2016 COMMUNITY HEALTH NEEDS ASSESSMENT

Essentia Health-Sandstone Overview LEAD PARTIES ON THE ASSESSMENT Essentia Health-Sandstone Tanya Christopherson, 109 Court Avenue South Clinical Dietitian and Sandstone, MN 55072 Nutrition Services Director

Essentia Health-Sandstone is part of Essentia Jean Rodvold, Community Health Intervention Health, a nonprofit, integrated health system Specialist East Region caring for patients in Minnesota, Wisconsin,

North Dakota and Idaho. Headquartered in TABLE OF CONTENTS Duluth, Minn., Essentia Health combines the Overview ...... 1 strengths and talents of 14,000 employees, who serve our patients and communities through Essentia Health: Here With You ...... 2 the mission of being called to make a healthy Caring for our Community ...... 3 difference in people’s lives. Progress to Date on 2013 Community Health

Essentia Health-Sandstone is a 25-bed critical Needs Assessment ...... 3 access hospital that was established in 1956 in 2016 Community Health Needs Assessment ..... 5 Sandstone, Minnesota. It has an adjacent skilled Objectives ...... 5 nursing facility and ambulance service. Description of Community Served by Essentia Essentia Health-Sandstone offers emergency Health-Sandstone ...... 5 care 24 hours a day, seven days a week. It is a Process Overview ...... 8 certified Level 4 trauma center and an Acute Stroke Ready hospital. An Urgent Care Assessment Process ...... 10 department also serves the community. Phase 1: Assessment ...... 10

The hospital is collaborating with community Key Findings ...... 10 partners on a new medical campus that will Community Input ...... 11 include the hospital, a Gateway Clinic, Thrifty White Pharmacy and a senior care facility. Limitations ...... 12 Essentia Health is partnering with the North Pine Area Hospital District, a governing body, to Phase 2: Prioritization ...... 12 assure and guide the procurement and quality Phase 3: Design of Strategy and Implementation of healthcare services for central Pine County, Plan ...... 13 which includes 13 townships and six cities. Conclusion ...... 13 Appendix ...... 14 APPENDIX A: Community Health Status Indicators ...... 15 APPENDIX B: Community Input Participants ... 18

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Essentia Health: Here With You At Essentia, our mission and values guide us every day. Together, we deliver on our promise to be here with our patients and members of our communities from the beginning to the end of life, both in our facilities and where they live, work and play.

Mission We are called to make a healthy difference in people's lives.

Vision Essentia Health will be a national leader in providing high quality, cost effective, integrated health care services.

Values • Quality • Hospitality • Respect • Justice • Stewardship • Teamwork

Belief Statements • Our highest priority is the people we serve. • We believe that the highest quality health care requires a regard for both the soul and science of healing and a focus on continuous improvement. • We believe in the synergy of sponsorship among faith-based and secular organizations. • We believe in the value of integrated health care services. • We believe in having a meaningful presence in the communities we serve.

2 Caring for our Community Our commitment to community health and wellness goes well beyond the work of the Community Health Needs Assessment. Through donations of funds, along with employees’ time and talents, Essentia Health invests in a variety of programs and outreach efforts. Across the organization, we support community coalitions, housing, food shelves, mental health, congregational outreach, community infrastructure, public health, education, safety and other nonprofit organizations. These investments are designed to promote better health, help lessen inequities in our communities, improve access to health care and strengthen relationships with those we serve.

Progress to Date on 2013 Community Health Needs Assessment Obesity, physical inactivity and poor nutrition as risk factors for chronic Priority Area diseases such as Type 2 diabetes. Adults, ages 18 and older, who are currently prediabetic or possess risk factors Target Population for developing Type 2 diabetes Reduce body weight and increase physical activity in program participants, Goal thereby reducing their risk for Type 2 diabetes. Accomplishments to Date: • Increased capacity to provide the National Diabetes Prevention Program (NDPP) by training two additional lifestyle coaches, for a total of three. • Continue work to coordinate and promote NDPP courses as able. • Collaborating with other organizations that provide evidence-based programs, such as NDPP, to delay or reduce the onset of Type 2 diabetes in the community.

Additional Achievements:

Immunizations

Essentia Health-Sandstone conducted multiple public influenza vaccine clinics. These flu clinics were open to the public, increasing both access to care and access to immunizations for community members.

Preventative Care

The hospital has held diabetic nutrition education programs within the community to increase awareness of Type 2 diabetes and the role nutrition, weight management and physical activity play in the prevention of the disease.

The hospital has also conducted community education events on nutrition, healthy eating, heart health and colon health. The colon health presentation has also included the display of Essentia Health’s inflatable colon to further educate the public.

The hospital presented educational opportunities to the community on bike safety and also held a bike helmet giveaway. Not only does this education prevent injuries while biking, but also promotes overall

3 community health by promoting physical activity. Water safety events with lifejacket giveaways continued to educate and prevent water injuries as well as promote physical activity.

Secondary Prevention/Screening

Numerous health fairs have been conducted in which a body composition analyzer has allowed community members to be educated on weight status indicators and desirable ranges for better health. The hospital conducts both community blood pressure and blood sugar checks on a monthly basis, not only providing greater access to health care, but the necessary screening to test for chronic conditions and diseases. Additionally, one car seat safety clinic was also held in the community.

Community Health Promotion

Each year, Essentia Health-Sandstone participates in a women’s and a men’s health event and diabetes expo. The hospital is committed to improving community health by organizing backpack donations so local schools can them to give students who may need food on weekends. Starting April 2016, Essentia Health-Sandstone began collaborating with the University of Minnesota Extension to start “Cooking Matters for Families” classes in Pine County designed to teach families how to cook healthy.

The hospital provides informational brochures on tobacco use and cessation as well as reduction of excessive/binge drinking at the hospital and at any health fair or event they are presenting at. The hospital also provided community education to the students of East Central School as a participant in a mock car crash, which simulated a drunk-driving accident.

4 2016 Community Health Needs Assessment

Objectives Essentia Health is called to make a healthy difference in people’s lives. To fulfill that mission, we seek opportunities to both enhance the care we provide and improve the health of our communities. In conducting the Community Health Needs Assessment, Essentia Health has collaborated with community partners to embrace these guiding principles:

• Seek to create and sustain a united approach to improving health and wellness in our community and surrounding area; • Seek collaboration towards solutions with multiple stakeholders (e.g. schools, work sites, medical centers, public health) to improve engagement and commitment focused on improving community health; and • Seek to prioritize evidence-based efforts around the greatest community good that can be achieved through our available resources.

The goals of the 2016 Community Health Needs Assessment were to: 1. Assess the health needs, disparities, assets and forces of change in Essentia Health-Sandstone’s service area. 2. Prioritize health needs based on community input and feedback. 3. Design an implementation strategy to reflect the optimal usage of resources in our community. 4. Engage our community partners and stakeholders in all aspects of the Community Health Needs Assessment process.

Description of Community Served by Essentia Health-Sandstone Essentia Health-Sandstone serves central Pine County, which includes the cities of Askov (55704), Finlayson (55735), Hinckley (55037), and Sandstone (55072). These four ZIP codes represent the hospital’s primary service area. The area also has a casino, a federal correctional facility, a county jail, portions of both the Nemadji and St Croix state forests and parks, a section of the Mille Lacs Tribal Reservation, numerous lakes, and recreational areas. It was determined, based on the capacity of the hospital, that the community served would be defined by these four ZIP codes to allow best use of its available resources in addressing community needs.

Essentia Health-Sandstone is the only acute-care facility in Pine County. Other primary care hospitals are 25-35 miles away with the nearest tertiary care centers located 90 miles south in Minneapolis/St. Paul or 70 miles north in Duluth. Existing healthcare facilities within the region include Mercy Hospital (Moose Lake), FirstLight Health System (Mora, Pine City and Hinckley), Gateway Family Health Clinics (Sandstone, Hinckley and Moose Lake), and Fairview Medical Clinic (Pine City). In order to best serve the entire region, the hospital is working with area health care organizations as part of a coalition led by

5 Kanabec-Pine-Isanti-Chisago Public Health with the goal of jointly assessing the community’s health and coordinating planning processes across the east central region in the future.

Due to the rural nature of the region, data for populations smaller than county level is frequently unavailable or of limited value. Therefore, the following assessment data are presented at the county and state level to ensure stability of the estimates. When available, ZIP code or U.S. Census tract level data will supplement the county-level information to provide a deeper understanding of the health needs of the community.

Table A: Overall demographics description Pine Minnesota County Population1 29,069 5,489,594 Population age 65 or over (%)1 18.4 14.3 American Indian or Alaska Native (%)1 3.2 1.3 Black or African American (%)1 2.4 5.9 Hispanic or Latino (%)1 2.9 5.1 Median household income1 $44,680 $60,828 People of all ages living in poverty (%)2 15.2 11.5 People under 18 years living in poverty (%)2 21.7 14.9 Population aged 25 and older with less than or equal to high school education 54.6 34.1 or equivalent (%)2

Pine County is located in the east central region of the state. Residents of this county are increasingly older and lower income, experience higher poverty rates, lower education levels, and face higher rates of obesity, diabetes and other chronic conditions. Ethnically the county is less diverse than the U.S. population, but is experiencing exceedingly high growth rates in populations of color, tripling the national growth rate between 2000 and 2010.

The Community Health Need Index (CNI) was utilized to reveal these areas of higher need. The CNI identifies the severity of health disparity for every ZIP code in the US and demonstrates the link between community need, access to care and preventable hospitalizations. CNI scores range from 5 (highest health disparity/highest community need) to a 1 (lowest health disparity/lowest community need). The highest CNI scores in the Essentia Health-Sandstone service area are located in Hinckley (3.6) and Sandstone (3.0).

1 U.S. Census Bureau, Population Estimates Program (PEP), Updated annually. U.S. Census Bureau, 2010 Census of Population, P94-171 Redistricting Data File. Accessed April 19, 2016. 2 Minnesota Department of Health, Minnesota County Health Tables. http://www.health.state.mn.us/divs/chs/countytables/. Accessed April 21, 2016.

6 Poverty, education, age and race are all factors contributing to the inequitable health outcomes in Pine County. According to the Minnesota Department of Health’s White Paper on Income and Health, “Poverty in Minnesota is not evenly distributed across racial/ethnic groups, ages or educational levels. Poverty is concentrated among populations of color, children, people with less education, female- headed households and rural Minnesotans.” 3

People in Minnesota with lower incomes are more likely to:

• Have an infant die in the first year of life • Report that their health is fair or poor • Report having diabetes • Report having seriously considered attempting suicide4

With a section of the Mille Lacs Tribal Reservation residing nearby, the health needs of the American Indian population are an important aspect of this assessment. As reported by the Indian Health Service, “The American Indian and Alaska Native people have long experienced lower health status when compared with other Americans. Lower life expectancy and the disproportionate disease burden exist perhaps because of inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences. These are broad quality of life issues rooted in economic adversity and poor social conditions.

• Diseases of the heart, malignant neoplasm, unintentional injuries, and diabetes are leading causes of American Indian and Alaska Native deaths (2007-2009). • American Indians and Alaska Natives born today have a life expectancy that is 4.4 years less than the all-races population (73.7 years to 78.1 years, respectively). • American Indians and Alaska Natives continue to die at higher rates than other Americans in many categories, including chronic liver disease and cirrhosis, diabetes mellitus, unintentional injuries, assault/homicide, intentional self-harm/suicide, and chronic lower respiratory diseases.”5

Thanks to our mission and our Benedictine roots, Essentia addresses the health needs of the area’s most underserved populations; this dedication will be echoed in the implementation strategy for the Community Health Needs Assessment to ensure a special emphasis is placed on populations facing the highest disparities in health outcomes as identified above.

3 Minnesota Department of Health, White Paper on Income and Health, March 3, 2014 https://www.health.state.mn.us/data/legislative/docs/2014incomeandhealth.pdf Accessed April 19, 2016. 4 Minnesota Department of Health, White Paper on Income and Health, March 3, 2014 https://www.health.state.mn.us/data/legislative/docs/2014incomeandhealth.pdf, Accessed April 19, 2016. 5 U.S. Department of Health and Human Services, Indian Health Service, Indian Health Disparities https://www.ihs.gov/newsroom/factsheets/disparities/ Accessed April 19, 2016.

7 Process Overview Essentia’s Community Health Committee developed a shared plan for the 15 hospitals within the system to conduct their 2016 Community Health Needs Assessments (CHNA). This plan was based on best practices from the Catholic Health Association and lessons learned from the completion of Essentia’s first CHNAs in 2013. This process was designed to:

• Incorporate community surveys and existing public data. • Directly engage community stakeholders. • Collaborate with local public health and other healthcare providers.

From there, each of Essentia’s three regions was responsible for adapting and carrying out the plan within their communities and hospital service areas. Essentia Health-Sandstone convened a multi-sector steering committee composed of hospital, clinic, public health, local business, government, schools, tribal health and social service agencies in the county to guide the CHNA process. The Bridge to Health Survey, along with gathered secondary data from local, state and national sources, was paired with community conversations to paint a picture of the community’s health and help identify priority health needs. The committee was involved in data analysis, prioritization, and will continue to guide implementation planning for the 2016 CHNA process.

The Essentia Health-Sandstone assessment was conducted in four stages: assessment, prioritization, design and finalization. The process began in October 2015 and the assessment portion was completed in May 2016 with the final presentation of the Community Health Needs Assessment for Essentia Health-Sandstone being presented and approved by leadership and the Board of Directors on June 21, 2016. The East Region Board of Directors accepted and approved this report on June 8, 2016. The following describes the assessment steps and timeline.

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ASSESS Conduct Asset Service Area Analyze Secondary Gather Community Mapping of Available Evaluate Progress on Define Service Area (April - October Demographics Data Input Community 2013 CHNA Priorities 2015) Resources

PRIORITIZE Set Criteria for Choose Prioritization Choose Needs to (December 2015 Prioritized Needs Method Address - March 2016)

DESIGN Design Identify the "team" Determine strategy Choose Set SMART Implementation Plan Goal Setting (March - April for each strategy options Strategies/Programs Objectives and Evaluation 2016) Framework

Review with key FINALIZE Present to Hospital stakeholders for final Board for Approval (May 2016) feedback

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Assessment Process

Phase 1: Assessment Essentia Health-Sandstone did not directly collect primary health information, but instead collaborated with a group of health-related organizations for The Bridge to Health Survey, a multi-county mailed survey conducted in northeastern Minnesota and Douglas County in Wisconsin. The Bridge to Health Survey was used as the primary data source for the CHNA. The full report, including survey methodology can be found online at www.bridgetohealthsurvey.org. Secondary data was gathered from county, state and national sources and were used to validate primary data as well as identify trends, make comparisons and track benchmarks. Geographic location, special sub-populations, health disparities and inequities were key considerations taken in reviewing the data. In order to understand the health of the community and facilitate the identification of community health needs, a set of indicators were identified. This list includes data on both health outcomes as well as the social, environmental, and behavioral drivers of health. See Appendix A for the full list of indicators and secondary data sources.

Community input was gathered through key informant interviews, focus groups, community meetings and online surveys. Community input received was collated and analyzed for key themes. Additionally, a multi-sector steering committee was formed to guide the needs assessment process. This group represented the broad interests of the community and included representatives with expertise in public health from Kanabec-Pine Community Health Services, as well as members of medically underserved, low-income, and minority populations in the community, or individuals or organizations serving or representing the interests of such populations. See Appendix B for a complete list of participants and who they represent. The steering committee convened three times over the course of January to May in 2016, and was involved in each step of the needs assessment, from data analysis, prioritization to implementation and planning.

Key Findings The Robert Wood Johnson Foundation and the University of Wisconsin's Population Health Institute’s County Health Rankings place Pine County at 82nd out of 87 counties for Health Outcomes (Length of Life & Quality of Life indicators) and 83rd out of 87 counties for Health Factors, with health behaviors and social and economic factors having the largest influence on health outcomes.

The 2015 Bridge to Health Survey revealed that Pine County, in comparison to the other counties surveyed, has among the highest prevalence of unhealthy behaviors.

• 77.4% are overweight or obese, with 51.1% obese • 30.5% reported no physical activity in the past 30 days • 32.3% reported binge drinking • 24.7% reported currently smoking

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Social and economic conditions are key drivers in determining the health of a community and were a common thread in community conversations and surveys. Based on the 2015 Bridge to Health Survey, we have found that families living at 200% of poverty or less have a higher prevalence of diabetes, heart ailments and mental health conditions; they eat less fruits and vegetables, exercise less, have higher rates of tobacco use and worry about having adequate food.

Community Input When asked “What makes you healthy?” community input participants most often responded with answers related to health behaviors such as healthy eating, physical activity, and sleep as illustrated in picture a (at right). Participants also spoke about what would make their community healthier, which most often included more parks and trails, community centers and local places to exercise. People felt it very important that there be places for community to gather, particularly for youth so that they were engaged in healthy, positive activities. The community saw their park system and natural environment to be community strength, as well as local organizations such as the hospital, public health department, schools and community organizations.

“What are the current issues impacting health in your community?”

The above question was asked to all community input participants. The above left picture depicts the responses collected. When all were taken into account, the following were the top responses from the community.

1. Alcohol, tobacco and other drugs 2. Mental health 3. Socioeconomic status 4. Obesity and chronic disease

Substance abuse, mental health and poverty were issues brought up in every community conversation. These were often seen as some of the underlying problems preventing people from making healthy choices.

In order to make optimal use of limited resources, the assessment and design process include an analysis of community assets and activities currently taking place to improve the health of the community. These processes of asset-mapping identified opportunities for partnership and collaboration, as well as define where significant efforts were already taking place and where gaps exist. The following is a short list of some of the most pertinent findings:

• Partners in Healthy Living offers workplace wellness strategies and healthcare partnerships.

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• Kanabec-Pine Public Health is focusing on mental health, obesity, alcohol, tobacco and other drug use. • Pine County received a grant to lower alcohol consumption in youth. • University of Minnesota Extension offers “Cooking Matters” classes. • Central Minnesota Council on Aging provides support for evidence-based programs and trainings.

Essentia Health-Sandstone is committed to developing partnerships with numerous sectors to do this work, including schools, area business, public health, law enforcement, religious groups, other health care organizations, local government and other nonprofits.

As a result of the 2013 CHNA, Essentia Health-Sandstone initiated a partnership with Partners in Healthy Living, the local Statewide Health Improvement Program (SHIP) in Pine County. The hospital also partnered with the University of Minnesota Extension to start offering “Cooking Matters” classes, the first ever in the county. Each class will have the potential to impact 10 families and five children who are below 150% poverty level. The National Diabetes Prevention Program has impacted 15 adults in this community through the three classes that have been offered.

No written comments were received from the 2013 CHNA. Any comments would have been taken into consideration in this report.

Limitations In 2015, several methodological changes occurred with the Bridge to Health Survey that impact the 2015 survey results and the ability to trend the survey results over time. The survey changed from telephone to mail for budgetary reasons. Additionally a new process was used for the data weighting. There are also several sources of bias that can affect data collected via survey, including non-response and factors related to respondents.

Limitations in the assessment process included minimal representation of the American Indian population in community input. Further exploration of existing health data for this population is needed as well as conversations with Band members. In the implementation planning process and throughout the three year CHNA cycle, the hospital plans to work on establishing a partnership with the Mille Lacs Band of Ojibwe and work towards culturally sensitive initiatives focused on improving health inequities among this population.

Phase 2: Prioritization Needs were prioritized based on the following criteria:

• Importance of problem to community • Feasibility of intervention • Opportunity for partnership

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The steering committee participated in a dot voting activity to identify and prioritize health needs. Each member was asked to write down the top two health needs in the community based on presented assessment results. These were then categorized based on common themes into the areas of mental health; alcohol, tobacco and other drugs; health habits/lifestyle; socioeconomic status; access to healthy food; social cohesion and families; and access to resources. Each member was then able to vote for the top health need based on the identified prioritization criteria listed above. After the vote, dots were tallied to rank the top two health needs. These areas were then further broken down to understand the most critical components of each area. The resulting priorities were identified as:

1. Healthy lifestyle choices 2. Mental health

Alcohol, tobacco and other drugs was a priority that the steering committee felt fit within either of these categories and was important to include; therefore, it will be included within the priority of Mental Health in order to address the high rates of substance use in the community. In further discussion of these priorities, socio-economic factors, such as income and education, are key drivers and should be factored into how strategies are chosen in the implementation planning stage.

Phase 3: Design of Strategy and Implementation Plan The hospital will work to design an implementation strategy with internal stakeholders as well as external partners and stakeholders who represent the existing health care facilities and resources within the community that are available to respond to the health needs of the community as identified in this assessment. This implementation strategy will be reviewed and approved by the hospital board of directors prior to November 15, 2016.

Essentia Health has incorporated Community Health and Wellness into the FY 2016-2018 System Strategic Plan under “Building Healthy Communities.” The system has also outlined an allocation of resources available to each hospital as a percentage of net revenue less bad debt to address the priorities set forth in the Community Health Needs Assessments.

Conclusion As part of a nonprofit health system, Essentia Health-Sandstone is called to make a healthy difference in people’s lives. This needs assessment illustrates the importance of collaboration between our hospital and its community partners. By working collaboratively, we can have a positive impact on the identified health needs of our community during Fiscal Years 2017-2019. There are other ways in which Essentia Health-Sandstone will indirectly address local health needs, including the provision of charity care, the support of Medicare and Medicaid programs, discounts to the uninsured and others. A detailed implementation plan to address the identified health needs will be finalized and available in the fall of 2016.

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Appendix

A. Community Health Status Indicators B. CHNA Steering Committee and Community Input participants

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APPENDIX A: Community Health Status Indicators Community Health Status Indicators for Essentia Health-Sandstone

Number in parenthesis indicates County Health Rankings & Pine MN Bridge to Healthy Roadmaps ranking for named health outcome or factor for County Health People Pine County out of 87 counties in Minnesota. Survey8 2020 Targets6

Premature Premature deaths (under 75 309.4 268.2 NA NA

death years) age adjusted (2013)³

Cancer, age adjusted death rate 161.4 161.3 NA 161.4 (2009-2013)¹

Heart Disease, age adjusted death 121.2 118.9 NA 103.4 rate (2009-2013)¹ Length of Life (75) Life of Length

Low birth Percent Low Birth Weight (%) 4.5 4.9 NA 7.8

weight (2014)³

Poor or fair Health Status fair or poor (%) 12.5 11.8 18.5 NA health (2012)³

Poor mental Poor Mental Health Days4 3.2 2.9 4.24 NA health days Health Outcomes (75) (70) Life of Quality Tobacco Use Adult Smoking (%) (2012)³ 18.4 18.8 24.7 12

Mothers who smoked during 28.4 10.8 NA 1.4* pregnancy (%) (2009-2013)¹

Diet & Physical Inactivity/No Exercise (%) 18 17.4 30.5 32.6 Exercise (2012)³

Access to exercise opportunities 51 84 NA NA (%)4

Percent adults who consumed 5 or NA 21.9 38.3 NA more servings of fruits and vegetables yesterday7

Adult Obesity (%) (2012)³ 26.7 25.9 51.1 30.5

Alcohol & Binge Drinking (%)4 20 21 32.3 24.4 Drug Use Alcohol Related Motor Vehicle 14.3 33.2 NA NA Fatalities (%) (2012)³

Drug overdose deaths4 13 9 NA 11.3 Health Factors (77) Health Behaviors (79)

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Sexual Teen Birth Rate 18-19 years (2012- 52.3 30.7 NA 105.9 Activity 2014)³ per 1,000

Rate per 100,000 of Chlamydia 235 400 NA NA (2015)5

Access to Adults without health insurance, 12.3 9.5 8 0 Care under age 65 (%) (2013)²

Primary care physicians4 5,820:1 1,100:1 NA NA

Mental Health providers4 1,080:1 490:1 NA NA

Licensed and Practicing Dentists 13.7 55.6 NA NA (per capita) (2013)³

Quality Care COPD hospitalizations (per 10,000, 42.4 28 NA 50.1 ages 45+, age-adjusted) (2011- 2013)²

Heart attack hospitalizations (per 36 29.2 NA NA 10,000, ages 35+, age-adjusted) (2011-2013)²

Diabetic Monitoring (%)4 84 89 NA 71.1 Clinical Care (44) Care Clinical Education Four year graduation rate per 100 77 78.4 NA 82.4 (2012-2013)¹

Employment Unemployed (annual average) (%) 7.5 5.1 2.7 NA (2013)¹

Family & Children in single-parent 30 26.1 NA NA Social households (%) (2010-2014)³ Support

Income Median household income (2010- 44,680 61,481 NA NA 2014)² ($)

Children in poverty (%) (2010- 21.7 14.9 NA NA 2014)²

People of all ages living at or 37.4 27.1 42.2 NA below 200% of poverty (%) (2010- 2014)³

Children eligible for free/reduced 49.9 38.5 NA NA price lunch (%) (2013-2014)¹ Social Economic & Factors(79)

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Community Unintentional Injury, age adjusted 59.8 38.6 NA 36.4 Safety premature death rate (2009- 2013)¹

Assaults ED Visits (age adjusted 299.1 264.9 NA NA rate per 100,000) (2008-2012)³

Air & Water Private well with > 2 44 46 NA NA Quality micrograms/L* (%) (2008-2013)²

Fine particles, average annual 8.4 12** NA NA concentration (2011)²

Housing & Severe Housing Problems (%)4 18 14 NA NA Transit Long commute - driving alone (%)4 36 30 NA NA Physical Environment

Sources and notes:

Minnesota Department of Health, Minnesota State, County, and Community Health Board Vital 1 Statistics Trend Report, 1994-2013. http://www.health.state.mn.us/divs/chs/trends/index.html Minnesota Department of Health, Minnesota Public Health Data Access. 2 https://apps.health.state.mn.us/mndata/.April 21, 2016. Minnesota Department of Health, Minnesota County Health Tables. 3 http://www.health.state.mn.us/divs/chs/countytables/. April 21, 2016. 4 County Health Rankings, http://www.countyhealthrankings.org/ Accessed April 26 2016 Minnesota Department of Health, 2015 Minnesota Sexually Transmitted Disease Statistics. http://www.health.state.mn.us/divs/idepc/dtopics/stds/stats/2015/stdreport2015.pdf. April 5 21,2016 6 Healthy People 2020, https://www.healthypeople.gov/2020/topics-objectives 7 Behavioral Risk Factor Surveillance System, http://www.cdc.gov/brfss/ Accessed April 29 2016 Bride to Health Survey, Rural St. Louis County data, 8 http://www.bridgetohealthsurvey.org/index.php/reports ͥHP 2020 target to increase abstinence from cigarette smoking among pregnant women to 98.6%

*micrograms per cubic meter **standard

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APPENDIX B: Community Input Participants

CHNA Steering Committee Participants* Who they represent East Central High School, Honors Society Student Youth Sandstone Chamber of Commerce Business East Central Schools District Youth HHS Mille Lacs Band of Ojibwe American Indian (minority) Northern Pines Area Hospital District Board Health care Public Health, medically underserved, low-income Kanabec-Pine Community Health and minority Essentia Health-Sandstone Health care Lakes and Pines Community Action Council Low-income, seniors, children and families Family Pathways Low-income Gateway Clinic Health care Essentia Health-Sandstone Patient & Family Advisory Council Community Fire Department & Emergency Medical Service Health care Hinckley-Finlayson Public School District Youth City of Sandstone Government Catholic Charities & Senior Dining Low-income, seniors

Community Input Participants* Who they represent Sandstone Chamber of Commerce Business Essentia Health-Sandstone Patient & Family Advisory Community Council

Senior Providers Network Seniors Central Minnesota Office on Aging Seniors University of Minnesota Extension, SNAP ed Low-income Catholic Charities, Meals On Wheels, Senior Dining Seniors, low-income Program

North Area Pine Hospital District Board Health care Community Advisory Group Women, children and families East Central High School Students and Staff Community, youth Hinckley Finlayson High School Students and Staff Community, youth Public Health, medically underserved, low-income and Kanabec-Pine Community Health minority Family Pathways Low-income Lakes and Pines Community Action Council Low-income, seniors, children and families Chris' Food Center Business

*names available upon request

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