Community Needs Assessment Marion County Marion County Florida Located in Central Florida with a population of 343, 778. Marion county is in central Florida. 2 Social Determinants Factors included in this category, generational poverty, widespread homelessness, persistent issue of overweight and obesity, lack of affordable housing, shortage of healthcare and dental care providers, water fluoridation is lacking in most communities, struggling and failing schools, and built environment impedes access to recreation areas and safe places for physical activity. Addressing social determinants of health is important for improving health and reducing health disparities. 3 Marion County Most Utilized Hospitals Hospital NameNumber of DischargesFlorida Hospital Ocala15,739Ocala Regional Medical Center8,940West Marion Community6,532 Medical Resources Available Clinical and nutrition services Wellness programs Environmental health Infectious Disease services Clinical and nutrition services include - Supplements for women and children, immunizations throughout various locations within the county, dental services, family planning, and centers which treat sexually transmitted diseases. Wellness programs which include – disease prevention and management such as diabetes. Weight programs, children healthy promotional programs, and health education. Environmental health which includes - Environmental Health programs are essential to public health. They work to achieve a safe and healthy environment for the community. Environmental Health staff monitor conditions that could present a threat to health and safety of the public. Infectious Disease services which involves, The Florida Department of Health in Marion County is responsible for the surveillance of reportable communicable diseases, including enteric diseases, vaccine-preventable diseases, invasive bacterial diseases, arthropod-borne diseases, and others. Infectious disease control programs are designed to protect the residents and visitors of Marion County 5 Community Needs Assessment Marion County community needs include, access to primary prevention and healthcare, oral health, mental and behavioral health, education and training. Primary prevention efforts are focused on preventing illness and injury before it happens. Prevention includes environmental and policy change as well as education, behavior revision and lasting investments in systems that encourage healthy living. Oral health influences physical, emotional, and social well-being. Poor oral health causes pain and disability. With pain and disability hinders work and school which causes issues with attendance and performance. Oral issues will in turn costs residents, taxpayers and healthcare systems millions of dollars to treat. Mental and physical health are equally important factors for overall health and quality of life. Mental and behavior health includes emotional, psychological and social we ...

1. Community Needs Assessment
Marion County
Marion County Florida
Located in Central Florida with a population of 343, 778.
Marion county is in central Florida.
2
Social Determinants
Factors included in this category, generational poverty,
widespread homelessness, persistent issue of overweight and
obesity, lack of affordable housing, shortage of healthcare and
dental care providers, water fluoridation is lacking in most
communities, struggling and failing schools, and built
environment impedes access to recreation areas and safe places
for physical activity.
Addressing social determinants of health is important for
improving health and reducing health disparities.
3
Marion County Most Utilized Hospitals
Hospital NameNumber of DischargesFlorida Hospital
Ocala15,739Ocala Regional Medical Center8,940West Marion

2. Community6,532
Medical Resources Available
Clinical and nutrition services
Wellness programs
Environmental health
Infectious Disease services
Clinical and nutrition services include - Supplements for
women and children, immunizations throughout various
locations within the county, dental services, family planning,
and centers which treat sexually transmitted diseases.
Wellness programs which include – disease prevention and
management such as diabetes. Weight programs, children
healthy promotional programs, and health education.
Environmental health which includes - Environmental Health
programs are essential to public health. They work to achieve a
safe and healthy environment for the community. Environmental
Health staff monitor conditions that could present a threat to
health and safety of the public.
Infectious Disease services which involves, The Florida
Department of Health in Marion County is responsible for the
surveillance of reportable communicable diseases, including
enteric diseases, vaccine-preventable diseases, invasive
bacterial diseases, arthropod-borne diseases, and others.
Infectious disease control programs are designed to protect the
residents and visitors of Marion County
5

3. Community Needs Assessment
Marion County community needs include, access to primary
prevention and healthcare, oral health, mental and behavioral
health, education and training.
Primary prevention efforts are focused on preventing illness and
injury before it happens. Prevention includes environmental
and policy change as well as education, behavior revision and
lasting investments in systems that encourage healthy living.
Oral health influences physical, emotional, and social well -
being. Poor oral health causes pain and disability. With pain
and disability hinders work and school which causes issues with
attendance and performance. Oral issues will in turn costs
residents, taxpayers and healthcare systems millions of dollars
to treat.
Mental and physical health are equally important factors for
overall health and quality of life. Mental and behavior health
includes emotional, psychological and social well-being and
impacts how stress is handled, interpersonal relationships, and
healthy decision-making.
6
Priority Concerns
Access to Primary Prevention
Oral Health
Mental and Behavioral Health
Access to Primary Prevention and Health Care Services with

4. focus on, Community wellness and Access to primary care.
Oral Health including, Access to oral health services and
Expansion of prevention initiatives
Mental and Behavioral Health including, Access to care for
mental health conditions and substance abuse treatme nt services
7
Steps to improvement
Promote Community Wellness
Improve Access to Primary Care
Improve Access to Oral Health Services
Improve Oral Health Through Expansion of Prevention
Initiatives
Community Wellness
Decrease tobacco access, increase educational opportunities in
middle schools, and increase treatment in high schools. Reduce
the number of middle school and high school students who used
cigarettes, cigars, smokeless tobacco, or electronic vapor
products.
Increase access to healthy affordable foods within food deserts,
increase education on healthy eating options and increase
participation in physical activity, reduce the Marion County
middle and high school obesity rate.
9
Access to Primary Care
Increase the number of individuals using free clinics, reduce the

5. uninsured rates, and increase the number of services provided.
Decrease the number of adults who could not see a doctor in the
past year due to cost.
Increase Medicaid providers who will see high risk pregnancies
and provide resource guide to pregnant women, and decrease the
number of women receiving late or no prenatal care.
10
Access to Oral Health Care
Increase mobile and portable clinic dental availability in high
risk neighborhoods, increase evening and weekend dental
appointment availability, and strengthen referral system.
Reduce the oral health emergency department visit rate.
Increase the percentage of adults who have visited a dentist or
dental clinic.
Prevention Initiatives
Education to water system operators on funding available to add
fluoridation to water systems and increase the percentage of
Marion County population receiving optimally fluoridated
water.
Performance Indicators
Performance indicators used include:
Number of individuals that have established a primary care
physician.
Amount of those individuals who have decreased risk factors
associated with chronic illnesses from the result of seeking

6. primary prevention.
Increased percentage of adults who have visited or received
services for oral care.
Decreased percentage of oral health emergency department visit
rate.
Percentage of individuals within the county who have
fluoridated water
Performance indicators are used as a form of measurement to
demonstrate if goals are being achieved.
13
References
FloridaHealth.gov (2021). Programs and Services.
Https://floridahealth.gov
Institute of Medicine (U.S.). (2012). Primary Care and Public
Health : Exploring Integration to Improve Population Health.
National Academies Press.
Marioncountyhealth.gov (2020). COMMUNITY HEALTH
IMPROVEMENT PLAN.
2020_2024_community_health_improvement_plan_chip.pdf
(floridahealth.gov)
Rollins, L., Gordon, T. K., Proeller, A., Ross, T., Phillips, A.,
Ward, C., Hopkins, M., Burney, R., Bojonowski, W., Hoffman,
L., Daniels, Y., Mobley, M., Mubasher, M., & Akintobi, T. H.
(2020). Community-Based Strategies for Health Priority Setting
and Action Planning. American Journal of Health
Studies, 35(2), 102–114.
Wellglorida.ord (2020). County Health Profile: Marion County
Data. Marion County Data | WellFlorida.
Running head: Assessing Data Sets for Population Health

7. Management 1
Assessing Data Sets for Population Health Management
8Assessing Data Sets for Population Health Management
Kimberly Huff
Rasmussen College
Author Note
Deliverable 2 Submitted January 19, 2021
Data Sets
Data sets are an important component when conducting many
different forms of research. Collecting data allows one to
examine the information from different elements. After data is
collected it could be manipulated when needed using a
computer. In previous times patient information was recorded
using the pen and paper method. Using computer methods today
allow for ease of access.
Increasing the quality of care is at the forefront of many
healthcare organizations. With that said, medical data serves as
an essential component where the quality of care is concerned.
The majority of data comes from the patient. Patients can
supply data that lead healthcare workers to develop patient-
specific ways to prevent diseases, personalize treatments, and
enhance overall health outcomes. Healthcare data is also
essential in the management and administration of the hospital
or facility and makes it easier to track a patient’s medical trek.
Data is also crucial in reducing or eliminating medical errors.
Population health management focuses on the improvement of

8. the healthcare delivery system within a specified area. To
determine appropriate measures to take the data must be current
and accurate. Different information to include in the data sets
that can be utilized are socioeconomic determinants and
electronic health records.
Socioeconomic determinants will provide valuable information
such as the level of education, occupation, and income of the
people residing in a selected area. Once evaluated this type of
information can aid in tracking prominent illness within the
area. Using electronic medical records will aid in logging
different illnesses/diseases and their outcomes. These data sets
will be critical in allowing the health system PHM program in
the selected area. The data sets will provide relevant
information which will in turn be beneficial when organizing
the PHM program.
Gathering personal information such as age, sex, and ethnicity,
occupation, and income will be important as once analyzed it
will allow one to determine if those factors influence disease
and illness. Using the HER system will allow all participants to
view the information as needed and offer the chance to gather
additional information when needed. The data gathered should
be checked for accuracy. Having accurate data will ensure the
success of the program.
Gathering data from different sources will provide a broad
range overview. Many areas are large such as Marion County so
accurate data would be essential when determining ways to
decrease illness and disease. Data within a PHM program is
typically informed data so all data must be true and accurate in
its entirety to be analyzed correctly.
Diabetes
Diabetes has become an issue for many people around the
world. Diabetes is a condition that develops when blood sugar
in the body rises above average, and this occurs when the
pancreas fails to work as required. Many times diabetes can be
controlled by diet and exercise. In some cases medication
management would need to be utilized if diet and exercise fail.

9. Promoting education is key to any health improvement plan.
Relevant and adequate data is a requirement when researching
disease and illness.
Data can be gathered within the community which include,
number of individuals diagnosed with diabetes, age, race,
ethnicity, comorbidities, socioeconomic status, and location of
residence. Air pollution is the primary environmental factor
contributing to diabetes, as it results in increased insulin
resistance. Once this information is obtained, further analysis of
the information can be completed to determine if there is a
pattern of the disease.
Despite diabetes being a lifestyle condition, the disease
develops because of various social factors, including poverty.
Disadvantaged people may not be able to afford healthy foods,
have inadequate access to prevention resources and healthcare
management, increasing their susceptibility to diabetes. Also,
low education. People with low education achievement have
insufficient knowledge about the development and prevention of
diabetes.

10. References
Dahl, S., & Brennhofer, S. (2018). PHM-Focused Healthcare
Delivery. In S. Dahl, & S. Brennhofer, Training to Deliver
Integrated Care (pp. 65-78). Cham: Springer.
Institute of Medicine (U.S.). (2012). Primary Care and Public
Health : Exploring Integration to Improve Population Health.
National Academies Press.
Marioncountyhealth.gov (2020). COMMUNITY HEALTH
IMPROVEMENT PLAN.
2020_2024_community_health_improvement_plan_chip.pdf
(floridahealth.gov)
Mennis, J., & Stahler, G. (2016). Racial and ethnic disparities
in outpatient substance use disorder treatment episode
completion for different substances. Journal of substance abuse
treatment, 63, 25-33.
Powell, P., D Corathers, S., Raymond, J., & Streisand, R.
(2015). New approaches to providing individualized diabetes
care in the 21st century. Current diabetes reviews, 11(4), 222-
230. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4864491/
Rollins, L., Gordon, T. K., Proeller, A., Ross, T., Phillips, A.,
Ward, C., Hopkins, M., Burney, R., Bojonowski, W., Hoffman,
L., Daniels, Y., Mobley, M., Mubasher, M., & Akintobi, T. H.
(2020). Community-Based Strategies for Health Priority Setting
and Action Planning. American Journal of Health
Studies, 35(2), 102–114.
Running head: BIG DATA IN DIABETES MANAGEMNT
2
BIG DATA IN DIABETES MANAGEMENT

11. Big Data in Diabetes Management
Student’s Name
Institutional Affiliation
Many organizations use data for the purpose of data analytics.
However, before organizations can get valuable information
about big data, they may need knowledge of various significant
data sources. As a PHM program leader, I would focus on
diabetes management and find out the significant data sources
used to analyze patients who have diabetes. Examples of
substantial data sources include the media, cloud, the web, IoT,
and databases (Russom, 2011). The different sources of big data
are aimed at providing data for purposes of customer analytics,
industrial analytics, business process analytics, and analytics
for fraud detection. In our case, healthcare information can be
found in many sources throughout the web.
The best big data that may use in diabetes management would
be artificial intelligence and IoT. Digital health takes into
account advanced medical technologies and digital
communication (Al-Turjman, 2019). Machine learning enables
us to take into account the identification, prediction of patterns,
and inductive reasoning. Today, diabetes management is facing
a whole lot of challenges, including the decreased number of
diabetologists and an increase in the number of patients
(Eswari, Sampath, & Lavanya, 2015). With the use of artificial
intelligence, diabetologists can take full responsibility for their
patients (Ross, Anderson, Kodate, Thompson, Cox, & Malik,
2014). Robust data analysis will ensure that gaps in care are
identified, and the necessary measures are taken to mitigate
risks.
Less digital ways of acquiring patient information in the past
included ADT alerts, demographics, and ICD-10 codes
(Nyenwe, Ashby, Tidwell, Nouer, & Kitabchi, 2011). Although
there are effective ways, they may not provide varied data on
patients with diabetes. They also do not help in proper analysis ,

12. and therefore integrating artificial intelligence and IoT may
help in obtaining and analyzing big data for diabetes patients.
References
Al-Turjman, F. (Ed.). (2019). Artificial Intelligence in IoT.
Springer.
Eswari, T., Sampath, P., & Lavanya, S. (2015). Predictive
methodology for diabetic data analysis in big data. Procedia
Computer Science, 50, 203-208.
Nyenwe, E. A., Ashby, S., Tidwell, J., Nouer, S. S., & Kitabchi,
A. E. (2011). Improving diabetes care via telemedicine: Lessons
from the Addressing Diabetes in Tennessee (ADT)
project. Diabetes Care, 34(3), e34-e34.
Ross, A. J., Anderson, J. E., Kodate, N., Thompson, K., Cox,
A., & Malik, R. (2014). Inpatient diabetes care: complexity,
resilience and quality of care. Cognition, technology &
work, 16(1), 91-102.
Russom, P. (2011). Big data analytics. TDWI best practices
report, fourth quarter, 19(4), 1-34.
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