2015 Community-Health-Needs- Assessment- - … SJHS...2015!Community-Health-Needs-Assessment-! ......

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2015 Community Health Needs Assessment

In partnership with:

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TABLE OF CONTENTS

About the Community Health Needs Assessment………………………………... 3 Mission Statement and Introduction…………………………………………………. 2012 Executive Summary……………………………………………………………. 2015 Executive Summary ………………………………………………………..

3 4 5

Community Served…………………………………………………………………. Geographic Area Served……………………………………………………………... Population Demographics……………………………………………………………. Saint Joseph Health System Facilities……………………………………. Services Provided…………………………………………………………………….

6 6 7

10 10

Process & Methodology ……………………………………………………………. Primary Data Collection……………………………………………………………... County Health Statistics……………………………………………………………...

11 11 18

Collaborative Partners……………………………………………………………... 25 Significant Community Health Needs……………………………………………... Prioritization Process………………………………………………………………… Lessons Learned……………………………………………………………………... Community Insight…………………………………………………………………... Implementation Plan………………………………………………………………….

25 25 27 27 28

Action Plans…………………………………………………………………………. Community Health Needs Matrix…………………………………………………….

29 29

Appendix……………………………………………………………………………. Community Sites and Partnering Organizations…………………………………….. Community Benefit Council FY 2012-2015 Members……………………………… Community Benefit Council FY 2016-2018 Members………………………………

30 30 31 32

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1. INTRODUCTION TO SAINT JOSEPH HEALTH SYSTEM's 2015 CHNA 1.1 Mission Statement

We, Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities. Our Mission is more than ideology. It’s an important standard that we hold ourselves to, in everything we do. Our faith principles are at the core of our business. And our faith demands that we do whatever it takes to have a positive impact on those around. Every three years, Saint Joseph Health System (SJHS) performs community needs assessments to evaluate the overall health status of the communities it serves. The information from these assessments is routinely used to guide the strategic planning processes of the organization-at-large. In 2011, the Mission and Outreach Departments were given the task of conducting an expanded Community Health Needs Assessment (CHNA) that met new federal requirements. The March 2010 passage of the Patient Protection and Affordable Care Act (PPACA) introduced new reporting requirements for private, not-for-profit hospitals to maintain 501(c)(3) tax-exempt status. Effective for tax years beginning after March 2012, each hospital must:

• Conduct a CHNA at least once every three years on a facility-by-facility basis • Identify action plans to address unmet community health needs • Report the results of each CHNA publicly

Using focus group discussions with questions approved by Trinity Health, SJHS conducted its 2015 CHNA for use in the Primary Care Service Area including the counties of St. Joseph and Marshall in Indiana. Individual reports and results applicable to each county will be provided. SJHS set out to determine the community's needs and determine where to commit community outreach resources, especially for the poor and underserved. The assessment provides an opportunity to design an implementation plan and share our efforts toward improved health and quality of life, while building upon the foundation of our existing efforts to improve the health of our community and the populations we serve. The 2015 CHNA report will provide:

1. A summarized analysis of the successes from the 2012 CHNA report and resources already committed to support SJHS's upcoming community benefit activities.

2. A detailed community profile of our St. Joseph County community members, including the results of primary data collection from focus group discussions.

3. A strategy for addressing the needs identified as the highest priority of concern for St. Joseph County as a result of the number of people affected, available resources, and our ability to make an impact.

4. Access to 2015 CHNA results to inform the community and serve as a continual guide for evaluating the health of our community and best efforts to reach out an improve activities for our community members with the greatest needs.

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1.2 Summary of 2012 CHNA Previously, the 2012 CHNA revealed several needs. The top three were: 1) Diabetes 2) Pre-natal Care 3) Senior Services

Our Response: Over the past 3 years, SJHS has implemented action plans designed to fulfill these significant community needs. To address the issues of diabetes, SJHS expanded Senior Fit programming, contributed to the creation of a healthy foods table at a local food bank, and distributed a monthly calendar of SJHS diabetic classes and events. Regarding the issue of Pre-natal Care, SJHS participated in the creation of pre-natal consortium and created a social media website to reach pre-natal patients and clients. To expand and promote Senior Services, SJHS employed a Senior Services Navigator, increased 55+ memberships, and expanded Senior Fit. Due to resource constraints, a transportation program for Senior and at-risk populations was not feasible at this time. Nevertheless, SJHS increased our presence at health fairs and began providing services through our Mobile Medical Unit (MMU) for community members in Marshall County. The community's needs will continually be evaluated between CHNA reports and plans to address these needs are subject to change, accordingly. As one of the largest recognized employment leaders in our community, and leader in healthcare, SJHS upholds the integrity of remaining faithful to who we say we are.

SJHS continues to dedicate many resources to community benefit in several different areas. Millions of dollars have been spent in the past for clinical, community support and educational purposes. In the upcoming 2016 fiscal year (FY 2016), SJHS has committed:

• $530, 910 for clinical services that benefit the underserved, such as the Saint Joseph Health Center.

• $168, 214 for community support donations, in-kind contributions, and community building activities.

• $24, 329 for health professions educational opportunities for both clinicians and non-clinicians. SJHS’s past efforts to satisfy the needs of the community were met with success and there is no doubt future endeavors will do the same. While not able to fulfill every need identified through the 2015 CHNA, SJHS will make every effort to address the defined and redefined priorities that are in keeping with its Mission.

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1.3 Executive Summary Realizing the importance of and desiring to respond to the needs of the communities in the service areas of SJHS, its Community Benefit Council was determined to align the Mission of SJHS with the vocalized needs of the community by creating a document that would serve as one of the key components of the system’s FY2016-2018 Implementation Plan. The findings of the CHNA will also assist leadership in stewarding resources entrusted to SJHS by providing services where assistance is most needed. A benefit to this CHNA process, differently than past CHNAs, is the separate and distinct groupings of respondents by county. As a result, focus group participants and related responses are pertinent to the health status of St. Joseph County for our SJHS—Mishawaka Medical Center and Marshall County for our SJHS—Plymouth Medical Center. Focus Groups The methodology for conducting focus groups involved engaging various community groups and organizations at a number of locations in the community during the months of August through November 2014. The important issues for discussion were:

• Public Health Issues • Access to Available Community Resources

The focus groups were asked to respond to a broad group of questions composed by SJHS and the Community Benefit Council. The questions were designed to be applicable to all focus group participants. In total, the participation results were as follows: St. Joseph County Participation: 359 participants in 43 focus groups Marshall County Participation: 64 participants in 10 focus groups The focus group participants consisted of people of different ages, socioeconomic status, occupation, and ethnic/cultural backgrounds. A few examples of the many groups represented:

• Young Professionals • Seniors • Business Leaders • Clinics

• Expectant & New Mothers • Latino Community Members • Veterans

A major advantage of completing the CHNA through the use of focus groups is the large amount of qualitative information and perspective that can be gained from a small group of individuals. For this reason, the knowledge gained from participating individuals in St. Joseph and Marshall Counties provided insight into the needs of the groups of individuals listed above and other similar groups. This advantage in particularly notable in Marshall County, where the population is smaller and much more rural, requiring individuals to wear multiple hats in the community. Response Generally speaking, the needs expressed throughout the assessment were common to the people of St. Joseph and Marshall Counties. Subcommittees were formed to address the concerns and suggestions brought forth by the focus groups. The subcommittees met to discuss ideas for improving the areas they were assigned (mental health, transportation, and provider access). After discussion, the ideas of the subcommittees were formalized into action plans and reevaluated to determine feasibility. Once the action plans were approved, the budgeting process began.

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Combining the assets of the local communities with the Mission, energy, and insight of SJHS, the council members have great belief in the potential to address some of the needs identified by community members. 2. COMMUNITY SERVED 2.1 Geographic Area Served SJHS serves 899,381 people in a diverse nine county system market in Indiana and Michigan through our continuum of care. The Primary Service Area includes St. Joseph, Marshall, and Elkhart Counties in Indiana and Berrien County, Michigan. The secondary service area encompasses Fulton, LaPorte, Pulaski and Starke Counties in Indiana and Cass County, Michigan. SJHS—Plymouth Medical Center serves the 101,660 residents of Indiana’s Southern Tier, which includes Marshall, Fulton, Starke and Pulaski counties. These counties are relatively rural in nature with light industry centered in the towns of Plymouth and Bremen. Nearby Culver is the home of Culver Academies, which attracts students to Indiana from all over the world. Our region includes a variety of quality education opportunities, including both public and private schools from preschool through high school. Those pursuing a higher level of education have several options, including the University of Notre Dame, Indiana University at South Bend, St. Mary's College, Holy Cross College, Ancilla College, Bethel College, Indiana Tech and Ivy Tech State College. Total population for the System Service Area is only expected to grow 0.2% from 2014 through 2019. Compared to the State of Indiana, the System Service Area has a lower projected population growth, a higher median age and a decline in Females of Child Bearing Age 15-44 at 0.5%. The population aged 65 and older represents 15.2% of the total population, and is expected to increase 13% over the next five years. Total population for the Southern Tier service area is expected to decline slightly 0.6% from 2014 through 2019. Individuals age 65 and older represent 16.6% of the total population, and that group is expected to increase 11.4% over the next five years. Median household income ($54,759) is below that for the states of Indiana, Michigan and Ohio, though it remains stable across the region, with areas of marginally higher affluence in Marshall and Fulton Counties. As in most rural Midwestern communities, the population is almost exclusively made up of white non-Hispanic individuals of northern European descent, although there has been an increase in the Hispanic population over the past ten years. In 2013, 13% of individuals in Marshall County lived in poverty*, with 15.5% of Fulton County residents, 16.5% of Starke County residents and 13.9% of those in Pulaski County. In Indiana overall, in 2013 15.5% of families lived in poverty. There are also three Critical Access Hospitals (CAH) in this area—Community Hospital of Bremen, Pulaski Memorial Hospital, and Woodlawn Hospital—at which primary care professionals with prescriptive privileges furnish outpatient primary-care services. The current unemployment rate of 5.9% is higher than the Indiana rate of 5.5% and lower than the national average of 6.3% for August 2014 the most recent data available. Moody’s rates Indiana as recovering. Education, healthcare, and government are the major employers in the local economy.

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Estimates of the *uninsured in the System Service Area is 130,157 and ranges from 19.3% in Marshall County, IN to 14.7% in Cass County, MI. This is compared to an Indiana rate of 16.6%. *U.S. Census Bureau/Small Area Health Insurance (SAHIE) Program/March 2014 **U.S. Census Bureau, Small Area Income and Poverty Estimates (SAIPE) Program, December 2013 2.2 Population Demographics The figure below shows the entire SJHS system service area as described in the geographic area served.

Figure 1. SJHS - System Service Area The geographic area targeted for CHNA participation was limited to the residents of Marshall County, Indiana. This allows SJHS to best compare the results and needs of the CHNA for our Plymouth Medical Center with publicly available county information related to health and demographics. A deeper dive into specific locations within Marshall County with the greatest need will allow SJHS to best commit our resources to those who are poor and underserved.

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Figure 2. Marshall County (IN)

Marshall County is located in Northwest Indiana and services a significant portion of SJHS's Southern Tier market. Table 1 (below) outlines additional relevant statistics of the demographic information relevant to Marshall County in relation to demographics of the entire state of Indiana. The content analysis report will provide a more detailed comparison of this data and the demographics of 2015 CHNA focus group participants.

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Table 1. County Demographics

*County Health Rankings 2015 Statistics **Governing 2010 Statistics ***City-Data 2013 Statistics Many of Marshall County's population demographics mirror the demographics of Indiana. Overall, Marshall County is slightly older, from the perspective of median age and overall proportion. An above average percentage of Marshall County's population identifies as Hispanic and there is a much smaller African American population in comparison to the Indiana average. A majority of the focus group sample statistics for Marshall County mirror the overall county statistics. There are a few exceptions. The median age of CHNA participants was well above the county average, as there was a much smaller representation among young participants in Marshall County, which may also be the result of excluding the "Under 18" population. The large variance in proportion of females to males participating in SJHS focus groups is probably the most notable difference when compared to county statistics. The races and ethnicities of focus group participants are almost identical to the Marshall County proportions. Another notable difference is the location of focus group participants based on zip code information collected with other demographics. A majority of participants reportedly live in Plymouth. Several participants from outlying areas were able to speak on behalf of others in their location. Due to the rural nature of Marshall County, it was much more difficult to gain participation from individuals living outside of Plymouth, or other more populated areas.

Marshall County Demographics*

Indiana

Population 47,109 6,537,334 Age **

Median Age 39.0 37.4 Under 18 26.0% 24.1% 18-24 8.3% 10.1% 25-44 23.1% 25.4% 45-64 27.2% 26.4% 65+ 15.5% 13.9%

Sex/Gender Female persons 52.4% 50.7% Male persons 47.6% 49.3%

Race/Ethnicity % Non-Hispanic White 88% 81% % Non-Hispanic African American <1% 9% % Hispanic 9% 6% % Asian <1% 2% % American Indian/Alaskan Native <1% <1% % Native Hawaiian/Other Pacific Islander <1% <1% % Other or Multiple Races/Ethnicities Listed

<1% <1%

Location*** Plymouth 76.6% - Bremen 14.1% - Culver 4.7% - Other 4.7% -

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2.3 Saint Joseph Health System Facilities SJHS is a Ministry Organization of Trinity Health, the fourth largest Catholic healthcare system in the country. We provide personalized, faith-based care paired with the latest in advanced medical technology and procedures. SJHS is a not-for-profit, multi-hospital health system located in North Central Indiana, offering a full range of services. Our system includes:

• 254-bed acute care hospital at the Mishawaka Medical Center • 58-bed acute care hospital at the Plymouth Medical Center • 40-bed Saint Joseph Rehabilitation Institute • 20 practices of the Saint Joseph Physician Network • Community health centers and additional points of access

2.4 Services Provided As part of our mission, SJHS provides several health and wellness programs at no or low cost. Outreach Services works to continually evaluate and respond to the most important needs of the community through our Community Health Needs Assessments (CHNA) and partnerships with other local not-for-profit organizations through committees. Various committees and representations work with us to ensure the success of SJHS's community benefit activities. Examples of such services include the operation of our community health centers, medical education, subsidized care, early detection and prevention programs, screenings, health fairs and more. The programs below are specific programs and services that support the needs of our community, many of which are a result of needs assessed through past CHNA.

2.4.1 Community Health Centers

SJHS sponsored health centers provide wellness education, prevention and a comprehensive array of primary care services to St. Joseph and Marshall Counties. The centers were established to serve the uninsured, underinsured and Medicaid populations. The centers also include medication assistance programs for those patients who qualify for these services. In addition to the health centers, SJHS's Mobile Medical Unit (MMU) provides free or low-cost mammograms to women in our community to promote early detection.

2.4.2 Pre-natal Care Coordination

These services were developed to improve outcomes of pregnancy and reduce infant mortality rates through assessment, education, referrals and support. This outreach and home visiting program targets pregnant women who may be at risk due to medical or psychosocial factors.

2.4.3 School Health Initiatives

In agreement with Penn-Harris Madison, School City of Mishawaka, and Plymouth Community School Corporation, SJHS provides a nursing paraprofessional in each school who works in conjunction with a

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consulting nurse or registered on-site nurse for more than 200,000 school health visits annually. Additionally, SJHS works with several area high schools and the University of Notre Dame to provide certified athletic trainers for sporting events.

2.4.4 Senior Services

These programs provide support to seniors in our community through initiatives like State Health Insurance Program (SHIP) that includes counseling and assistance to those who need help with Medicare and other related health insurances. We work to promote Senior Fit exercise classes offered at several locations throughout the community free of charge. Our Senior Services Navigator is able to provide a constant contact for our aging population through continual updates, newsletters, lunch and learns, and much more.

2.4.5 Tobacco Initiatives

As the lead organization for Tobacco-Free St. Joseph County, SJHS works against the tobacco industry’s influence through advocacy, social alteration and policy change. Smoking cessation classes are provided free of charge.

*Visit sjmed.com for a complete list of services and community benefit programs.

3. PROCESS AND METHODOLOGIES FOR COMMUNITY INPUT 3.1 Primary Data Collection The methodology for conducting primary data collection occurred through the organization of community focus groups. Coordinating and scheduling focus groups involved contacting community members for a single, hour-long discussion with each group occurring from August to November 2014. The community members contacted were reached through emails, phone calls, flyers, and health fairs, or by request, with efforts from SJHS Associates, committees, and partnering organizations. The recommended groups targeted for discussion were identified with the support of the Community Benefit Council. A complete list of past and present council members and their affiliations can be found in Appendices B and C. Other groups were included in discussions as recommended. This data included names and addresses of patients, donors, and Associates of SJHS as well as the population at large that had no prior contact with SJHS. The focus group discussions consisted of a series of 10 questions designed to gather information about: (1) the individual’s health concerns, (2) access to available resources, (3) how to help the community, and (4) general demographic information. The groups varied in number of participants from two to over ten, and totaled 64 individuals in Marshall County. The questions focused on topics viewed to be critical to various members of the community. The summarized results show the percent of focus group discussions in which each topic arose. Typically, discussions responded to all questions but a lack of understanding and similarity caused a lower response rate to certain questions. Focus group facilitators provided further summaries of responses to each question based on key discussion points and common themes among participant discussions.

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3.1.1 Summary of Focus Group Participants A total of 10 focus groups were conducted in St. Joseph County. A complete list of focus groups and focus group locations can be seen in Appendix A. The amount of information collected was impressive. Nearly all groups responded to all ten discussion questions throughout the one-hour timeframe. The focus groups were conducted in Spanish when necessary. Community Member Participation: 64 participants in 10 focus groups Marshall County Key Demographics

• 91% of the sample identified their gender as female, while 9% indicated their gender as male. • 94% of the sample identified their race as Non-Hispanic White and 6% Hispanic. • 77% of the respondents lived in Plymouth, 14% in Culver, 5% in Breman, and 5% in "Other." • These percentages largely mirror the population within the participating communities.

The typical participant in St. Joseph County was a 54 year-old, Non-Hispanic White female, living in Plymouth. These demographics closely mirror the demographics of Marshall County (See Section 2.2 for further comparison). 3.1.2 Discussion Summary from Marshall County Focus Groups Upon completing several CHNA reports in the past, SJHS determined that focus group discussions would most accurately assess the impact of existing services and programming in addition to providing recommendations for future improvements. A series of questions were assembled to provide opportunities for community members to have an open discussion and freely express their health concerns and perceptions of available services. Examples of several of the groups represented are:

• Young Professionals • Seniors • Business Leaders

• Clinics • Expectant & New Mothers • Latino Community Members • Veterans

In addition to community members coming from various backgrounds, several organizations representing individuals from varying backgrounds were also key components in the participation and support SJHS received in this process. The groups varied in numbers of participants, but the average was more than six per group. Thanks to several community members and organizations, the focus groups were conducted at eight different community sites. Focus group participants were asked to freely discuss the questions given to them and discuss possible actions that could be taken by SJHS to improve the health status of Marshall County. The questions focused on topics viewed to be critical to various members of the community. 3.1.3 Focus Group Discussion Discussions were summarized by condensing the large amount of qualitative information into the percentage of groups mentioning a particular topic throughout the discussion (% of cases). The percent of

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responses is the percent of all total responses for that question. Since, only the most relevant responses are highlighted, percentages may vary from question to question. Additionally, content summaries of the information are provided to allow for a better understanding of the common topics and themes surrounding each question and the resulting responses. Participants were not limited to responding to each question in order, and responses to multiple questions often came throughout a participant's story or conversation.

Public Health Issues Question 1—When asked what public health issues concern you:

Responses Percent of Cases N Percent

Top 6 Mental Health 7 9.86% 70.00% Poverty 6 8.45% 60.00% Primary Care Access 6 8.45% 60.00% Insurance Coverage 5 7.04% 50.00% Obesity 5 7.04% 50.00% Senior Services 5 7.04% 50.00%

Total 71 47.88% 340.00%

Responses per group 7.10 Mental health was inclusive of a range of conditions from depression and anxiety to substance abuse. Poverty was inclusive topics such as of joblessness, homelessness, resource-limited, and income-constrained. Often, the responses to this question did not address physical conditions but were related to social concerns. Social concerns were typically categorized with the responses to Question 2.4 with other barriers to receiving services. However, many of the social concerns were strongly associated with mental health and poverty. Lack of services and collaboration were major components related to discussions surrounding these topics. Additionally, low-income housing availability in Marshall County residents in poverty was a common theme of poverty discussions. There were several themes surrounding primary care access discussions. Many focus group participants indicated that wait times prevent them from seeing a primary care provider. Wait times, in conjunction with a lack of extended hours and urgent care services, were common reasons for emergency room misuse. These problems further complicate provider access for uninsured and underinsured individuals seeking services. Question 2—When asked what topics participants would be willing to learn about and want to attend:


Top 3 Healthy Cooking & Nutrition 5 17.86% 50.00% Mental Health Support 4 14.29% 40.00% General Education & Prevention 3 10.71% 30.00%

Total 28 42.86% 120.00%

Responses per group 2.80

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Healthy cooking, nutrition, and exercise classes were the most frequently mentioned educational opportunities SJHS could provide to the community. Many of the groups mentioned cost and accessibility are important components for participation in programs. Access to these options was increasingly important for individuals residing in many of the outlying areas of Marshall County. In addition to preventative education, several participants mentioned access to available preventative screenings in the community. Mental health support was commonly identified by a lack of services for individuals with mental health concerns in Marshall County. Question 3—When asked ways participants would be interested in viewing or listening to programs:


Top 2 Seminars & Presentations 5 33.33% 50.00% Support Groups 4 26.67% 40.00%

Total 15 60.00% 90.00%

Responses per group 1.50 Many focus groups found this question difficult to answer. A lack of understanding is likely attributable to the low response rate and lack of variability in responses. Although many community members believed increasing seminars and presentations would help educate the community, several groups reported low attendance rates at previously attended educational opportunities provided by SJHS or other agencies. Many groups found the discussion-based atmosphere provided during the focus group discussions to be helpful in sharing their questions and concerns about health. Increasing availability and variety of support groups would help engage more community members in discussions to improve their health. Question 4—When participants were asked if they were aware of our ongoing education on issues such as smoking, obesity, diabetes, prenatal care, dental health, and mental health:

• 30% responded "No" • 70% responded "Yes" • The results below outline the most frequently identified Outreach Services of the 70% of groups

responding "Yes":


Top 3 Mobile Medical Unit 3 27.27% 42.86% Tobacco Initiatives 2 18.18% 28.57% Health Fairs 2 18.18% 28.57%

Total 11 63.63% 100.00%

Responses per group 1.57 SJHS offers a wide range of Outreach Services and ongoing education is an important component to increase awareness of these services. Groups often did not recognize what SJHS considers an Outreach

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Service. Thus, the MMU is believed to be the most frequently mentioned Outreach Service as a result of its high visibility at various locations in the community. A number of focus groups believed MMU presents a recognizable opportunity to spread more information of SJHS services. There are also opportunities to expand existing Outreach Services from St. Joseph County into Marshall County, as needed. Question 5—When asked if there was a single location to receive information and services, would you be more willing to seek services:

• 10% responded "No" • 90% responded "Yes" • Follow-up questions of the 90% of groups responding "Yes," revealed the most desired services

to have in a multi-agency, centralized location to be:


Top 4 Job Placement Services 4 11.43% 44.44% Education 3 8.57% 33.33% Clinical Services 3 8.57% 33.33% Multiple Agencies 3 8.57% 33.33%

Total 35 37.14% 144.43%

Responses per group 3.89 This question often received the most enthusiastic discussion points from participants. As seen in Question 2.4, transportation and navigating services are some of the leading barriers that prevent community members from receiving services. A location with multiple health/social agencies in a single location will ideally many of these common barriers and improve access to receiving services that community members may otherwise forego. Interestingly, many participants did not recognize the Community Resource Center in Plymouth as an existing multi-agency building with centralized services. Several of the groups mentioning "No" did not always understand what information and resources could be provided at this location. The rural dynamic of Marshall County creates the barrier of finding a centralized location that is most convenient for community members. The most commonly mentioned reasons preventing the success of this location were the need for multiple locations in the community and distance/travel.

Access to Available Community Resources Question 6—When asked how you find where to go and what to do when you need a service:


Top 5 Churches 7 21.21% 70.00% Local Non-profits 5 15.15% 50.00% Word of Mouth 5 15.15% 50.00% Community Resource Center 3 9.09% 30.00% Schools 3 9.09% 30.00%

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Total 33 70.50% 230.00%

Responses per group 3.26 Churches were frequently mentioned as the community hubs for finding and distributing information. It is possible the high response rate for Local Non-Profits was due to the number of focus groups participating at a non-profit site. Many people suggested word of mouth. This is believed to be because they did not perceive any difficulty with finding information and resources. Often, participants discussed their preference to seek services in person, rather than attempting to find information. Question 7—When asked how you gain access to information:


Top 3 Internet 4 16.00% 40.00% Radio 4 16.00% 40.00% Library 3 12.00% 30.00%

Total 25 44.00% 110.00%

Responses per group 2.50 The low response rate to this question was likely a result of a lack in variety of responses from participants and similarity to the previous question. However, there was less of a personal component in the responses to this question. Participants perceived this question as referring to finding information on their own. As Marshall County is very spread out, community members noted that each town has their own hub for finding information, which may include local websites, banks, and even fire stations. Question 8—When asked what tools you use to gain and share information:


Top 2 Computer 4 40.00% 40.00% Phone 4 40.00% 40.00%

Total 10 80.00% 80.00%

Responses per group 1.00

Throughout focus group discussions, it became apparent that the low response rate to this question was likely a result of not understanding the question, similarity to the previous question, and repetitiveness of the previous questions. The low response rate to this question was likely a result of not understanding the question, similarity to the previous question, and repetitiveness of the previous questions. Question 9—When asked what obstacles exist to getting services you need:


Top 5 Transportation 9 17.65% 90.00%

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Insurance Coverage 5 9.80% 50.00% Language & Cultural Competency

4 7.84% 40.00%

Navigating Services 4 7.84% 40.00% Wait Times 4 7.84% 40.00%

Total 51 50.97% 260.00%

Responses per group 5.10 This question received the second highest response rate of all questions. Thus, there was a variety of responses. It is important to note, many of these responses were given in relation to Question 1.1. Focus groups participants frequently overlooked physical conditions as the most important concern with well-being and immediately recognized social determinants, creating difficulties with treating physical conditions, as more important. Without a formal public transit system, community members with transportation needs often suffer to access services. Lack of providers creates further complications and longer wait times for uninsured and underinsured individuals. Furthermore, there is a large Hispanic population whose needs often go unmet as a result of few Spanish-speaking individuals and services available in Marshall County. Question 10—When asked what services are critical for those with transportation problems:


Top 5 Senior Services 4 18.18% 40.00% Voucher Programs 3 13.64% 30.00% Bus Services 2 9.09% 20.00% Convenient Hours 2 9.09% 20.00% Grocery Store 2 9.09% 20.00%

Total 22 59.09% 130.00%

Responses per group 2.20 Participants responded in two ways: (1) what services community members rely on as a result of transportation barriers and (2) what services are difficult to reach as a result of transportation barriers. Community members eligible for transportation assistance noted vouchers as the most critical service to meet their immediate needs. Although local agencies provide transportation for seniors, it was still associated with barriers because of cost, hours, and eligibility requirements. 3.2 County Health Statistics

Several resources are available to provide a more detailed insight into the health status of a State on a county-by-county basis. St. Joseph is one of 92 counties currently in the state the Indiana. The resources offer various insights and reaffirm the need for improvement in several target areas. The health indicators can be combined with the primary source data collected from SJHS's 2015 CHNA report in order to capture a more accurate picture of our findings and how they are related to the statistics reported from various other state and federal organizations. The Robert Wood Johnson Foundation's County Health Rankings seen in Table 2 provides an analysis for comparing secondary data with the information

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gathered from the focus groups in our 2015 CHNA. Additional relevant resources included these publicly available databases:

• Centers for Disease Control and Prevention (CDC) • County Health Rankings and Roadmaps 2014 • County Health Rankings and Roadmaps 2015 • City-Data • Dignity Health—Community Needs Index • Governing • United States Census Bureau/Small Area Health Insurance (SAHIE) Program/March 2014 • United States Census Bureau, Small Area Income and Poverty Estimates (SAIPE) Program,

December 2013 • United States Department of Health and Human Services

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Table 2. Marshall County Health Status Indicators and Rankings

Health Measures Marshall County '14 Marshall County '15 Indiana Top U.S. Performers*2014 Rank

(of 92)2015 Rank

(of 92)

16 937 20

Premature Death 7,122 6,765 7,520 5,3177 7

Poor or Fair Health 11% 11% 16% 10%Poor Physical Health Days 3.0 3.0 3.6 2.5Poor Mental Health Days 3.1 3.1 3.7 2.4Low Birthweight 6.5% 6.4% 8.3% 6.0%

24 2016 14

Adult Smoking 21% 21% 23% 14%Adult Obesity 31% 32% 31% 25%Food Environment Index 8 7.8 7.5 8.7Physical Inactivity 29% 27% 28% 21%Access to Exercise Opportunities 48% 62% 64% 85%Excessive Drinking 11% 11% 16% 10%Alcohol-Impaired Driving Deaths 14% 10% 26% 14%Sexually Transmitted Infections 96 138 427 123Teen Births 37 35 40 20

43 37Uninsured 19% 19% 17% 11%Primary Care Physicians 1,568:1 1,567:1 1,539:1 1,051:1Dentists 2,612:1 2,617:1 2,015:1 1,392:1Mental Health Providers 1,809:1 1,240:1 890:01:00 521:01:00Preventable Hospital Days 50 46 76 46Diabetic Screening 84% 87% 84% 90%Mammography Screening 51% 53% 61% 71%

45 41High School Graduation 85% 89% 87%Some College 48% 51% 60% 70%Unemployment 8.90% 7.80% 8.40% 4.40%Children in Poverty 19% 18% 22% 13%Inadequate Social Support** 18%Income Inequality* 4.1 4.3 3.7Children in Single-Parent Households 22% 26% 33% 20%Social Associations* 17.4 12.7 22.0Violent Crime 80 91 329 64Injury Deaths 60 60 61 49

2 2Air Pollution - Particulate Matter 13.2 13.2 13.5 9.5Drinking Water Violations 0% 0% 2% 0%Severe Housing Problems 11% 12% 14% 9%Driving Alone to Work 80% 79% 83% 71%Long Commute - Driving Alone 28% 29% 30% 15%

Physical Environment

Length of LifeHEALTH OUTCOMES

Quality of Life

HEALTH FACTORSHealth Behaviors

Clinical Care

Social & Economic Factors

Source: Statistics from County Health Rankings (IN) *New Category **Category Removed

Key Top Quartile (Rank: 1-23) Rating improved in 2015

2nd Quartile (Rank: 24-46) Rating got worse in 2015

3rd Quartile (Rank: 47-69) Rating stayed the same

4th Quartile (Rank: 70-92)

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According to the Robert Wood Johnson Foundation's health rankings of Indiana, Marshall County ranks 9th out of 92 counties in overall Health Outcomes. This ranking places Marshall County seven counties better in 2015 compared to 2014. Marshall County also saw improvements in its Health Factors ranking during the same time by ranking 20th up from 24th. Marshall County saw the greatest improvements in the Clinical Care category. The two new social categories, "Income Inequality" and "Social Associations," helped improve Marshall County's overall ranking for social and economic factors. Marshall County rates better in the income inequality index than Indiana. Additionally, Marshall County ranks significantly better than Indiana in the number of Social Associations per 1,000 people, and is nearing some of the Top U.S. performers in this category. There was also slight downturn in unemployment rate and the percentage of children in poverty. However, there were increases in the number of children in single-parent households and violent crimes. It will take strong improvement efforts towards education and other areas within this category by many agencies before results are seen in improved social and economic conditions. In turn, these improvements will ideally lead to the adoption of other healthy lifestyle decisions to include improvements in other categories in which Marshall County is already performing well in. Marshall County is heading in the right direction for clinical care and social factors contributing to the county's health status. Other areas to note are the lower number of dental providers in Marshall County. While most clinical care metrics improved from 2014 to 2015, the number of dental providers saw a slight decline when compared to the population. Social and economic factors saw modest improvements in 2015 and were not affected by the implementation of two new categories. However, the number of children in single-parent households and violent crime rates also saw increases. Certainly the social indicators play a large role in the vicious cycle created by lack of education, joblessness, and poverty as a whole. The high school graduation rates are exceptional in comparison to the state, but there are still low rates of advanced education for individuals in Marshall County. Interestingly, mental health the leading health concern for individuals in Marshall County, but the county's ranking indicate lower rates of excessive drinking, alcohol-related driving deaths, and smoking when compared to Indiana. Other factors, such as a lack of mental health services, access to services, and other barriers may also contribute to the perceived severity of mental health in the county. 4. COLLABORATIVE PARTNERS SJHS's community benefit activities and Outreach Services come in contact with many local organizations and participate in on-going committee discussions attempting to provide justice in the way of caring for those who need it most in our community. Our CHNA is no exception to collaboration. We understand collaboration and partnerships are the most effective avenue for impacting the health of our community. For these reasons, SJHS's Community Benefit Council contains not only SJHS associates, but community members with various representations to help us with this process.

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The Marshall County Community Benefit Council Members are:

Community Benefit Council FY 2016-2018 Committee Membership

• Connie Deery – Manager, Saint Joseph Health Center and Volunteers for SJHS—Plymouth

Medical Center • Jessye Gilley – Supervisor, Culver Boys & Girls Club • Sr. Nora Hahn – Volunteer, SJHS Board Member • Sara Hill – Executive Director, Marshall County Neighborhood Center • Les Johnson – Community Member • Mary Ann LaPlante – Chaplain, SJHS—Plymouth Medical Center • Michelle Peters – Community Benefit Ministry Officer –SJHS • Bro. Bob Overland—Director of Mission Integration, Poor Handmaids of Jesus Christ • Nancy Sellers – Emergency Department Technician –SJHS—Plymouth Medical Center • Jane Witkowski – Executive Director, Saint Joseph Visiting Nurses Association • Jackie Wright – Executive Director, Marshall County Council on Aging • Geoff Zimpelman – Administrative Resident , SJHS

A combination of these members and other community members participated in the creation of the strategic action plans for the next three years. The Community Benefit Council will hold us accountable during this process and serve as guidance for any necessary adaptations. Ultimately, the Mission and Ministry Committee, a subcommittee of the SJHS Board of Directors, will determine any future changes to the implementation plan based on the needs of our community. 5. SIGNIFICANT COMMUNITY HEALTH NEEDS 5.1 Prioritization Process The priority areas for the FY2016-2018 strategic plan from the 2015 CHNA were developed through conversations regarding the results from the primary data collection, in conjunction with other activities and resources existing in the community. The conversations began in December of 2014 and continued on until February 2015. Since the primary data collection consisted entirely of qualitative information from the ten focus groups in Marshall County, the Community Benefit Council was able to listen and reaffirm the community member's needs to improve the four areas of priority. Additionally, the members were able to speak on behalf of their representation in other committees and organizations to improving services most critical to our community members. Initial meetings to discuss the primary data collection results allowed for open discussion on a number of priority areas. Many of initial priority areas contained several of the same underlying health concerns. Upon evaluating the recommended priority areas brought forth by the Community Benefit Council, the Mission and Ministry Committee of the Board recommended the following four focus areas, which include psychological and social determinants of health as well as physical needs:

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Top Community Health Needs

Community Hub

Transportation

Mental Health

Provider Access

1. Community Hub—Community members were calling for something to bring together and make it easier to access services in Marshall County. While there are many great social and service organizations providing community support, the efforts are often disjointed and inefficient. Many residents in Marshall County have access to a community hub through the Community Resource Center located in Plymouth. The Community Resource Center provides access to multiple agencies providing health insurance services, senior support, healthcare, conference rooms, and much more. For this reason, expanding our Outreach Services in Marshall County to include a Community Health Nurse to act as an educator and navigator can help create a more consistent presence for SJHS in the community.

2. Transportation was the most frequently mentioned topic from all focus groups. More than three-quarters of all focus groups identified transportation to be a problem in our community. Often, community members recognized transportation as a problem in our community prior to anything else because of the difficulty it creates to accessing services, and even things like groceries, getting to work, and getting to a pharmacy. Transportation is the underlying problem to a vicious cycle of activities fueling the large number of individuals affected by poverty in our community. Because transportation has been mentioned in several CHNA reports in the past, it is prioritized as its own category and perhaps the most pressing category for SJHS and our partners to begin addressing.

3. Mental Health was mentioned as the leading health concern in Marshall County, above the often more recognizable physical conditions. The category encompasses a number of different topics, including mental health conditions, access to mental health services, and insurance coverage for mental health services. Mental health was tied to several other conversations surrounding poverty and barriers to care as well. It was a necessary category to be included in SJHS's strategic priority areas because of its impact on all aspects of an individual's health.

4. Provider Access includes a number of different topics related to eligibility and accessing primary, specialty, and urgent care services in a timely manner. Insurance coverage, difficulty navigating the system, and other social barriers are largely at the root of many provider access concerns. This category may also include

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accessing services related to healthy lifestyles, nutrition, chronic conditions, and finding resources in the community. Certain areas in this category may not be addressed by SJHS's community benefit team, as they could be tied into other existing strategic initiatives, such as accessing clinical services, chronic disease management services, and others.

5.2 Lessons Learned SJHS took a unique and new approach to the 2015 CHNA process. Separate CHNAs were completed for St. Joseph and Marshall Counties to accurately represent the individuals and their needs in our two primary markets. Thus, we were able to identify the differences and similarities of the individuals in our SJHS—Mishawaka Medical Center and SJHS—Plymouth Medical Center markets. This is the first time the results from the content analysis were separated for the two counties and this methodology will continue for future CHNAs. In addition to separate CHNA reports, previous CHNAs relied on information from a combination of surveys and focus group discussions. The focus group discussions came secondarily to gain input from our community members on improving SJHS services for the highest priority health concerns. This time, SJHS completed the content analysis entirely through the use of focus groups discussions that allowed for community members to expand on their concerns and give us a better understanding of what concerns are most important to address. SJHS values the input of our community members. We completed nearly all focus group discussions at community sites in order to meet community members where they need help the most. In this, this allowed for conversations to occur in a comfortable and familiar environment for our participants. This led focus groups participants to freely share their opinions of SJHS services and the services of our community partners. From these discussions, SJHS determined which services are the most critical to address in the next three-year strategic plan for our CHNA. SJHS will continue to evaluate our CHNA process and improve the design of several focus group questions to be clearer and easier to understand for the next CHNA. Conducting the next CHNA using similar methodologies will allow SJHS to better compare and evaluate the impact of community programming. Completing the analysis in this manner will allow us to continually evaluate the impact of our on-going efforts towards awareness, education, and accessibility of services. 5.3 Community Insight Focus group participants were often more insightful than they believed. Some of the memorable and quotable moments:

“There is a high correlation of poverty and mental health. People can’t afford the medication, which spirals into joblessness.” —Marshall-Starke Development Center

“Bremen may have many of the same problems. Transportation is still a barrier there.” —Marshall County Resource Center Clients “It is difficult to give information on a grassroots level. People in South Bend don’t realize it’s not South Bend. For each area, you go to a different group for promotion; in Lakeville, it’s the fire station; the 1050 AM website is better than the newspaper; the “Walkerton Shopper”; in Bourbon, the bank is the hub. Information needs to get targeted towards each area in Marshall County.”

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—Council on Aging

“For things like Diabetes, there is nothing here as far as classes. You have to go to the library or go online. When it comes to the doctor, we want to talk directly to a physician. People stop in because they don’t get called back on the phone. There is a white collar vs. blue collar dynamic and even the white collars come from a blue collar background.” —Council on Aging

5.4 Implementation Plan At SJHS, we strive to fulfill every element of our Mission Statement through actions, not just words. Using the results of the Community Health Needs Assessment, we seek to improve the health of our community by empowering people with information, knowledge, and awareness. We will incorporate the suggested areas for improvement into the strategic plan. While we cannot realistically address every issue, we will endeavor to resolve those that most heavily affect our service areas. A complete list of Action Plans for our top prioritization areas is provided in the CHNA Matrix. Templates with more specific information regarding each of the implementation items can be found following the matrix. Prioritization areas were selected through a combination of CHNA results from St. Joseph County, Community Benefit Council input, and other relevant health statistics. In January 2015, the Mission and Ministry Committee of the Board made the recommendation to focus on the following four areas as our leading health concerns: (1) community hubs, (2) transportation, (3) mental health, and (4) provider access. Ensuing conversations helped form the finalized list of action plans and a detailed strategy for implementation will be followed to ensure completion success. The Community Benefit Council will continually track the progress of the implementation strategies for CHNA items during FY16-18. If resources do not allow certain items to carry on, strategies may be adjusted under the discretion of the Mission and Ministry Committee of the Board. SJHS's careful stewardship holds us accountable for the human, financial, and natural resources entrusted to our care. We stand and serve those who are poor and most vulnerable to improve our services available to meet those with the greatest needs in our community. Next Steps

Ø The FY15 Community Health Needs Assessment Report and FY16-FY18 CHNA implementation strategy will be integrated into the hospital’s strategic plan.

Ø The FY16-FY18 CHNA Implementation Strategy will be reviewed annually and presented to the

Mission and Ministry Committee, a sub-committee of the Board.

Ø In FY18, to maintain IRS compliance, a new Community Health Needs Assessment will begin to identify and re-assess the community health needs at that time. A Community Health Needs Assessment Report and a FY19-FY21 Implementation Strategy will respond the needs identified while maintaining programs developed from previous CHNA.

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Saint Joseph Health System

Community Health Needs Assessment Matrix - Action Plans FY 2016-2018

Recognized Need Awareness Education Accessibility Population

Served Expected Outcomes Community Partners

All Groups Employ a Community Health Nurse 10,000+ in Marshall County

Increase awareness of community services through partnership with multiple agencies, education, and

navigation support.

Marshall County Health Department

Mental Health

Collaborate with Marshall County

Health Department for Homelessness

Initiatives.

Engage appropriate professionals in the

creation, development, and operation of a

mental health consortium; Host

classes for kids and youth in Marshall County to gain life

skills.

Train School Health Aides in Mental Health

First Aid and seek opportunities for

expansion to other health/social service

workers;

2,000+ in Marshall County

Increase participation and awareness of mental health needs in Marshall County by working with various

community partners and mental health experts; Expand SJHS involvement in meeting community member's mental

health needs; improve life skills education and opportunities for

personal enhancement; encourage youth awareness of mental health

needs.

Marshall County Health Department,

Plymouth Community School Corporation,

Bowen Center, City of Plymouth Police

Department

Transportation

Begins grassroots efforts through the Voices for Transit toolkit to engage in

state and local policy discussions on transportation.

Seek funds and deploy Faith in Action programming to

community members in Marshall County to improve volunteers

services directed toward improving

transportation needs and delivery services.

Support Marshall County Council on

Aging's Transportation services to meet the

transportation needs of community members.


Begin involvement in transportation discussions with Marshall county agencies; increase participation in

grassroots efforts to support local and state transportation policies; increase transportation and delivery services available to community members;

enhance existing transportation services to meet the needs of

community members.

Marshall County Health Department, Poor Handmaids of

Jesus Christ, Marshall County Council on

Aging

Provider Access

Expand efforts to promote, educate, and create awareness for This Counts services and support; Enhance Community Resource

Center navigation.

Create a resource and understanding guide to promote walk-in and

extended service hours of health clinics in Marshall County.

Continue support at the Northern Indiana Food Bank for healthy food

options


Improve awareness of community health and wellness promotion

activities; Develop navigational and educational resources for health/social services in Marshall County; Increase access to healthy food options at local

food banks.

Community Resource Center agencies, Saint

Joseph Physician Network, Fitness Forum Sports and Wellness Lifeplex, Marshall County

Neighborhood Center

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APPENDIX A: CHNA 2015 Focus Groups

Group Location Date (2015)

SJHS—Plymouth Medical Center Associates 1

SJHS – Plymouth Medical Center October 7

SJHS—Plymouth Medical Center Associates 2

SJHS – Plymouth Medical Center October 9

Plymouth Community Members Community Resource Center October 14 Plymouth Resource Center Group Community Resource Center October 17 Marshall County Neighborhood Center Marshall County Neighborhood Center October 23 Women's Care Center Staff Women's Care Center October 23 Culver Boys & Girls Club Staff Culver Elementary School October 28 Culver Community Members Culver Elementary School October 29 Marshall County Council on Aging Staff and Clients

Marshall County Council on Aging November 10

Marshall-Starke Development Center Staff

Marshall-Starke Development Center November 21

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APPENDIX B Community Benefit Council

FY 2013-2015 Representatives

Saint Joseph Health System Community Benefit Council FY 2013-2015 Members

St. Joseph/Marshall Counties

• Loretha Buchanon – Retired, South Bend Community School Corporation • Marcia Combs – Director, Physician Network – Marshall County • Connie Deery – Manager, Saint Joseph Health Center and Volunteers for SJHS—Plymouth Medical Center • Ella Harmeyer – Faculty, College of Nursing, Saint Mary’s College • Matthew Lentsch – Director, Foundation and Marketing, Oaklawn (FY2015) • Jodie McCaskill – Business Manager, Family Medicine Center –SJHS • Waldo Mikels-Carrasco – Community Health Research Program Manager, University of Notre Dame • Carol Mills – CEO, Select Health Network • Karen Paluzzi – Manager, Strategic Planning and Analytics – SJHS • Sister Laureen Painter – Vice President, Mission Integration and Ministry Formation – SJHS • Michelle Peters – Community Benefit Ministry Officer – SJHS • John Pinter – Owner, Pinter Consulting • Braulio Rivero – Office Manager, Sister Maura Brannick Health Center and Multicultural Access – SJHS • Julia Rybicki – Staff Accountant, Finance – SJHS • Fred Thon – Retired, City of South Bend – Community Member • Robin Vida – Director of Health Education – St. Joseph County Health Department • Jane Witkowski – Executive Director, Saint Joseph Visiting Nurses Association • Geoff Zimpelman – Administrative Resident – SJHS (FY2015)

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APPENDIX C Community Benefit Council

FY 2016-2018 Representatives

Saint Joseph Health System Community Benefit Council FY 2016-2018 Members

Marshall County

• Connie Deery – Manager, Saint Joseph Health Center and Volunteers for SJHS—Plymouth Medical Center • Jessye Gilley – Supervisor, Culver Boys & Girls Club • Sr. Nora Hahn – Volunteer, SJHS Board Member • Sara Hill – Executive Director, Marshall County Neighborhood Center • Les Johnson – Community Member • Mary Ann LaPlante – Chaplain, SJHS—Plymouth Medical Center • Michelle Peters – Community Benefit Ministry Officer –SJHS • Bro. Bob Overland – Director of Mission Integration, Poor Handmaids of Jesus Christ • Nancy Sellers – Emergency Department Technician –SJHS Plymouth • Jane Witkowski – Executive Director, Saint Joseph Visiting Nurses Association • Jackie Wright – Executive Director, Marshall County Council on Aging • Geoff Zimpelman – Administrative Resident , SJHS

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