Table of Contents Introduction ...... 1 Oklahoma Office of Rural Health Partnership ...... 2 Previous Community Health Needs Assessment- Priorities, Implementation, and Evaluation ...... 2 Craig General Hospital Medical Services Area Demographics ...... 4 Figure 1. Craig General Hospital Medical Service Areas ...... 5 Table 1. Population of Craig General Hospital Medical Service Area ...... 6 Table 2. Existing Medical Services in Craig General Hospital Medical Services Area ...... 7 Table 3. Percent of Total Population by Age Group for the Craig General Hospital Medical Service Areas, Craig County and Oklahoma ...... 8 Table 4. Percent of Total Population by Race and Ethnicity for Craig General Hospital Medical Service Areas, Craig County and Oklahoma ...... 10 Summary of Community Meetings ...... 11 Economic Impact and Community Health Needs Assessment Overview, February 17, 2016 ...... 11 Table 5. Craig General Hospital Medical Service Area Health Sector Impact on Employment and Income, and Retail Sales and Sales Tax ...... 13 Health Data, February 24, 2016 ...... 14 Table 6. Health Factors (Overall Rank 36) ...... 15 Table 7. Health Outcomes (Overall Rank 41) ...... 16 Community Survey Methodology and Results, February 17, 2016- March 9, 2016 ...... 17 Table 8. Zip Code of Residence ...... 18 Table 9. Type of Specialist Visits ...... 19 Figure 2. Summary of Hospital Usage and Satisfaction Rates ...... 20 Table 10. Top Healthcare Concerns in Vinita ...... 21 Table 11. Additional Services Survey Respondents Would Like to See Offered at Craig General Hospital ...... 22 Primary Care Physician Demand Analysis, March 9, 2016 ...... 23 Table 12. Primary Care Physician Office Visits Given Usage by Local Residents in the Vinita, Oklahoma Medical Service Area ...... 23 Community Health Needs Implementation Strategy ...... 24 Community Health Needs Assessment Marketing Plan ...... 25

Appendix A- Hospital Services/Community Benefits ...... 26 Appendix B Community Meeting Attendees ...... 28 Appendix C- Meeting 1 Materials, February 17, 2016 ...... 32 Appendix D- Meeting 2 Materials, February 24, 2016 ...... 33 Appendix E- Survey Form and Meeting 3 Materials, March 9, 2016 ...... 36

Introduction New requirements for nonprofit, 501 (c)(3), hospitals were enacted under the Patient Protection and Affordable Care Act (ACA), passed on March 23, 2010. One of the most significant of the new requirements is the Community Health Needs Assessment (CHNA) that must be conducted during taxable years after March 23, 2012 and submitted with IRS form 990. A CHNA must then be completed every three years following.

While the requirements are fairly new, the IRS has made strides in defining hospitals that must complete the CHNA as well as details of what is expected in the CHNA report to be submitted. At this time the only entities that must complete the CHNA are hospital organizations defined as:

 An organization that operates a State-licensed hospital facility  Any other organization that the Secretary determines has the provision of hospital care as its principal function or purpose constituting the basis for its exemption under section 501 (c)(3).

The general goal behind the requirement is to gather community input that leads to recommendations on how the local hospital can better meet and serve residents’ needs. The community input is typically derived from a community survey and a series of open meetings. Local health data are presented. Community members then identify and prioritize their top health needs.

After listening to community input, the hospital defines an implementation strategy for their specific facility. The implementation strategy is a written plan that addresses each of the health needs identified in the community meetings. To meet Treasury and IRS guidelines an implementation strategy must:

 Describe how the hospital facility plans to meet the health need, or  Identify the health need as one the hospital facility does not intend to meet and explain why the hospital facility does not intend to meet the health need1

After the needs are identified that the hospital can address, the implementation strategy must take into account specific programs, resources, and priorities for that particular facility. This can include existing programs, new programs, or intended collaboration with governmental, nonprofit, or other health care entities within the community.2

1 Internal Revenue Service. 2011. Notice and Requests for Comments Regarding the Community Health Needs Assessment Requirements for Tax-Exempt Hospitals. Internal Revenue Bulletin: 2011-30. 2 Ibid 1

The facility must make the recommendations and implementation strategy widely available to community members. The facility must adopt the implementation strategy in that same taxable year.

Oklahoma Office of Rural Health Partnership The Oklahoma Office of Rural Health makes this program available to all rural facilities in Oklahoma free of charge. The Oklahoma Office of Rural Health works closely with the hospital and community members to develop an economic impact of the local health sector, develop and analyze a local health services survey, and gather and analyze local health data. The community meetings are facilitated by a resource team that includes Corie Kasier and Lara Brooks of the Oklahoma Office of Rural Health.

After the meetings conclude, the resource team assists the hospital in developing their implementation strategy. After implementation, the resource team will assist in evaluation of the strategies implemented and provide continued assistance with data and resources.

This document discusses the steps taken to conduct a CHNA for Craig General Hospital in 2016. It begins with a description of the hospital’s medical service area, including a demographic analysis, and then summarizes each meeting that took place during the CHNA process. The report concludes by listing the recommendations that came out of the process and presenting the hospital’s implementation strategy and marketing plan.

Previous Community Health Needs Assessment- Priorities, Implementation, and Evaluation Craig General Hospital internally completed a CHNA during 2013. Through this process, secondary data were gathered, and key community partners including public health were solicited for input. The following identifies each priority, implementation taken, and an evaluation or impact of the implementation.

Priority: Diabetes Prevention, Screening and Management

Service Implemented/Partnerships: Plan coordinate, and host health fairs for diabetes screening and education

Craig General Hospital has participated in several health screenings in our community and hosted our annual women’s health fair providing access to information about diabetes and screenings to an estimated 1000 per year.

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Priority: Wellness activities, diet and exercise

Service Implemented/Partnerships: Promote and serve as a resource for “Certified Healthy Business” initiatives

Craig General Hospital has communicated with 20 area businesses regarding the Certified Healthy Business process. Staff has worked with three businesses, with a total estimated employment of 500, to help develop their programs.

Priority: Wellness activities, diet and exercise

Service Implemented/Partnerships: Partner with school districts in the region to improve health related behaviors of our youth which will lead to more positive health behaviors in adulthood

Reduction in hospital and school budgets have limited the resources for this initiative, however, Craig General Hospital has provided the school with health information/speakers on smoking cessation, nutrition and substance abuse as requested.

Priority: Enhancement of specialty outreach

Service Implemented/Partnerships: Host a “living document” of community resources on the Craig General Hospital website

Craig General Hospital staff participated in the organization of the Craig County Wellness Initiative which meets regularly to share resources with other health related organizations in the county. One of the goals of this organization is a Healthy Vinita facebook page which is currently under development to serve as an ongoing resource for local health events, menus, and resources.

Priority: Access to care for low income individuals

Service Implemented/Partnerships: Team up with pharmaceutical companies to provide prescription access to low income patients, avoiding readmissions

A plan is being developed to train and maintain a list of community volunteers to assist with completing paperwork for pharmaceutical prescription drug programs.

Priority: Enhancement of specialty physician outreach

Service Implemented/Partnerships: Continued emphasis on specialty physician outreach in the hospital strategic plan

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Craig General Hospital staff has contacted and pursued relationships with physicians/groups in several specialties identified by the community including dermatology, pain management, orthopedics, podiatry, oncology and ENT. As a result of this effort a pain management physician is now seeing patients at Craig General Hospital and other contracts are in the works.

Awareness of Community Outreach

A question was included on the community survey (complete methodology detailed on page 17) to gauge survey respondents’ awareness of current community programs offered by the hospital. Eighteen individuals or 8.4 percent of the total indicated they were aware of community programs. Survey respondents were then asked to list which programs they knew. Each survey response had one respondent each. The table below outlines all programs listed by the survey respondents.

Please list community programs: Response Category No. % Vaccinations 1 12.5% Wellness program 1 12.5% Mental health 1 12.5% Support groups 1 12.5% Health screenings 1 12.5% Girls Night Out 1 12.5% St. John's Program for Babies 1 12.5% Urgent care 1 12.5% Total 8 100.0%

Craig General Hospital Medical Services Area Demographics Figure 1 displays the Craig General Hospital medical services area. Craig General Hospital and all area hospitals are delineated in the figure. The surrounding hospitals are identified in the table below by county along with their respective bed count.

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Figure 1. Craig General Hospital Medical Service Areas No. of City County Hospital Beds Vinita Craig Craig General Hospital 55 Grove Delaware INTEGRIS Grove Hospital 58 Pryor Mayes AllianceHealth Pryor 52 Nowata Nowata Jane Phillips Nowata Health Center, Inc. 25 Miami Ottawa INTEGRIS Baptist Regional Health Center 117 Claremore Rogers Hillcrest Hospital Claremore 81 Bartlesville Washington Jane Phillips Memorial Medical Center, Inc. 140 Columbus Cherokee, KS Mercy Hospital Columbus n/a Oswego Labette, KS Oswego Community Hospital n/a

As delineated in Figure 1, the primary medical service area of Craig General Hospital includes the zip code areas of Vinita, Big Cabin, Strang, Langley, Ketchum, Bluejacket, Welch. The primary medical service area experienced a population increase of 1.3 percent from the 2000 Census to the 2010 Census (Table 1). This same service area experienced a slight decrease in population of 0.9 percent from the 2010 Census to the latest available, 2010-2014, American Community Survey.

The secondary medical services area is comprised of the zip code areas Afton, Adair, and Chelsea. The secondary medical service area experienced an increase in population of 11.9

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percent from 2000 to 2010 followed by a population decrease of 4.1 percent from 2010 to the 2010-2014 American Community Survey.

Table 1. Population of Craig General Hospital Medical Service Area

2000 2010 2010-2014 % Change % Change Population by Zip Code Population Population Population 2000-2010 2010-10-14

Primary Medical Service Area

74301 Vinita 11,516 11,840 12,181 2.8% 2.9% 74332 Big Cabin 1,916 1,972 1,528 2.9% -22.5% 74367 Strang 540 587 492 8.7% -16.2% 74350 Langley 797 862 797 8.2% -7.5% 74349 Ketchum 619 318 344 -48.6% 8.2% 74333 Bluejacket 1,225 1,221 1,185 -0.3% -2.9%

74369 Welch 1,757 1,803 1,908 2.6% 5.8% Total 18,370 18,603 18,435 1.3% -0.9%

Secondary Medical Service Area

74331 Afton 6,260 7,258 6,568 15.9% -9.5% 74330 Adair 2,623 2,884 2,975 10.0% 3.2% 74016 Chelsea 5,544 6,005 5,934 8.3% -1.2% Total 14,427 16,147 15,477 11.9% -4.1%

SOURCE: Population data from the U.S. Bureau of Census, Decennial Census 2000, 2010 and American Community Survey 2010-2014(January 2016)

Table 2 displays the current existing medical services in the primary service area of the Craig General Hospital medical services area. Most of these services would be expected in a service area of Vinita’s size: six physician offices and clinics, two dental offices, two optometry offices, three chiropractic offices, one nursing home, one assisted living facility, four home health providers, four residential care facilities, one recovery center, one county health department, one EMS provider, two mental health and counseling providers, and three pharmacies. Craig General Hospital is a 55 bed facility with a 20 beds for geri-psych located in Craig County. The hospital provides 24-hour emergency department, acute inpatient services, hospitalist services, laboratory, diagnostic radiology (128 slice CAT Scan, MRI, nuclear

6 medicine, Ultrasound), social services, respiratory therapy, surgery, and obstetrics. A complete list of hospital services and community involvement activities can be found in Appendix A.

Table 2. Existing Medical Services in Craig General Hospital Medical Services Area Count Service 2 Hospitals: Craig General Hospital and Oklahoma Forensic Center 6 Physician offices and clinics 2 Dental offices 2 Optometry offices 3 Chiropractic offices 1 Nursing homes 1 Assisted living facility 4 Residential care facilities 1 Recovery center 4 Home health providers 1 County Health Department: Craig County 2 EMS providers 2 Mental health/Counseling services 3 Pharmacies

In addition to examining the total population trends of the medical service areas, it is important to understand the demographics of those populations. Table 3 displays trends in age groups for the primary and secondary medical service areas as well as Craig County in comparison to the state of Oklahoma. Overall, the over 65 age group has experienced an increase in population across all geographies from the 2010 Census to the latest, 2010-2014 American Community Survey. This cohort accounted for 14 percent of the total population at the state level. In terms of the medical service areas, this age group accounted for 19.1 percent of the primary medical service area, 18.7 percent of the secondary medical service area, and 18.2 percent of the population of Craig County. The 45-64 age group accounts for the largest share of the population in the primary (29.2%) and secondary (30.3%) service areas. This is compared to the state share of 25.4 percent of the total population.

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Table 3. Percent of Total Population by Age Group for the Craig General Hospital Medical Service Areas, Craig County and Oklahoma

Primary Medical Secondary Medical Craig County Oklahoma Age Service Area Service Area Groups

2010 Census 0-14 18.4% 18.5% 18.6% 20.7% 15-19 6.6% 6.2% 6.6% 7.1% 20-24 5.2% 4.5% 5.4% 7.2% 25-44 22.8% 20.5% 23.4% 25.8% 45-64 29.3% 31.4% 28.5% 25.7% 65+ 17.8% 19.0% 17.4% 13.5% Totals 100.0% 100.0% 100.0% 100.0%

Total 18,603 16,147 15,029 3,751,351 Population

10-14 ACS 0-14 17.4% 18.8% 18.3% 20.6% 15-19 6.6% 6.1% 6.2% 6.8% 20-24 6.0% 4.9% 5.8% 7.4% 25-44 21.6% 21.1% 22.7% 25.8% 45-64 29.2% 30.3% 28.8% 25.4% 65+ 19.1% 18.7% 18.2% 14.0% Totals 100.0% 100.0% 100.0% 100.0%

Total 18,435 15,480 14,792 3,818,851 Population

SOURCE: U.S. Census Bureau, Decennial Census data for 2010 and American Community Survey data for 2010- 2014 (www.census.gov [January 2016]).

Changes in racial and ethnic groups can impact the delivery of healthcare services, largely due to language barriers and dramatically different prevalence rates for specific diseases, such as diabetes. A noticeable trend in Oklahoma is the growth in the Hispanic origin population. In 2010, those of Hispanic origin accounted for 8.9 percent of the total state population. The latest American Community Survey data of 2010-2014 suggest that this population group has experienced an increase to 9.4 percent of the total population. This trend is

8 somewhat evident in Craig County and both medical service areas. The share of the population identified as of Hispanic Origin accounted for 2.8 percent of the primary medical service area’s population in 2010-2014 and 1.8 percent of the secondary medical service area during the same time period. The Hispanic Origin population accounted for 2.9 percent of the total population from 2009-2013 in Craig County. An even more striking trend is the larger share of Native American population residing in both medical service areas and Craig County. This cohort accounted for 15.4 percent of the primary medical service area, 16.5 percent of the secondary, and 17.0 percent of Craig County. This is compared to the state rate of 7.2 percent.

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Table 4. Percent of Total Population by Race and Ethnicity for Craig General Hospital Medical Service Areas, Craig County and Oklahoma

Primary Medical Secondary Medical Craig County Oklahoma Race/Ethnic Service Area Service Area Groups

2010 Census White 68.1% 72.3% 66.7% 72.2% Black 2.6% 0.2% 3.0% 7.4% Native American 1 19.7% 17.4% 20.4% 8.6% Other 2 1.4% 1.0% 1.5% 5.9%

9.1% 8.5% Two or more Races 3 8.1% 5.9% Hispanic Origin 4 2.4% 1.7% 2.5% 8.9%

Total Population 18,603 16,147 15,029 3,751,351

10-14 ACS White 67.1% 72.9% 66.6% 73.3% Black 2.9% 0.1% 3.3% 7.3% Native American 1 15.4% 16.5% 17.0% 7.2% Other 2 1.3% 0.9% 1.4% 4.5%

Two or more Races 3 13.4% 9.7% 11.8% 7.8% Hispanic Origin 4 2.8% 1.8% 2.9% 9.4%

Total Population 18,435 15,477 14,792 3,818,851

SOURCE: U.S. Census Bureau, Decennial Census data for 2010 and American Community Survey data for 2010- 2014 (www.census.gov [January 2016]). 1 Native American includes American Indians and Alaska Natives. 2 Other is defined as Asian Americans, Native Hawaiians, Pacific Islanders and all others. 3 Two or more races indicate a person is included in more than one race group. 4 Hispanic population is not a race group but rather a description of ethnic origin; Hispanics are included in the five race groups.

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Summary of Community Meetings Craig General Hospital hosted four community meetings between February 17, 2016 and March 23, 2016. The Oklahoma Office of Rural Health facilitated these meetings. Summaries of the information presented at each meeting are included below in chronological order.

Community members in attendance at these meetings included:

 Craig General Hospital representatives  Local pharmacy  Senior living facility representative  Craig County Health Department  Grand Nation, Inc.  Vinita Chamber of Commerce  Area youth services  Tribal Health System representative

Average attendance at the community meetings was 20-25 community members. A news release about the CHNA process and meeting dates was sent to the Vinita Daily Journal and other area newspapers. The meeting dates were posted on the Craig General Hospital social media channels. The hospital made significant efforts to reach a diverse and representative population of the medical service area and patients served including low income and racially diverse populations. Representatives from the public health sector were included to provide insight into what they see from a public health and underserved population perspective of community needs. Community members representing health, public safety, school, clergy, and senior sectors received personal invitations. Invitations were also sent to representatives from each community in the county.

Economic Impact and Community Health Needs Assessment Overview, February 17, 2016 A meeting was held to discuss the economic impact of the health sector and explain the process and need for the Community Health Needs Assessment. The economic impact of the health sector was reviewed at this meeting (and is summarized below).

Table 5 below summarizes the overall economic impact of the health sector on the Craig County, Oklahoma economy. A form requesting information was sent to all health care providers in the medical service area. Local providers were asked to share their employment levels and of those employees how many were physicians/optometrists/dentists/pharmacists/etc. When available, payroll information was also collected from the establishments. When payroll information was not available, payroll was estimated using state level averages from the Bureau of Labor Statistics.

The health sector in the Craig General Hospital medical service area employs 1,337 FTE individuals. After applying a county-specific employment multiplier to each respective sector,

11 there is a total employment impact of 1,752 FTE employees. The same methodology is applied to income. The local health sector has a direct income impact of nearly $57.4 million. When the appropriate income multiplier is applied, the total income impact is over $78.8 million. The last two columns examine the impact this has on the retail sector of the local community. Recent data suggest that just 23.7% of personal income in Craig County will be spent on taxable goods and services locally. Therefore, if we just examine the impact made on retail from those employed in the health sector, this would account for nearly $18.7 million spent locally, generating $186,841 on a 1% tax. A copy of the meeting materials that were distributed can be found in Appendix C.

At the conclusion of the meeting, community members were asked to identify their top health concerns based on the demographic information presented and their local expertise. The following concerns were identified:

• Residents leaving community for dialysis (Grove and Pryor have services) No local space available • Onsite oncology- hard for residents to travel for services • Psychiatry services- no outpatient clinic • Mental health patients are often sent to this area for mental health services • Limited # of providers, no private practice • Increasing suicide rates

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Table 5. Craig General Hospital Medical Service Area Health Sector Impact on Employment and Income, and Retail Sales and Sales Tax

Employment Income Retail 1 Cent Sales Health Sectors Employed Multiplier Impact Income Multiplier Impact Sales Tax

Hospitals 539 1.38 742 $23,792,590 1.58 $37,702,428 $8,935,475 $89,355

Physicians, Dentists, & Other Medical Professionals 198 1.42 282 $11,727,123 1.27 $14,847,586 $3,518,878 $35,189

Nursing Homes, Residential Care Facilities & Home Health 475 1.16 549 $15,265,560 1.19 $18,188,508 $4,310,676 $43,107

Other Medical & Health Services 100 1.47 147 $5,254,224 1.22 $6,396,886 $1,516,062 $15,161

Pharmacies 25 1.30 32 $1,357,236 1.25 $1,700,433 $403,003 $4,030

Total 1,337 1,752 $57,396,733 $78,835,842 $18,684,095 $186,841

SOURCE: 2014 IMPLAN database, IMPLAN Group, Inc.; Local data for employment, employee compensation and proprietor's income; income estimated based on state average incomes if local data not available * Based on the ratio between Craig County retail sales and income (23.7%) – from 2014 County Sales Tax Data and 2014 Personal Income Estimates from the Bureau of Economic Analysis.

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Health Data, February 24, 2016 A community meeting was held February 24, 2016, to examine various sources of local health data. Various sources of health data were examined including data from the County Health Rankings and Roadmaps Program through the University of Wisconsin Population Health Institute, and the Robert Woods Johnson Foundation and the 2014 Oklahoma State of the State’s Health Report compiled by the Oklahoma State Department of Health. The County Health Rankings program evaluates and ranks counties based on two distinct areas: Health Factors and Health Outcomes. Along with these two areas counties receive an overall rank within their state; therefore 1=best and 77=worst.

Health factors, considered tomorrow’s health, are comprised of health behaviors (rank: 22), clinical care (rank: 41), social and economic factors (rank: 50), and physical environment (rank: 20). Craig County’s overall health factors rank is 36. Areas of concern include Craig County’s smoking rate, adult obesity rate, teen birth rate, uninsured rate, number of preventable hospitals stays and diabetic screening rate of Medicare recipeints are all less desirable than the top U.S. performers. All health factors variables are presented in Table 6 along with Craig County specific data, the top U.S. performers, and the state average. The bold italicized categories are the areas identified by the County Health Rankings and Roadmaps as areas to explore (generally where Craig County ranks very poorly compared to the national benchmark).

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Table 6. Health Factors (Overall Rank 36) Craig Error Top U.S. Category (Rank) Oklahoma County Margin Performers Health Behaviors (22) Adult Smoking 21% 14-30% 14% 24% Adult Obesity 33% 27-40% 25% 32% Food Environment Index 7.1 8.4 6.7 Physical Inactivity 32% 26-39% 20% 30% Access to Exercise Opportunities 39% 92% 72% Excessive Drinking 13% 8-22% 10% 13% Alcohol-Impaired Driving Deaths 28% 14% 33% Sexually Transmitted Infections 359 138 442 Teen Birth Rate 66 57-75 20 54 Clinical Care (41) Uninsured 22% 20-24% 11% 21% Primary Care Physicians 2,458:1 1,045:1 1,567:1 Dentists 2,445:1 1,377:1 1,805:1 Mental Health Providers 222:1 386:1 285:1 Preventable Hospital Stays 94 81-106 41 71 Diabetic Screening 65% 56-74% 90% 78% Mammography Screening 60% 51-70% 71% 55% Social & Economic Factors (50) High School Graduation 87% 78% Some College 44% 39-50% 71% 58% Unemployment 6.1% 4.0% 5.4% Children in Poverty 28% 21-35% 13% 24% Income Inequality 4.4 3.7-5.1 3.7 4.6 Children in Single-Parent 33% 25-41% 20% 24% Household Social Associations 13.6 22.0 11.8 Violent Crime Rate 139 59 468 Injury Deaths 121 97-148 50 86 Physical Environment (20) Air-Pollution- Particulate Matter 9.4 9.5 10.3 Drinking Water Violations 49% 0% 23% Severe Housing Problems 11% 8-13% 9% 14% Driving Alone to Work 84% 80-87% 71% 82% Long Commute- Driving Alone 27% 23-31% 15% 25% Source: County Health Rankings & Roadmaps; University of Wisconsin Population Health Institute; Robert Wood Johnson Foundation

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The following figure depicts each county’s rank by shade. Craig County’s overall health factors ranking is more favorable than Ottawa, Delaware, and Mayes Counties and is comparable to Nowata County. Rogers County does have a more favorable ranking than Craig County.

In terms of health outcomes, considered, today’s health, Craig County’s ranking is 41st in the state. Health outcomes are comprised of two areas: length of life and quality of life. The variables for each of these sections are presented in Table 7.

Table 7. Health Outcomes (Overall Rank 41) Craig Error Top U.S. Category (Rank) Oklahoma County Margin Performers Length of Life (44) 8,497- Premature Death 10,362 5,200 9,121 12,226 Quality of Life (40) Poor or Fair Health 19% 14-26% 10% 19% Poor Physical Health Days 4.1 2.9-5.2 2.5 4.3 Poor Mental Health Days 4.3 2.9-5.6 2.3 4.2 Low Birth Weight 8.2% 6.7-9.7% 5.9% 8.3% Source: County Health Rankings & Roadmaps; University of Wisconsin Population Health Institute; Robert Wood Johnson Foundation

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The following figure shows county health outcomes rankings by shades. Craig County’s ranking is less favorable than Mayes, Delaware, Rogers, and Nowata Counties, but is comparable to Ottawa County. All meeting materials distributed at this meeting can be found in Appendix D.

At the conclusion of the meeting, community members were once asked to identify what health concerns stand out in the data the presented and their local expertise. The health concerns identified include:

 Available space for patients is out of county Lack of transportation, support system, ends up in ER Lack of patient beds/treatment facilities Cushing if often closest available facility  Grandparents raising grandkids- education  Teen pregnancy rates  Meth abuse

Community Survey Methodology and Results, February 17, 2016- March 9, 2016 A survey was designed to gauge hospital usage, satisfaction, and community health needs. The survey was available in both paper and web format. The survey was made available at the hospital and clinics. Surveys were also distributed at the first community meeting on February 17, 2016. Community members in attendance also received a follow-up email with a PDF copy of the survey and the electronic survey link. A copy of the survey form and results

17 can be found in Appendix E. Community members were asked to return their completed surveys to Craig General Hospital.

The survey ran from February 17, 2016 to March 2, 2016. A total of 214 surveys from the Craig General Hospital medical service area were completed. Of the surveys returned, 100 were electronic responses, and 114 were hard copy surveys. The survey results were presented at the March 9, 2016, community meeting.

Table 8 below shows the survey respondent representation by zip code. The largest share of respondents was from the Vinita (74301) zip code with 126 responses or 58.9 percent of the total. Welch followed with 23 responses, and Afton had 16.

Table 8. Zip Code of Residence Response Category No. % 74301- Vinita 126 58.9% 74369- Welch 23 10.7% 74331- Afton 16 7.5% 74354- Miami 6 2.8% 74350- Langley 5 2.3% 74340- Disney 5 2.3% 74332- Big Cabin 4 1.9% 74342- Eucha 3 1.4% 74349- Ketchum 3 1.4% 74055- Owasso 2 0.9% 74333- Bluejacket 2 0.9% 74344- Grove 2 0.9% 74346- Jay 2 0.9% 74366- Spavinaw 2 0.9% 74370- Wyandotte 1 0.5% 74367- Strang 1 0.5% 74361- Pryor 1 0.5% 74345- Grove 1 0.5% 74330- Adair 1 0.5% 74019- Claremore 1 0.5% 74017- Claremore 1 0.5% 74016- Chelsea 1 0.5% No response 5 2.3% Total 214 100.0%

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The survey focused on several health topics of interest to the community. Highlights of the results include:

Primary Care Physician Visits

- 70.6% of respondents had used a primary care physician in the Vinita service area during the past 24 months - 92.7% of those responded being satisfied - Only 68 respondents or 31.8% believe there are enough primary care physicians practicing in Vinita - 65.0% of the respondents would consider seeing a midlevel provider for their healthcare needs - 61.7% responded they were able to get an appointment, within 48 hours, with their primary care physician when they needed one

Specialist Visits

Summary highlights include:

- 55.6% of all respondents report some specialist visit in past 24 months - Most common specialty visited are displayed in Table 9 - Only 14.4% of specialist visits occurred in El Reno

Table 9. Type of Specialist Visits Type of Specialist No. Percent Top 5 Responses Orthopedist/Orthopedic Surg. 22 15.1% (2 visits in Vinita) Gastroenterologist 17 11.6% (5 visits in Vinita) Cardiologist 13 8.9% (5 visits in Vinita) Dermatologist 10 6.8% (0 visits in Vinita) OB/GYN 10 6.8% (0 visits in Vinita) All others 74 50.7% (9 visits in Vinita)

Total 146 100.0%

Some respondents answered more than once.

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Hospital Usage and Satisfaction

Survey highlights include:

- 68.3% of survey respondents that have used hospital services in the past 24 months used services at Craig General Hospital o St. Francis, Tulsa (5.8%), INTEGRIS Grove Hospital, Grove (5.8%), and INTEGRIS Baptist Regional Health Center, Miami (4.2%) followed o The most common response for using a hospital other than Craig General Hospital was physician referral (26.3%) followed by availability of specialty care (22.5%) o The usage rate of 68.3% was higher than the state average of 56.3% for usage of other rural Oklahoma hospitals surveyed - 86.8% of survey respondents were satisfied with the services received at Craig General Hospital o This is above the state average for other hospitals (85.8%) - Most common services used at Craig General Hospital: o Diagnostic imaging (28.6%) o Emergency room (22.9%) o Laboratory (19.5%)

Figure 2. Summary of Hospital Usage and Satisfaction Rates

86.8% Hospital Satisfaction 85.8%

68.3% Hospital Usage 56.3%

0.0% 20.0% 40.0% 60.0% 80.0% 100.0% Craig General Hospital Other OK Hospital Survey Averages

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Local Healthcare Concerns and Additional Services

Survey respondents were asked what concerns them most about healthcare in their community. The most common response was No concerns/don’t know with 15.5 percent of the survey responses. Losing the hospital/financial situation of the hospital/losing health services (15.0%) Table 10 displays all responses and the frequencies.

Table 10. Top Healthcare Concerns in Vinita Response Category No. % No Concerns/ Receive good care/Don't Know 34 15.5% Losing the hospital/Financial situation of hospital/Losing health services 33 15.0% Lack of providers/Difficult to see provider 24 10.9% Quality of care/Compassion for patient 20 9.1% Lack of specialists 15 6.8% Emergency care/Physician ER coverage 4 1.8% Lack of services/Variety of services 3 1.4% A new or updated facility 3 1.4% Increasing cost of care 3 1.4% Distance from services 2 0.9% Need 24 hour walk in clinic/Urgent care 2 0.9% Addressing issues in area/Treatment of conditions 2 0.9% Level of care/Training/Ability to handle life-threating conditions 2 0.9% More focus on wellness: diet and exercise 1 0.5% Insurance accepted by providers/Selection of providers 1 0.5% Continue to deliver babies locally 1 0.5% Mental health 1 0.5% Staph infection 1 0.5% Greater communication among providers 1 0.5% Updated technology 1 0.5% No response 66 30.0% Total 220 100.0%

Survey respondents also had the opportunity to identify what additional services they would like to see offered at Craig General Hospital. The most common response was specialists including dermatologist, specialists in general, OB/GYN, pediatrician, oncologist, pain management, allergist, orthopedist, neurologist, endocrinologist, urologist, gastroenterologist, podiatrist, and rheumatologist (collectively, 26.3%). No additional services/satisfied with what is available/don’t know (14.2%) followed. Table 11 displays the full listing of responses.

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Table 11. Additional Services Survey Respondents Would Like to See Offered at Craig General Hospital Response Category No. % Specialists (Dermatologist (17); Specialists in general (14); OB/GYN (5); Pediatrician (4); Oncologist (4); Pain Management (4); Allergist (3); Orthopedist (3); Neurologist (2); Endocrinologist (1); Urologist (1); Gastroenterologist (1); Podiatrist (1); Rheumatologist (1) 61 26.3% No additional services/Satisfied with what is available/Don't know 33 14.2% Improved quality of care 10 4.3% Mental health/Psychiatry services/Substance abuse 4 1.7% Everything/General services/Anything to benefit health 4 1.7% Weight loss specialty/Fitness/Nutrition classes/Healthy living 4 1.7% Outpatient nurse registry/Social worker on staff 3 1.3% Cancer care/Specialized cancer treatment 3 1.3% Improved ER care 3 1.3% Not aware of current services/More advertisement of services 2 0.9% Aquatic therapy 2 0.9% PET Scan/Updated equipment 2 0.9% Urgent care/Minor emergency clinic 2 0.9% Dietician 1 0.4% More specialists that work with Cherokee Nation 1 0.4% Rehab unit (heart, cancer) 1 0.4% Chiropractic care 1 0.4% Dialysis 1 0.4% Men's clinic 1 0.4% Cancer screenings 1 0.4% Wellness and prevention 1 0.4% Eye care 1 0.4% Digital mammogram 1 0.4% Midwife 1 0.4% EMTs station closer to Welch 1 0.4% Physicians at outlying clinics 1 0.4% More therapy equipment 1 0.4% Hyperbaric oxygen chamber 1 0.4% Cloud computing/Keeps patient records 1 0.4% Low cost urgent care 1 0.4% Major surgeries 1 0.4% Functional medicine 1 0.4% No response 80 34.5% Total 232 100.0%

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Primary Care Physician Demand Analysis, March 9, 2016 A demand analysis of primary care physicians was completed for the zip codes that comprise the Vinita primary and secondary medical services areas. This analysis examined average primary care physician visit rates by gender and by age groups. Once age- and gender- specific coefficients were applied, total primary care physician visit numbers were calculated by service area. Table 12 displays potential primary care physician rates by shares of service area. For example, if 90% of residents in the primary medical services area and 10% of residents in the secondary medical services area utilize services of primary care physicians in the Vinita medical services area, a total of 31,798 annual visits would occur. This would suggest that the Vinita medical services area would need 7.6 FTE primary care physicians to meet the needs of their existing population. Table 12 displays the estimated number of visits by share of medical services area.

Table 12. Primary Care Physician Office Visits Given Usage by Local Residents in the Vinita, Oklahoma Medical Service Area Usage by Residents of Primary Service Area 70% 75% 80% 85% 90% 95% 100%

5% 23,975 25,590 27,205 28,820 30,435 32,050 33,665 10% 25,338 26,953 28,568 30,183 31,798 33,413 35,029 15% 26,702 28,317 29,932 31,547 33,162 34,777 36,392 Service Area Service 20% 28,065 29,680 31,295 32,910 34,525 36,141 37,756 25% 29,429 31,044 32,659 34,274 35,889 37,504 39,119 30% 30,792 32,407 34,022 35,637 37,252 38,868 40,483 35% 32,156 33,771 35,386 37,001 38,616 40,231 41,846 by Residents of Secondary Secondary of by Residents

40% 33,519 35,134 36,749 38,364 39,980 41,595 43,210

Usage 45% 34,883 36,498 38,113 39,728 41,343 42,958 44,573 50% 36,246 37,861 39,476 41,092 42,707 44,322 45,937

If 90% primary medical service area and 10 to 15% secondary medical service area, then the usage would be: 31,798 to 33,162 total primary care physician office visits in the Vinita area for an estimated 7.6 to 7.9 Total Primary Care Physicians. (Based on 83.7 average weekly primary care physician visits with a 50 week year)

At the conclusion of the meeting, community members were once again asked what stood out to them from the survey results and physician demand analysis as health concerns.

 Urgent/After Hours care  Women’s Health  Obesity

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Community Health Needs Implementation Strategy During the March 23, 2016, meeting, hospital representatives and community members discussed how these concerns can be addressed. The following lists the concerns along with steps the hospital and community plan to take to remedy the situation.

• Mental Health- This concern was mentioned and discussed at every community meeting. It was noted the general population struggles finding outpatient resources, the hospital also struggles finding available beds for patients in the ED, and sometimes residential care patients max out the services that can be provided at that facility. It was also noted there is a great need in the community for a psychiatrist that can prescribe medication. There is also a great need for a pediatric psychiatrist. There is also not a crisis center for juveniles in a crisis in the area. Sometimes beds are found in Tulsa, but they have been taken before the patient arrives. • Available services in this area include: Grand Lake has 23 hour observation for patients in a crisis and do provide outpatient services- hospital has intensive outpatient geriatric services, transitions. The hospital also has a psychologist that sees patients at the Langley and Monkey Island clinic locations; this provider also goes to people’s homes and nursing homes for visits. The hospital also has inpatient geriatric services. • The community would like to see the availability of a psychiatrist to prescribe and manage medication for local patients. • If there were unlimited funds, the community members present would like to see a crisis center for adults and juveniles with a pediatric psychiatrist and an adult psychiatrist. • Substance abuse was also identified as a priority. This item was also discussed with the linkage to mental health and overall health and well-being issues. It was also noted that there is a lack of transitional housing for patients coming out of recovery to get back on their feet without starting or falling into previous habits or environments. It was also noted that the amount of drug awareness and education taught and provided within the public school system has decreased over time. • Current programs available in the community include: Rose Rock Recovery is court ordered for women. Recovery centers have an extensive waiting list. Outside counseling is available, but referrals are typically made via the parents (without DHS involvement). Drug court and mental health court programs. Many of the mental health court participants utilize Grand Lake. Also, Grand Nation, Inc. does have free drug test kits available for those who are interested. • The community members present noted that they would like to see more education in the community and leverage existing resources.

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• The resource team will also share contact information with representatives from the Oklahoma State Department of Mental Health and Substance Abuse Services and include them as a community to be partnered with a MPH student to design an educational program. • Increasing the number of specialists- This item was mentioned in the first meeting in terms of oncology services, and it was a large focus in the survey especially under additional services the survey respondent would like to see offered at Craig General Hospital. • The hospital currently utilizes telemedicine services for geropsych, and they are looking to increase their stroke services. They would like to add other specialties via telelmedicine. • The resource team will place Craig General Hospital in contact with the Telehealth Department at Oklahoma State University to see about expanding their services.

Community Health Needs Assessment Marketing Plan The hospital will make the Community Health Needs Assessment Summary and Implementation Strategy Plan available upon request at Craig General Hospital, and a copy will be available to be downloaded from the hospital’s website (www.craiggeneralhospital.com). This document will also be available on the OSU Center for Rural Health blog site: (http://osururalhealth.blogspot.com/p/chna.html).

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Appendix A- Hospital Services/Community Benefits

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Appendix B Community Meeting Attendees

Vinita Meeting Attendees Meeting 1: Community Health Needs Assessment Overview and Economic Impact Presentation 17-Feb-16 First Name Last Name Title Organization Xan Bryant N Regional Coordinator OSU-CHS Brandi Harmon Accreditation Coordinator Craig Co. Health Dept. Kylee Williams RN Craig Co. Health Dept. Tim Zufall Health Educator Craig Co. Health Dept. Tonya Moorehead Vinita Chamber of Commerce Pam Wolfe Admin., RN Heartsworth House Amber Dotson Pharmacy Technician Osborn Drugs Grant Coordinator for Rx abuse Cicley Downing prevention Grand Nation, Inc. Shannon Watkins Admin/Drug Testing Grand Nation Financial Jennifer Hinson Director Grand Nation, Inc. Melisa Daugherty Director of PT Care Craig General Hospital Northeastern Tribal Health Kim Chuculate CEO NTB, Miami, OK Systems Ann Carr RN, CNO Craig General Hospital Sandi Davis CGH Outreach Clinics Admin Craig General Hospital CGH- NEO Orthopedics and Jason Fuser PT-Director of Rehab Rehab Pam Schmidt Quality Director Craig General Hospital BJ Money Director DOC Services Inc Grand Lake Medical Park- Cindy Noble Nurse Practitioner Langley Darlene Nolte Chief HR Officer, Craig General Hospital Jete Edmisson ICFO Craig General Hospital Jerry Edington Renaissance Program Director Craig General Hospital ROCMDS Area Youth Heaher Ramseyer Alcohol Enforcement Coordinator Services

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Vinita Meeting Attendees Meeting 2: Health Indicators and Outcomes Presentation 24-Feb-16 First Name Last Name Title Organization Oklahoma Hospital Andy Fosmire VP for Rural Health Association Kylee Williams RN Craig Co. Health Dept. Michel Jones RN Craig Co. Health Dept. Xan Bryant N Regional Coordinator OSU-CHS Northeastern Tribal Health Kim Chuculate CEO NTB, Miami, OK Systems Herb Crum CEO Craig General Hospital Ann Carr RN, CNO Craig General Hospital Grand Lake Medical Park- Cindy Noble Nurse Practitioner Langley Sandi Davis CGH Outreach Clinics Admin Craig General Hospital Misty Bingham Director of Marketing Craig General Hospital Tina Chambers Office Manager Craig General Hospital Rachel Olsen HR Generalist Craig General Hospital Darlene Nolte Chief HR Officer, Craig General Hospital Pam Wolfe Admin., RN Heartsworth House MD Bluejacket E.M. Director Craig County Kevin Wofford Fire Chief City of Vinita Bryan Taylor Deputy Director Mercy Regional EMS April Lee LPN/DON Home of Hope Grant Coordinator for Rx abuse Cicley Downing prevention Grand Nation, Inc. Jeff Wood Deputy Director, EM Craig County EM

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Vinita Meeting Attendees Meeting 3: Survey Results and Primary Care Physician Demand Analysis 9-Mar-2016 Last First Name Name Title Organization Xan Bryant N Regional Coordinator OSU-CHS Rachel Olsen HR Generalist Craig General Hospital CGH Outreach Clinics Sandi Davis Admin Craig General Hospital Grand Lake Medical Park- Cindy Noble Nurse Practitioner Langley Ann Carr RN, CNO Craig General Hospital Lee Hilliard Outreach Enrollment Route 66 Health Clinic Kevin Wofford Fire Chief Vinita Fire Dept Justin Hintz PTA NE Orthopedics and Rehab Wade Patton Exec. Director Heartsworth Nursing Center Pam Wolfe Admin., RN Heartsworth House Director of Human Cindy Allen Resources Kamo Power Tonya Moorehead Vinita Chamber of Commerce Craig County Health Michel Jones Nurse Practitioner Department Jennifer Hinson Director Grand Nation, Inc. Misty Bingham Director of Marketing Craig General Hospital Shannon Watkins Admin/Drug Testing Grand Nation Financial Pam Schmidt Quality Director Craig General Hospital April Lee LPN/DON Home of Hope

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Vinita Meeting Attendees Meeting 4: Health Concern Prioritization and Implementation Discussion 23-Mar-16 Last First Name Name Title Organization Craig County Health Brandi Larmon Accreditation Coordinator Department April Lee LPN/DON Home of Hope Director of Human Cindy Allen Resources Kamo Power Jennifer Hinson Director Grand Nation, Inc. Shane Soden DME Director Craig General Hospital Justin Hintz PTA NEO Orthopaedic and Rehab Misty Bingham Director of Marketing Craig General Hospital Rachel Olsen HR Generalist Craig General Hospital Melisa Daugherty Director of Patient Care Craig General Hospital Grand Lake Medical Park- Cindy Noble Nurse Practitioner Langley Herb Crum CEO Craig General Hospital Darlene Nolte Chief HR Officer Craig General Hospital

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Appendix C- Meeting 1 Materials, February 17, 2016

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Appendix D- Meeting 2 Materials, February 24, 2016

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Appendix E- Survey Form and Meeting 3 Materials, March 9, 2016

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