanic 59,294 96.2% 64.7%Some High School 3,511 8.7% 8.9% Black Non-Hispanic 622 1.0% 12.1%High School Degree 18,026 44.8% 29.0% Hispanic 618 1.0% 15.8%Some College/Assoc. Degree 9,940 24.7% 28.2% Asian & Pacific Is. Non-Hispanic 245 0.4% 4.5%Bachelor's Degree or Greater 7,179 17.8% 27.5% All Others 843 1.4% 2.9%Total 40,255 100.0% 100.0% Total 61,622 100.0% 100.0%

© 2010, Claritas Inc., © 2011 Thomson Reuters. All Rights Reserved

2000 Total Population2010 Total Population2015 Total Population% Change 2010 - 2015

Race/Ethnicity

Age Distribution

2010 Household Income

Income Distribution

Race/Ethnicity DistributionEducation Level Distribution

2010-2015 Population 65+ Females 15-44 Median Median Median% Population Median % of Total % Change % of Total % Change Household Household Home

Area Change Age Population 2010-2015 Population 2010-2015 Income Wealth ValueUSA 4.1% 37.0 13.2% 15.5% 20.1% -0.7% $52,516 $59,249 $169,144Ohio -0.2% 38.3 14.1% 10.2% 19.7% -4.0% $48,303 $61,309 $122,474Knox County 3.6% 36.8 14.4% 11.4% 20.7% 0.5% $46,993 $73,139 $121,862

© 2010, Claritas Inc., © 2011 Thomson Reuters. All Rights Reserved

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Service Area Population Health Status Analysis According to the Aggregate

Composition of Demographic Characteristic Segments

Interpretation – Areas boxed in red indicate a statistically significant different demand from the national

average. Observations relevant to assessing community health needs include:

Chronic diabetes should be about 8% higher than the national average;

Healthy eating should be almost 10% lower than the national average;

Visits to OB/GYN should be about 10% lower than the national average;

Cancer screening for Cervical and Prostate cancers are about 10% lower than the national

average;

Chronic back pain treatment demand should be about 10% higher than the national average;

Chronic Osteoporosis treatment demand should be about 14% higher than the national average;

Demand for sport medicine services should be about 22% lower than the national average;

Cardiac stress testing demand should be about 10% below national average while chronic high

blood pressure and heart disease should be over 10% above the national average;

Taking responsibility for personal health is about 6% below national average;

Tobacco use should be about 13% above the national average; and

Use of health information should be from 10% to 30% below national averages.

Health Status TopicDemand as

% of National

% of Population

AffectedHealth Status Topic

Demand as % of

National

% of Population

Affected

BMI: Morbid/Obese 104.7% 26.7% Routine Screen: Cardiac Stress 2yr 89.1% 28.1%Vigorous Excersize 98.9% 50.2% Routine Screen: Cholesterol 96.2% 24.3%Chronic Diabetes 108.8% 11.3% Chronic High Cholesterol 100.9% 22.4%Healthy Eating Habits 91.9% 27.2% Chronic High Blood Pressure 112.7% 29.6%Not At All Healthy Eating Habits 115.3% 3.2% Chronic Heart Disease 113.5% 10.0%

FP/GP: 1+ Visit 103.1% 90.9% Depression 101.5% 35.8%OB/Gyn 1+ Visit 90.5% 48.2% I am responsible for my health 94.3% 61.9%Ambulatory Surgery last 12 Months 101.5% 25.9% I follow through with treatments 99.3% 51.8%

Emergency Room Use 103.0% 39.7% Tobacco Use: Cigarettes 113.4% 35.9%Urgent Care Use 96.9% 43.2% Chronic Allergies 102.3% 25.4%

Mammography in Past Yr 96.9% 43.7% Internet: Use Social Networking Sites 90.1% 27.2%Cancer Screen: Colorectal 2 yr 96.2% 24.3% Internet: Use To Communicate With MD 70.1% 8.5%Cancer Screen: Pap/Cerv Tst 2 yr 90.0% 54.2% Health Info Svcs: 3+ Use 91.4% 36.9%Routine Screen: Prostate 2 yr 92.7% 29.2% Looked For Provider Ratings 89.6% 12.8%

Chronic Lower Back Pain 110.8% 26.9% Charitable Contrib: Hosp/Hosp Sys 96.6% 23.0%Chronic Osteoporosis 114.1% 11.7% Charitable Contrib: Other Health Org 93.4% 36.5%Sports Injury 77.1% 13.8% Medical Tourism: Willingness To Travel 92.7% 21.2%

Weight / Lifestyle Heart

Emergency Service

Miscellaneous

Orthopedic

Behaviors

Miscellaneous

Pulmonary

Routine Services

Cancer

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Vulnerable Populations26

26 Reference 990 Part V B 1 f

Vulnerable Populations Include People Who Total% of

Population

Have no high school diploma (among adults age 25 and older) 7,033 11.9%

Are unemployed 1,923 3.2%

Are severely work disabled 1,141 1.9%

Have major depression 3,568 6.0%

Are recent drug users (within past month) 4,089 6.9%

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Conclusions from the demographic analysis

1. The service area comprises of 22,801 households and 14.5% of the residents of the age 65 or more in Knox County, Ohio. The elderly population is slightly higher than the percent of the population the elderly comprise in the state or in the national population;

2. The population of the area is estimated to be 59,986 and by 2015 should be 62,020, a rate of growth somewhat slower than the rate of growth in Ohio or the national growth rate;

3. The area is dominantly white; all minorities comprise only 3.8% of the population;

4. The population segment comprising “Women of childbearing age” is in line with the national rate but 1% higher than the average in Ohio;

5. The indication of a High incident of chronic diabetes unfortunately agrees with the prior observation of a low use of diabetic screening by Knox County residents. It appears this risk factor is not an artifact of obese residents, rather it may relate, in part, to poor eating habits that also occurs at an excessive rate among residents;

6. Chronic high blood pressure and heart disease along with a low rate of routinely taking advantage of cardiac stress testing all agree with Heart disease as the leading cause of death;

7. Low demand for cancer screening agrees with Cancer being among the leading causes of death in the County;

8. The high smoking rate again appears as a prevalent adverse health factor; and

9. The population is reluctant to show responsibility for their own health and does not take advantage of resources for obtaining health information.

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Appendix G: Knox County Leading Causes of Death27

27 http://www.healthyohioprogram.org/comprofiles/knox.pdf and responds in part to IRS 990 Part V B 1 f

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Appendix H: Knox County Selected Additional Health Status Factors28

Male Life Expectancy has increased since the 1987 value of 71.1 Years

Female Life Expectancy has increased since the 1987 value of 78.8 Years

Male life expectancy has improved faster than Female Life Expectancy, narrowing the gap between the sexes by two years, and achieving overall improvement.

28 http://www.healthmetricsandevaluation.org/tools/data-visualization/life-expectancy-county-sex-and-race-us-1987-2007

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Palliative Care Programs (programs to relieve pain, symptoms, and stress of

serious illness) are available in Knox County29

In Knox County a Palliative Care Program is available from:

Knox Community Hospital

29 www.getpalliativecare.org

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Area Hospice Locations

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Designated Professional Shortage Areas30

No health professional shortage areas exist in Knox County.

30 Source: http://datawarehouse.hrsa.gov

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Knox County Stroke Death Rate Exceeds State and National Rates31

31 http://apps.nccd.cdc.gov/giscvh2/Results.aspx

Comorbidities

Diabetes Very High Incidence

Atrial Fibrillation High Incidence

Hypertension Very High Incidence

Source: http://apps.nccd.cdc.gov/giscvh2/

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Knox County Heart Disease Death Rate Approaches the National Rate and is

below the Ohio Average32

32 http://apps.nccd.cdc.gov/giscvh2/Results.aspx

Comorbidities

All Heart Disease Low Incidence

Coronary Heart Disease Normal Incidence

Acute Myocardial Infraction Normal Incidence

Cardiac Dysrhythmia Normal Incidence

Heart Failure Very Low Incidence

Other Heart Diseases Normal Incidence

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Prevalence of Diabetes for Total Population 30 and over33

Data is drawn from the Behavioral Risk Surveillance System and analyzed in this display. On a relative

basis, the 2008 estimated prevalence of diabetes in Knox County is in the fourth lowest decile group.

33 http://www.healthmetricsandevaluation.org/tools/data-visualization/diabetes-prevalence-county-us-maps

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Selected Medical Personnel Supply Compared to Surrounding Counties

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Business Patterns34

34

Pattern Indicators Total

Number of physician offices 30

Number of physician offices per 1,000 population 1

Number of dentist offices per 1,000 population .31

Number of dentist offices 17

Number of drug stores 7

Number of drug stores per 1,000 population .12

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Key Conclusions from consideration of the other statistical data examinations.

1. Ranking the causes of death finds the leading causes to be the following: o Heart Disease;

o Cancer;

o Stroke;

o Chronic Lower Respiratory Disease;

o Unintentional Injury; and

o Diabetes Mellitus.

2. The incident of stroke is close to the state average but it does exceed the national average rate. Of significance, there is a very high incident of diabetic and hypertension comorbidities;

3. Heart disease rates place Knox County in the lowest quartile of Ohio Counties;

4. Knox County is not designated as a Medically Underserved Area; and

5. Knox County has a palliative care program and hospice program.

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Appendix I: Illustrative Schedule H (Form 990) Part V B Potential Response

Illustrative IRS Schedule H (form 990) Part V B35

Community Health Need Assessment Answers 1. During the tax year or any prior tax year, did the hospital facility conduct a community health

needs assessment (Needs Assessment)? If "No," skip to line 8

Illustrative Answer – Yes

If “Yes,” indicate what the Needs Assessment describes (check all that apply):

a. A definition of the community served by the hospital facility

b. Demographics of the community

c. Existing health care facilities and resources within the community that are available to

respond to the health needs of the community

d. How the data was obtained

e. The health needs of the community

f. Primary and chronic disease needs and health issues of uninsured persons, low-income

persons and minority groups

g. The process for identifying and prioritizing community health needs and services to

meet the community health needs

h. The process for consulting with persons representing the community’s interests

i. Information gaps that limit the hospital facility’s ability to assess all of the

community’s health needs

j. Other (describe in Part VI)

Illustrative Answer – check a. through i. Answers available in this report are found as follows:

1. a. – See Footnote #13 (page 10)

1. b. – See Footnote #14 (page 11)

1. c. – See Footnote #18 (page 18)

1. d. – See Footnote #6 (page 6)

1. e. – See Footnote #11 (page 7)

1. f. – See Footnote #9 (page 7), #26 (page 62) & #27 (page 64)

1. g. – See Footnote #12 (page 8)

1. h. – See Footnote #7 (page7)

1. i. – See Footnote #5 (page 6) 35 Questions are drawn from 12/15/2011 Draft Forms and may have changed at the time when the hospital is to make its 990 h filing

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1. j. – No response needed

2. Indicate the tax year the hospital facility last conducted a Needs Assessment: 20 _ _

Illustrative Answer – 2012

See Footnote #1 (Title page)

3. In conducting its most recent Needs Assessment, did the hospital facility take into account

input from persons who represent the community served by the hospital facility? If “Yes,”

describe in Part VI how the hospital facility took into account input from persons who

represent the community, and identify the persons the hospital facility consulted

Illustrative Answer – Yes

See Footnote #8 (page 7) & #10 (page 7) & #22 (Appendix B, page 39)

4. Was the hospital facility’s Need Assessment conducted with one or more other hospital

facilities? If “Yes,” list the other hospital facilities in Part VI.

Illustrative Answer – No

5. Did the hospital facility make its Needs Assessment widely available to the public? If “Yes,”

indicate how the Needs Assessment was made widely available (check all that apply)

a. Hospital facility’s website

b. Available upon request from the hospital facility

c. Other (describe in Part VI)

Illustrative Answer – check a. and b.

The hospital will need to obtain Board approval of this report, document the date of

approval and then take action to make the report available as a download from its web

site. It also may be prudent to place a notice in a paper of general circulation within the

service area noting the report is available free upon request.

6. If the hospital facility addressed needs identified in its most recently conducted Needs

Assessment, indicate how (check all that apply):

a. Adoption of an implementation strategy to address the health needs of the hospital

facility’s community

b. Execution of an implementation strategy

c. Participation in the development of a community-wide community benefits plan

d. Participation in the execution of a community-wide community benefits plan

e. Inclusion of a community benefit section in operational plans

f. Adoption of a budget for provision of services that address the needs identified in the

Needs Assessment

g. Prioritization of health needs in its community

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h. Prioritization of services that the hospital facility will undertake to meet the needs in

its community

i. Other (describe in Part VI)

Illustrative Answer – check a, b, f, g, and h.

6. a. – See footnote #19 (page 24)

6. b. – See footnote #19 (page 24)

6. f. – See footnote #3 (page 4) and #21 (page 29)

6. g. – See footnote #12 (page 8)

6. h. – See footnote #12 (page 8)

7. Did the hospital facility address all of the needs identified in its most recently conducted Needs

Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why

it has not addressed such needs?

Illustrative Answer – No

Part VI suggested documentation – See Footnote #20 (page 29)

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2012 Community Needs Health Assessment

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