Middleboro Community Needs Assessment

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The Health Systems Administration program at Georgetown has its students complete case projects for a fictional community, Middleboro. Throughout the program we created several deliverables: Community Profile, Community Health Assessment, Strategic Plan, Marketing Plan, and Business Plan.

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  • Defining population health: concerns the health outcomes of a group of individuals, including the distribution of such outcomes within the groupObjectives of population health studies: describe, explain, predict, control.Describe the state of health of the population and identify prevalent health problemsExplain why the state of health is the way it is and why certain health problems occurPredict health effects and strategies for risk avoidancePrevent disease and promote healthWhen we can describe, explain, predict, and control the health of a population, we can answer why why some people are healthier than others
  • Conceptual framework to think about why some people are healthier than others
  • For HC, comparable to other places (Capital City and the US).
  • Comparatively across HC, CC, USA (HC is healthy)Objective: show that HC is relatively the same- no major outliers, Overall HC is comparatively healthy compared to Capital City and the USA, mortality rates are similarBut within population when comparing mortality rates in total, more people are dying from chronic diseases such as heart disease, followed by cancer and then stroke
  • HC internally (HC is doing poorly in chronic diseases)Within HC internally, clear distinction that chronic diseases are a major problem. The 3 leading causes of death (other than other) are related to chronic disease. as you can see heart disease, and MN (eg cancer), and stroke are the primary causes of death. In this community health profile we are going to be discussing heart disease and cancer in further detail.If you want to talk about “other causes” just mention that while they do make up a significant portion of the death rate as we don’t know what they specifically are we can’t make any community health related conclusions regarding them.The health indicator framework will be applied as applicable to chronic diseases to describe, explain, predict, control
  • Conceptual framework to think about why some people are healthier than others
  • Relatively speaking, HC has a similar mortality rate to nearby CC . This suggests that the overall health of the population is comparable to other populations. Age does not appear to be a contributing factor to the chronic disease issue.
  • As you can see the populations of the towns in Hillsboro County are relatively stagnant. The exception is Jasper which has had a population which is steadily growing.Population is not increasing in HC, so is not significant factor contributing to chronic disease issuePopulation trend doesn’t relate to chronic diseaseThis is a point to keep in mind for when we discuss health systems
  • While there are relatively the same amount of people employed in HC as CC/State
  • Conceptual framework to think about why some people are healthier than others
  • -no insurance coverage is high (spiked 5 years ago) in the community (as seen in the red line) -no health insurance – no access to needed health coverage, which has negative impact on chronic disease in the community
  • -for those with health insurance, the health system appears to be serving them relatively well (people not coming back as much – hospitals achieving the right outcomes)-also, the observed slightly higher readmission rate within 30 days may suggest that the population is experiencing problems with chronic disease
  • -for those with health insurance, the health system appears to be serving them relatively well-health insurance coverage is low, but for those with, the health delivery system seem to be fine
  • Conceptual framework to think about why some people are healthier than others
  • Compared to Capital City and the US, HC has the worst mortality rates in cardiovascular health and cancer (leading causes of death for HC)
  • HC has higher heart disease mortality rate than both Capital City and the U.S.Currently within HC, 35% of population is dying from diseases of the heart
  • First behavior under cardiovascular health – cholesterol awarenessMeasured people who’ve had their cholesterol checked within the last five years (not so many people), cholesterol checked, and those who do have high cholesterol (we have most ppl who have cholesterol compared to CC and state wise)
  • Hypertension can lead to cardiovascular diseaseHC has the highest hypertension prevalence compared to CC and StateGraph: people who know they have high blood pressure (prevelance)
  • -so, obesity may not be significant contributing factor to chronic diseases… but further research needed (for example age-adjusted)-for those that have high BMI, may be factor in prevalence/incidence of chronic disease
  • HC has comparatively similar mortality rates to CC and USA. However, internally shows that cancer is the second leading cause of death20% of population with HC has died from cancer
  • - HCis the worst in smoking compared to CC and the State, higher proportion of smokers everyday in HC = correlates to less former smokers in HC-smoking contributes to high rate of chronic disease, specifically cancer
  • -because sizable percentage of population is employed in blue-collar sectors (agriculture and manufacturing) there may be a higher chance of exposure to factors that contribute to chronic disease conditions such as poor cardiovascular health and cancer. In manufacturing this might be: in agriculture this might be: pollutants – factors in cancer, according to a Johns Hopkins study from 1994 published by the American Journal of Epidemiology. http://aje.oxfordjournals.org/cgi/content/abstract/139/11/1055
  • Positive parts of health
  • -indicates type of health insurance has changed – fee for service to managed care-this is a positive trend because managed care seeks to better manage chronic disease-as trend continues, we expect improved outcomes with respect to chronic disease
  • Positive parts of health
  • Middleboro Community Needs Assessment

    1. 1. MIDDLEBOROCOMMUNITY HEALTHPROFILEJessica Jacobs, Karen Jose, ErinLenhardt, Veronica Locke, DanielLynn
    2. 2. POPULATION HEALTH Concerns the health outcomes of a group of individuals including the distribution of such outcomes within the group (Kindig and Stoddart) Objective: to describe, explain, predict, control
    3. 3. HEALTH INDICATORS A limited yet comprehensive set of coherent and significant indicators that can be monitored over time and disaggregated to relevant social units (Stoto) Intended to help everyone more easily understand the importance of health promotion and disease prevention and to encourage wide participation in improving health in the next decade (Healthy People 2010)
    4. 4. SUSA HEALTH INDICATORS FRAMEWORK Social and Physical Environment Health-Related Health Behaviors Outcomes Health Systems
    5. 5. HILLSBORO’S HEALTH STATUS Comparatively similar health status as other communities Within the community, chronic disease prevalence is an issue:  Cardiovascular health  Malignant neoplasm
    6. 6. HILLSBORO MORTALITY RATES Comparative Mortality Rates 30Rate per 10,000 People 20 10 0 Hillsboro County Capital City USA
    7. 7. HILLSBORO COUNTY Hillsboro County Cause Adjusted Mortality 40Cause of Death Rate per 100 Deaths 35 30 25 20 15 10 5 0
    8. 8. SUSA HEALTH INDICATORS FRAMEWORK Social and Physical Social and Physical Environment Environment Health-Related Health Behaviors Outcomes Health Systems
    9. 9. SOCIAL AND PHYSICAL ENVIRONMENT Key indicators as they relate to chronic disease  Demographics  Age  Population  Employment market
    10. 10. AGE ADJUSTED MORTALITYRATE Age Adjusted Mortality Rate 40Rate per 1,000 People (65+ years) 30 20 10 0 Hillsboro County Capital City
    11. 11. POPULATION TRENDS Hillsboro County Population Comparison Population Trends 200000 50000 180000 40000 30000 160000People People 20000 140000 10000 120000 0 CY-25 CY-20 CY-15 CY-10 CY-5 CY 100000 Middleboro Jasper Harris City CY-25 CY-20 CY-15 CY-10 CY-5 CY Statesville Mifflenville Carterville Minortown Boalsburg Hillsboro County Population Capital City
    12. 12. EMPLOYMENT TRENDS Employment Trends 60 45Percentage of Population 30 15 0 Hillsboro County Capital City State Wide
    13. 13. SUSA HEALTH INDICATORS FRAMEWORK Social and Physical Environment Health-Related Health Behaviors Outcomes Health Systems Health Systems
    14. 14. HEALTH SYSTEMS Access and coverage as they relate to chronic disease  Health Insurance  Readmission Rates
    15. 15. INSURANCE PROVIDER TRENDS Insurance Provider 25 Year Trend 60 50Percentage of Population 40 30 20 10 0 CY-25 Cy-20 CY-15 CY-10 CY-5 CY No Insurance Medicare Medicaid Blue Cross/Blue Shield Commercial Other- VA, etc
    16. 16. READMISSION RATES Readmissions 20 15Percentage of Discharges 10 5 0 Within 7 Days Within 15 Days Within 30 Days Hillsboro Capital City
    17. 17. INFANT MORTALITY Infant Mortality 8 6Rate Per 1,000 4 2 0 Hillsboro County Capital City United States
    18. 18. SUSA HEALTH INDICATORS FRAMEWORK Social and Physical Environment Health-Related Health Related Health Behaviors Behaviors Outcomes Health Systems
    19. 19. HEALTH RELATED BEHAVIORSSignificant Chronic Illnesses:  Cardiovascular Disease  Key Indicators:  Cholesterol Awareness  Hypertension Awareness  BMI Demographics  Exercise  Malignant Neoplasm (Cancer)  Key Indicators:  Substance Abuse (Tobacco and Alcohol)  Fruits and Vegetables  Job Market
    20. 20. CARDIOVASCULAR HEALTHComparative Mortality Internal Death Rate Heart Related Mortality Heart Related 35 Death Rates Heart 30 Related 35% 25Rate per 10,000 20 15 Other 10 Causes 65% 5 0 Hillsboro County Capital City USA
    21. 21. CHOLESTEROL AWARENESS Cholesterol Awareness 80 70 60Percent of Adult Population 50 40 30 20 10 0 Cholesterol Checked (Within Last 5 Years) High Cholesterol (Ever) Hillsboro County Capital City State Wide
    22. 22. HYPERTENSION AWARENESS Hypertension Prevalence 40 30Percentage of Adult Population 20 10 0 Hillsboro County Capital City State Wide
    23. 23. BMI DEMOGRAPHICS BMI Demographics 60Percentage of Adult Population 40 20 0 Neither Overweight or Obese Overweight (BMI 25.0-29.9) Obese (BMI 30.0-99.8) (BMI < 24.8) Hillsboro County Capital City State Wide
    24. 24. MALIGNANT NEOPLASMSComparative Mortality Internal Death Rate Malignant Neoplasms Proportion of Mortality Rate Malignant Neoplasms 20 Deaths Malignant Neoplasms 15 20%Rate Per 10,000 10 Other Causes 80% 5 0 Hillsboro County Capital City USA
    25. 25. SUBSTANCE ABUSE - TOBACCO Smoking Status 30Percent of Adult Population 25 20 15 10 5 0 Everyday Some Days Former Smoker Hillsboro County Capital City State
    26. 26. EMPLOYMENT RELATED FACTORS Middleboro Employment Sectors Manufacturing Agriculture Other Industries 30% 51% 19%
    27. 27. POSITIVE HEALTH FACTORS Hillsboro appears to be succeeding in some areas as related to chronic diseases:  Exercise  Fruits and vegetables  Managed care penetration
    28. 28. EXERCISE Exercise 80Percentage of Adult Population 60 40 20 0 Any Physical Activity (Within Last Month) Cardiovascular Exercise Hillsboro County Capital City State Wide
    29. 29. FRUITS AND VEGETABLES Fruit and Vegetable Consumption 40 30Percentage of Adult Population 20 10 0 Consume 5+ Servings per Day Hillsboro County Capital City State Wide
    30. 30. MANAGED CARE PENETRATION 25-Year Trend Insurance Types 100 90 80Percentage of Insured Population 70 60 50 40 30 20 10 0 CY-25 CY-20 CY-15 CY-10 CY-5 CY FFS Managed Care
    31. 31. CONCLUSION Overall, similar health outcomes as other communities But, chronic disease is an issue  Cholesterol, Hypertension, Tobacco usage  Access to care: declining health insurance coverage Moving forward,  Continue positive trends: exercise, healthy foods, managed care penetration  Implement prevention & health promotion programs, improved coordination of care, expand insurance coverage

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