Community Health Needs Assessment Table of Contents

I. Executive Summary II. Methodology

a) CHNA Scope and Purpose

b) Local Collaborating CHNA Parties (The identity of any and all organizations with which the organization collaborated and third parties that engaged to assist with the CHNA)

c) CHNA and Town Hall Research Process (A description of the process and methods used to conduct the CHNA, a description of how the organization considered the input of persons representing the community, and an explanation of the process / criteria used in prioritizing such needs)

d) Community Profile (A description of the community served by the facility and how the community was determined)

III. Community Health Status

a) Town Hall CHNA Findings: Areas of Strengths and Areas to Change and/or Improve

b) County Health Area of Future Focus (A prioritized description of all of the community needs identified by the CHNA)

c) Historical Health Statistics

IV. Inventory of Existing County Health Resources

a) A description of the existing health care facilities and other resources within the community available to meet the needs identified through the CHNA

V. Detail Exhibits

a) Patient Origin and Access to Care

b) Town Hall Attendees, Notes and Feedback (Who attended with qualifications)

c) Public Notice and News

d) Primary Research Detail 1

1 *Shaded lines note IRS requirements

1 I. Executive Summary

[VVV Consultants LLC]

2 I. Executive Summary

Appanoose County, IA - 2016 Community Health Needs Assessment (CHNA)

Creating healthy communities requires a high level of mutual understanding and collaboration among community leaders. The development of this assessment brings together community health leaders and providers, along with local residents, to research and prioritize county health needs and document community health delivery successes. This health assessment will serve as the foundation for community health improvement efforts for the next three years. The last CHNA for Appanoose County, IA was published in June of 2013. (Note: The Patient Protection and Affordable Care Act (ACA) requires not-for-profit hospitals to conduct a CHNA every three years and adopt an implementation strategy to meet the needs identified by the CHNA). This assessment was coordinated and produced by VVV Consultants LLC (Olathe, Kansas) under the direction of Vince Vandehaar, MBA.

Important CHNA benefits for both the local hospital and health department, as well as for the community, are as follows: 1) Increases knowledge of community health needs and resources 2) Creates a common understanding of the priorities of the community's health needs 3) Enhances relationships and mutual understanding between and among stakeholders 4) Provides a basis upon which community stakeholders can make decisions about how they can contribute to improving the health of the community 5) Provides rationale for current and potential funders to support efforts to improve the health of the community 6) Creates opportunities for collaboration in delivery of services to the community and 7) Provides guidance to the hospital and local health department for how they can align their services and community benefit programs to best meet needs.

Town Hall “Community Health Strengths” cited for Mercy Medical Center—Centerville’s Primary Service Area are as follows:

Appanoose County, IA - Community Health "Strengths" Topic Topic 1 On-site CT Scan and MRI 14 Have a hospital in our community 2 Mental health services are starting to 15 Health and wellness coalition at the hospital improve due to new access 3 Community involvement in health 16 River Hills offers services to the under-served 4New,youngprovidersinthe 17 Local hospice community 5 EMS services 18 Support groups (Parkinson's and Diabetes) 6 Providers are engaged, trustworthy and 19 All levels of care are available in our build relationships community 7 Good schools 20 Good VA health 8Improvedhomecareservices21 YMCA 9 Availability of healthcare education to 22 Hospitalist program the public 10 Community Resources meeting every 23 Outdoor activities two months 11 Church involvement for poor and 24 Focus on oral health in elementary schools elderly 12 Oak Place mental health stabilization 25 Sustainable agriculture program at the house Community College 13 Social hosting ordinance was passed

3 Town Hall “Community Health Changes and/or Improvements Ranking” cited for Mercy Medical Center—Centerville’s Primary Service Area are as follows:

Town Hall Community Health Needs - Year 2016 Mercy Medical Center- Centerville PSA 56 Town Hall Attendees, 220 Votes

# Health Needs to Change and/or Improve Votes % Accum 1 After Hours Clinic / Urgent Care Services 45 20.5% 20.5% Increased Visiting Specialists Clinics (Orthopedics, Wound Care, 2 Oncology, Podiatry, Pain Management, Cardiac and 29 13.2% 33.6% Rheumatology) 3 Poverty 26 11.8% 45.5%

4 Personal Health Accountability 24 10.9% 56.4%

5 Rural Ambulance Service (911 Mapping Updates) 18 8.2% 64.5%

6 Healthcare Transportation 17 7.7% 72.3%

7 DHS Presence in Centerville 14 6.4% 78.6%

8 Communication of Available Healthcare Services 12 5.5% 84.1%

Total Town Hall Votes 220 100.0% Other Items Noted: Pediatric Mental Health, Inpatient Detox, Depression, Activities/Jobs for the Handi-Capped, Teen Sex Education, Activities for Seniors, Nutrition, Provider Recruitment Starting in Schools, Cost of Healthcare Services, Family Planning Services and Radon.

Key Community Health Needs Assessment Conclusions from secondary research for Mercy Medical Center—Centerville’s Primary Service Area are as follows:

IA HEALTH RANKINGS: According to the 2016 RWJ County Health Rankings study, Appanoose County’s highest State of Iowa rankings (of 99 counties) were in Physical Environment.

TAB 1. Demographic Profile TAB 2. Economic/Business Profile TAB 3. Educational Profile TAB 4. Maternal and Infant Health Profile TAB 5. Hospitalization / Providers Profile TAB6.BehavioralHealthProfile TAB 7. Risk Indicators & Factors TAB 8. Uninsured Profile TAB 9. Mortality Profile TAB 10. Preventative Quality Measures

x TAB 1: Appanoose County has a population of 12,661 residents as of 2014. The percent change in population in Appanoose County from April 1, 2010 to July 1, 2014 is -1.8%. The percent of languages spoken in the home other than English in Appanoose County is 2.3%, lower than the Iowa rural norm of 5.2%. The are 1,045 veterans in Appanoose County, lower than the Iowa rural norm of 1,173. The percent of children living in single- parent households in Appanoose County is 33%, higher than the Iowa rural norm of 25.9%. The percent of poverty levels in Appanoose County is 16.3%, higher than the Iowa rural norm of 12.7%. The voter turnout in Appanoose County is 48.5%, lower than the Iowa rural norm of 53.6%.

4 x TAB 2: The per capita money income in the past 12 months in Appanoose County is $21,599, lower than the Iowa rural norm of $24,657. The percent of housing units in multi-unit structures in Appanoose County is 12%, higher than the Iowa rural norm of 10.5%. The percent of severe housing problems in Appanoose County is 13%, higher than the Iowa rural norm of 10.6%. The unemployment rate in Appanoose County is 6.4%, higher than the Iowa rural norm of 4.8%. The child food insecurity rate in Appanoose County is 14.4%, higher than the Iowa rural norm of 12.4%. The percent of persons with a long commute driving alone in Appanoose County is 20%, lower than the Iowa rural norm of 24.9%. x TAB 3: In Appanoose County, 35.7% of students are eligible for free lunch, higher than the Iowa rural norm of 29.4%. 12% of child are in poverty in Clay County, lower than the Missouri metro norm of 19.1%. The 4-year high school graduation rate in Appanoose County is 123, lower than the Iowa rural norm of 145. x TAB 4: The rate of mothers smoking during pregnancy in Appanoose County is 80, higher than the Iowa norm of 62. The rate of mothers under age 20 in Appanoose County is 36, higher than the Iowa rural norm of 28. The rate of out-of-wedlock births in Appanoose County is 131, higher than the Iowa rural norm of 104. x TAB 5: The ratio of the population in Appanoose County to primary care physicians is 1,270, lower than the Iowa rural norm of 1,987. The percent of patients in Appanoose County who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) is 72%, lower than the Iowa rural norm of 74.3%. The percent of patients in Appanoose County who reported yes, they would definitely recommend the hospital is 63%, lower than the Iowa rural norm of 72.6%. x TAB 6: The percent of the Medicare population in Appanoose County with depression is 15.4%, higher than the Iowa rural norm of 14%. The percent of alcohol-impaired driving deaths in Appanoose County is 18%, lower than the Iowa rural norm of 22.9%. x TAB 7: The adult obesity percent in Appanoose County is 30%, higher than the Iowa rural norm of 31%. The percent of adult smoking in Appanoose County is 28%, higher than the Iowa rural norm of 19%. The percent of excessive drinking in Appanoose County is 23%, higher than the Iowa rural norm of 19.8%. The percent of physical inactivity in Appanoose County is 31%, higher than the Iowa rural norm of 26.4%. The number of poor physical health days in Appanoose County is 5.4, higher than the Iowa rural norm of 2.9. The rate of sexually transmitted infections in Appanoose County is 181, lower than the Iowa rural norm of 226. The percent of the Medicare population in Appanoose County with Hypertension is 57.6%, higher than the Iowa rural norm of 52.8%. The percent of the Medicare population in Appanoose County with Heart Failure is 16.7%, higher than the Iowa rural norm of 14%. The percent of the Medicare population in Appanoose County with Chronic Kidney Disease is 16.2%, higher than the Iowa rural norm of 13.7%. The percent of the Medicare population in Appanoose County with COPD is 15.2%, higher than the Iowa rural norm of 11%. The percent of the Medicare population in Appanoose County with Atrial Fibrillation is 6.8%, lower than the Iowa rural norm of 8.8%. The percent of the Medicare population in Appanoose County with Osteoporosis is 3%, lower than the Iowa rural norm of 5.9%.

5 x TAB 8: The uninsured percent in Appanoose County is 12.7%, higher than the Iowa rural norm of 12%.

x TAB 9: The Heart Disease mortality rate in Appanoose County is 370 per 100,000, higher than the Iowa rural norm of 215. The Chronic Obstructive Pulmonary Disease mortality rate in Appanoose County is 28, lower than the Iowa rural norm of 46.

x TAB 10: The percent of two-year-old coverage of individual vaccines and selected vaccination series is 48%, lower than the Iowa rural norm of 67%. The percent of diabetic monitoring in Appanoose County 83%, lower than the Iowa rural norm of 88.4%. The percent of mammography screenings in Appanoose County is 60.5%, lower than the Iowa rural norm of 62.9%.

Key 2016 Community Feedback Conclusions

In February of 2016, Mercy Medical Center—Centerville (MMCC) collected stakeholder feedback from their primary service area consumers, community leaders and groups, public and other organizations, and other providers. These stakeholders (N=263) provided the following community feedback insights via an online perception survey:

x 68.8% of MMCC primary service area stakeholders would rate the overall quality of healthcare delivery in their community as either Very Good or Good, with Very Good being the highest ranking. x MMCC primary service area stakeholders are satisfied with the following services: Ambulance Services, Chiropractors, Hospice, Inpatient Services, Outpatient Services and Pharmacy. x MMCC primary service area stakeholders are not satisfied with the following services: Child Care, Dentists, Emergency Room, Eye Doctor/Optometrist, Family Planning Services, Mental Health Services, School Nurse and Visiting Specialists. x 82.7% of MMCC primary service area stakeholders have received healthcare services outside of their community over the past two years. x MMCC primary service area stakeholders perceive the following causes of disease or disability a problem in their community: Abuse/Violence, Alcohol, Drugs/Substance Abuse, Mental Illness, Obesity, Poverty, Suicide and Wellness Education.

6 As seen below, the community still senses a health need for Develop After Hours Clinic Services, Integrate/Expand Veteran Care, Fight Obesity (Exercise and Healthy Foods), Further Economic Development, Recruit Primary Care Physicians, Expand Mental Health Services (Providers and Placement), Renovate Mercy Medical Center—Centerville’s Emergency Facility, Educate on Personal Health Accountability and Seek YMCA Funding.

Mercy Medical Center - Centerville (Primary Service Area) Appanoose Co, IA N=263

From our last CHNA (2013), a number of health needs were identified as priorities. Are any of these 2013 CHNA needs still an "Ongoing Problem" in our Mercy Medical Center-Centerville service area? Not a Somewhat Most Major Response Answer Options Problem of a Problem % Pressing Problem Count Anymore Problem Rank 16 73 114 92.1% 203 1 Develop After Hours Clinic Services 17 105 68 91.1% 190 6 Integrate/Expand Veteran Care Fight Obesity (Exercise and Healthy 19 95 83 90.4% 197 5 Foods) 24 89 84 87.8% 197 6 Further Economic Development

Recruit Primary Care Physicians 25 89 88 87.6% 202 2 Expand Mental Health Services 31 96 69 84.2% 196 3 (Providers and Placement) 34 62 101 82.7% 197 4 Renovate Mercy Emergency Facility Educate Personal Health 35 111 48 82.0% 194 8 Accountability

Seek YMCA Funding 39 125 31 80.0% 195 9 Develop Community Healthcare 68 99 27 64.9% 194 10 Directory

7 II. Methodology

[VVV Consultants LLC]

8 II. Methodology a)Scope and Purpose

The new federal Patient Protection and Affordable Care Act requires that each registered 501(c)3 hospital conduct a Community Health Needs Assessment (CHNA) at least once every three years and adopt a strategy to meet community health needs. Any hospital who has filed a 990 is required to conduct a CHNA. IRS Notice 2011-52 was released in late fall of 2011 to give notice and request comments.

JOB #1: Meet/Report IRS 990 Required Documentation

1. A description of the community served by the facility and how the community was determined; 2. A description of the process and methods used to conduct the CHNA; 3. The identity of any and all organizations with which the organization collaborated and third parties that it engaged to assist with the CHNA; 4. A description of how the organization considered the input of persons representing the community (e.g., through meetings, focus groups, interviews, etc.),whothose persons are, and their qualifications; 5. A prioritized description of all of the community needs identified by the CHNA and an explanation of the process and criteria used in prioritizing such needs; and 6. A description of the existing health care facilities and other resources within the community available to meet the needs identified through the CHNA.

Section 501(r) provides that a CHNA must take into account input from persons who represent the broad interests of the community served by the hospital facility, including individuals with special knowledge of or expertise in public health. Under the Notice, the persons consulted must also include: Government agencies with current information relevant to the health needs of the community and representatives or members in the community that are medically underserved, low-income, minority populations, and populations with chronic disease needs. In addition, a hospital organization may seek input from other individuals and organizations located in or serving the hospital facility’s defined community (e.g., health care consumer advocates, academic experts, private businesses, health insurance and managed care organizations, etc.).

JOB #2: Making a CHNA Widely Available to the Public

The Notice provides that a CHNA will be considered to be “conducted” in the taxable year that the written report of the CHNA findings is made widely available to the public. The Notice also indicates that the IRS intends to pattern its rules for making a CHNA “widely available to the public” after the rules currently in effect for Form 990. Accordingly, an organization would make a facility’s written report widely available by posting the final report on its website either in the form of (1) the report itself, in a readily accessible format or (2) a link to another organization’s website, along with instructions for accessing the report on that website. The Notice clarifies that an organization must post the CHNA for each facility until the date on which its subsequent CHNA for that facility is posted.

9 JOB #3: Adopt an Implementation Strategy by Hospital

Section 501(r) requires a hospital organization to adopt an implementation strategy to meet the needs identified through each CHNA. The Notice defines an “implementation strategy” as a written plan that addresses each of the needs identified in a CHNA by either (1) describing how the facility plans to meet the health need or (2) identifying the health need as one that the facility does not intend to meet and explaining why the facility does not intend to meet it. A hospital organization may develop an implementation strategy in collaboration with other organizations, which must be identified in the implementation strategy. As with the CHNA, a hospital organization that operates multiple hospital facilities must have a separate written implementation strategy for each of its facilities.

Great emphasis has been given to work hand-in-hand with leaders from hospitals, the state health department and the local health department. A common approach has been adopted to create the CHNA, leading to aligned implementation plans and community reporting.

10 IRS Notice 2011-52 Overview Notice and Request for Comments Regarding the Community Health Needs Assessment Requirements for Tax-exempt Hospitals

Applicability of CHNA Requirements to “Hospital Organizations”

The CHNA requirements apply to “hospital organizations,” which are defined in Section 501(r) to include (1) organizations that operate one or more state-licensed hospital facilities, and (2) any other organization that the Treasury Secretary determines is providing hospital care as its principal function or basis for exemption.

How and When to Conduct a CHNA

Under Section 501(r), a hospital organization is required to conduct a CHNA for each of its hospital facilities once every three taxable years. The CHNA must take into account input from persons representing the community served by the hospital facility and must be made widely available to the public. The CHNA requirements are effective for taxable years beginning after March 23, 2012. As a result, a hospital organization with a June 30 fiscal year end must conduct an initial CHNA for each of its hospital facilities by June 30, 2013, either during the fiscal year ending June 30, 2015 or during either of the two previous fiscal years.

Determining the Community Served

A CHNA must identify and assess the health needs of the community served by the hospital facility. Although the Notice suggests that geographic location should be the primary basis for defining the community served, it provides that the organization may also take into account the target populations served by the facility (e.g., children, women, or the aged) and/or the facility’s principal functions (e.g., specialty area or targeted disease). A hospital organization, however, will not be permitted to define the community served in a way that would effectively circumvent the CHNA requirements (e.g., by excluding medically underserved populations, low-income persons, minority groups, or those with chronic disease needs).

Persons Representing the Community Served

Section 501(r) provides that a CHNA must take into account input from persons who represent the broad interests of the community served by the hospital facility, including individuals with special knowledge of or expertise in public health. Under the Notice, the persons consulted must also include: (1) government agencies with current information relevant to the health needs of the community and (2) representatives or members of medically underserved, low-income, and minority populations, and populations with chronic disease needs, in the community. In addition, a hospital organization may seek input from other individuals and organizations located in or serving the hospital facility’s defined community (e.g., health care consumer advocates, academic experts, private businesses, health insurance and managed care organizations, etc.).

11 Required Documentation

The Notice provides that a hospital organization will be required to separately document the CHNA for each of its hospital facilities in a written report that includes the following information: 1) a description of the community served by the facility and how the community was determined; 2) a description of the process and methods used to conduct the CHNA; 3) the identity of any and all organizations with which the organization collaborated and third parties that it engaged to assist with the CHNA; 4) a description of how the organization considered the input of persons representing the community (e.g., through meetings, focus groups, interviews, etc.), who those persons are, and their qualifications; 5) a prioritized description of all of the community needs identified by the CHNA and an explanation of the process and criteria used in prioritizing such needs; and 6) a description of the existing health care facilities and other resources within the community available to meet the needs identified through the CHNA.

Making a CHNA Widely Available to the Public

The Notice provides that a CHNA will be considered to be “conducted” in the taxable year that the written report of the CHNA findings is made widely available to the public. The Notice also indicates that the IRS intends to pattern its rules for making a CHNA “widely available to the public” after the rules currently in effect for Forms 990. Accordingly, an organization would make a facility’s written report widely available by posting on its website either (1) the report itself, in a readily accessible format, or (2) a link to another organization’s website, along with instructions for accessing the report on that website. The Notice clarifies that an organization must post the CHNA for each facility until the date on which its subsequent CHNA for that facility is posted.

How and When to Adopt an Implementation Strategy

Section 501(r) requires a hospital organization to adopt an implementation strategy to meet the needs identified through each CHNA. The Notice defines an “implementation strategy” as a written plan that addresses each of the needs identified in a CHNA by either (1) describing how the facility plans to meet the health need, or (2) identifying the health need as one that the facility does not intend to meet and explaining why the facility does not intend to meet it. A hospital organization may develop an implementation strategy in collaboration with other organizations, which must be identified in the implementation strategy. As with the CHNA, a hospital organization that operates multiple hospital facilities must have a separate written implementation strategy for each of its facilities.

Under the Notice, an implementation strategy is considered to be “adopted” on the date the strategy is approved by the organization’s board of directors or by a committee of the board or other parties legally authorized by the board to act on its behalf. Further, the formal adoption of the implementation strategy must occur by the end of the same taxable year in which the written report of the CHNA findings was made available to the public. For hospital organizations with a June 30 fiscal year end, that effectively means that the organization must complete and appropriately post its first CHNA no later than its fiscal year ending June 30, 2013, and formally adopt a related implementation strategy by the end of the same tax year. This final requirement may come as a surprise to many charitable hospitals, considering Section 501(r) contains no deadline for the adoption of the implementation strategy.

12 Year 2015 - IRS and Treasury Finalize Patient Protection Rules for Tax-Exempt Hospitals ACCOUNTING TODAY 1/2/15

The Internal Revenue Service and the Treasury Department have issued final regulations under the Affordable Care Act to protect patients in tax-exempt hospitals from aggressive debt collection practices and to provide other rules for charitable hospitals.

Under the final regulations, each Section 501(c)(3) hospital organization is required to meet four general requirements on a facility-by-facility basis: establish written financial assistance and emergency medical care policies; limit the amounts charged for emergency or other medically necessary care to individuals eligible for assistance under the hospital's financial assistance policy; make reasonable efforts to determine whether an individual is eligible for assistance under the hospital’s financial assistance policy before engaging in extraordinary collection actions against the individual; and conduct a community health needs assessment, or CHNA, and adopt an implementation strategy at least once every three years. The first three requirements are effective for tax years beginning after March 23, 2010 and the CHNA requirements are effective for tax years beginning after March 23, 2012.

The ACA also added a new Section 4959, which imposes an excise tax for failure to meet the CHNA requirements, and added reporting requirements. These final regulations provide guidance on the entities that must meet these requirements, the reporting obligations relating to these requirements and the consequences for failing to satisfy the requirements. “Charitable hospitals represent more than half of the nation’s hospitals and play a key role in improving the health of the communities they serve,” wrote Emily McMahon, Deputy Assistant Secretary for Tax Policy at the U.S. Department of the Treasury, in a blog post Monday explaining the requirements. “But reports that some charitable hospitals have used aggressive debt collection practices, including allowing debt collectors to pursue collections in emergency rooms, have highlighted the need for clear rules to protect patients. For hospitals to be tax-exempt, they should be held to a higher standard. That is why the Affordable Care Act included additional consumer protection requirements for charitable hospitals, so that patients are protected from abusive collections practices and have access to information about financial assistance at all tax-exempt hospitals.” She noted that as a condition of their tax-exempt status, charitable hospitals must take an active role in improving the health of the communities they serve, establish billing and collections protections for patients eligible for financial assistance, and provide patients with the information they need to apply for such assistance. “These final rules adopt the same framework of proposed regulations but simplify the compliance process for charitable hospitals, while continuing to provide meaningful guidance on protections for patients and requirements to assess community health needs,” she added.

13 Under the new rules, hospitals cannot charge individuals eligible for financial assistance more for emergency or other medically necessary care than the amounts generally billed to patients with insurance (including Medicare, Medicaid, or private commercial insurance). In addition, every tax-exempt hospital must establish and widely publicize a financial assistance policy that clearly describes to patients the eligibility criteria for obtaining financial assistance and the method for applying for financial assistance.

Charitable hospitals are also prohibited from engaging in certain collection methods (for example, reporting a debt to a credit agency or garnishing wages) until they make reasonable efforts to determine whether an individual is eligible for assistance under the hospital’s financial assistance policy.

In addition, each charitable hospital need to conduct and publish a community health needs assessment at least once every three years and disclose on the tax form that it files on an annual basis the steps it is taking to address the health needs identified in the assessment.

Many of the requirements have been in place since the Affordable Care Act passed in 2010, but in response to comments on the proposed regulations, the final rules also expand access to translations for patients, by lowering the threshold for having translations of financial assistance policies available from 10 percent of the community served as proposed, to five percent of the community served or population expected to be encountered by the hospital facility, or 1000 persons, whichever is less, according to McMahon. “The final rules also revise the notification requirements to maintain important protections for patients while making it easier for hospitals to comply with them,” she wrote. “General notifications regarding a hospital’s financial assistance policy must appear on bills and in the hospital. However, individual written and oral notifications of the hospital’s financial assistance policy are now only required when a hospital plans to use extraordinary collections actions, such as reporting a debt to a credit bureau, selling the debt to a third party or garnishing wages.”

While charitable hospitals must continue to make a good-faith effort to comply, the rules provide charitable hospitals with time to fully update their policies and programming to implement the changes. But if a charitable hospital fails to meet the consumer protection provisions required by the law, the hospital could have its tax-exempt status revoked. If a hospital fails to properly conduct a community health needs assessment or adopt an implementation strategy, an excise tax will apply, McMahon noted. “However, if a hospital fails to meet a requirement, but the failure is neither willful nor egregious, the hospital can correct and publicly disclose the error to have it excused, thus avoiding revocation of tax-exempt status, but the excise tax would still apply,” she wrote.

14 II. Methodology b) Collaborating CHNA Parties

Working together to improve community health takes collaboration. Listed below is an in-depth profile of the local hospital and health department CHNA partners:

Mercy Medical Center—Centerville Profile

1 Old Hwy 5, Centerville, IA 52544 CEO: Clint Christianson

About Us: Mercy Medical Center has served Centerville and Appanoose County for over 100 years. The hospital, community, and healthcare have all changed radically since 1910 when the Sisters of Mercy began their ministry here. The hospital has changed physical locations twice.

Our current technologies such as surgical lasers, color flow Doppler ultrasound, C.T., MRI, laparoscopic surgery, P.E.T. scans and telemedicine existed only in the minds of science fiction writers of the day.

But with regard to healthcare in our area, there are things that haven't changed. The vision of Catherine McAuley and her Sisters of Mercy has not wavered in Centerville. Although the faces have changed and the numbers have increased, the compassion, excellence, and dedication of the doctors and hospital employees has been as constant as the daily rising of the sun.

All of us at Mercy Medical Center - Centerville are privileged to be in the position of serving in a ministry of healing. The author Julianna Casey noted that healthcare is about people who are vulnerable and anxious interacting with people who seek to alleviate suffering, to heal, and to accompany others in their struggles. In all of Mercy Medical Center's endeavors beginning with wellness/health promotion and ending with faith based hospice services, it is our Mission to promote the well-being of people in the communities we serve by living the values that define and guide all of our actions.

We know you will find our web site information interesting. In our hospital we foster a commitment to continuous quality improvement. Please help us in that endeavor by using the e-mail connection located in the site to contact us with comments, questions, and suggestions.

Thank you for allowing us to serve you.

Our Mission: The mission of Mercy Medical Center - Centerville and Catholic Health Initiatives is to nurture the healing ministry of the Church by bringing it new life, energy, and viability in the 21st century.

Fidelity to the Gospel urges us to emphasize human dignity and social justice as we move toward the creation of healthier communities.

15 Our Vision:

x REVERENCE - Profound spirit of awe and respect for all of creation, shaping relationships to self, to one another and to God, and acknowledging that we hold in trust all that has been given to us. x INTEGRITY - Moral wholeness, soundness, uprightness, honesty, sincerity, as a basis of trustworthiness. x COMPASSION - Feeling with others, begin one with others in their sorrows and joy, rooted in the sense of solidarity as members of the human community. x EXCELLENCE - Outstanding achievement, merit virtue; continually surpassing standards to achieve/maintain quality.

Mercy Medical Center—Centerville offers the following services: x Anesthesia x Outpatient Infusion x Cancer Care x Radiology (Imaging) x Cline Family Dialysis x Rehabilitation Services x Clinic x Respiratory Therapy x Diabetes Education x Senior Life Solutions x Emergency Room x SHIIP x Gift Shop x Sleep Studies x Health Coach Service x Special Care Unit x Laboratory x Specialist Clinic x Long Term Care x Surgery x Medical/Surgical Unit x Web Nursery x Nutrition Services x Obstetrics

16 Appanoose County Public Health

209 E Jackson St, Centerville, IA 52544

Our Mission: As public health professionals, we strive to promote physical and mental health and prevent disease, injury, and disability.

We protect and improve the health of individuals, families, and our community.

Our Services: x Skilled Nursing x Family Planning/Birth Control x IDSS-Iowa Disease Surveillance Services System x HAWKI Enrollment x VFC Program-Vaccines for Children x WIC Program x School/Licensed Day Care x Maternal Health Screening Immunization Audit Screenings x Lead testing x Flu Clinic x I-Smile x Health Education/Promotion x WIC/Maternal and Child Health x Adult Immunizations Clinics x Blood Pressure Screening Clinics x Presumptive Eligibility x Child Health Screening Services

17 II. Methodology b) Collaborating CHNA Parties Continued

Consultant Qualifications

VVV Consultants LLC Company Profile: 601 N. Mahaffie, Olathe, KS 66061 (913) 302-7264

VINCE VANDEHAAR, MBA Principal Consultant and Owner of VVV Consultants LLC VVV Consultants LLC was incorporated on May 28th, 2009. With over 30 years of business and faculty experience in helping providers, payors and financial service firms obtain their strategic planning and research and development needs, Vince brings in-depth health industry knowledge, research aptitude, planning expertise and energy. VVV Consultants LLC services are organized, formal processes of listening to the voice of the customer. Vince started his consulting business after working for Saint Luke’s Health System (SLHS) of Kansas City for 16 years. (Note: Saint Luke’s Hospital of Kansas City, SLHS’s largest hospital, won the Malcolm Baldrige National Quality Award in March of 2003. The Baldrige examiners cited Vince’s department as “Best Practice” in the areas of customer satisfaction, market research and evaluation efforts ).

VVV Consultants LLC consultants have in-depth experience helping hospitals work with local health departments to engage community residents and leaders to identify gaps between existing health community resources and needs and construct detailed strategies to meet those needs, while still adhering to the hospital’s mission and budget. Over the past 20 years, Vandehaar has completed eight comprehensive Baldrige aligned Community Health Needs Assessments for Saint Luke’s of Kansas City System facilities (3 campuses) and was contracted to conduct two additional independent department of health consulting projects (prior to IRS 990 regs). To date, VVV has completed 55 CHNA IRS-aligned assessments for Iowa, Kansas, Missouri and Nebraska hospitals and health departments.

Vince Vandehaar, MBA is actively involved in the Kansas City community. He is a member the Greater Kansas City Employee Benefits Association, the Society for Healthcare Strategy and Market Development, the American Marketing Association Kansas City Chapter and Co-Chair of the AMA Kansas City Healthcare Special Interest Group. In addition to these roles, from 2000 to 2008, Vince served as the state chairman for MHA’s Data Committee and was a member of KHA’s Data Taskforce.

Collaborating Consultants

Alexa Backman, MBA - VVV Consultants LLC Associate Consultant

18 II. Methodology c) CHNA and Town Hall Research Process

Mercy Medical Center—Centerville’s Community Health Needs Assessment (CHNA) process began in late October 2015. At that time, an inquiry was made by Ann Young, Vice President-Mercy Experience, to VVV Consultants LLC to explore the possibility of conducting a comprehensive IRS-aligned CHNA. VVV Consultants LLC then reviewed CHNA experience, in-depth CHNA requirements and regulations, CHNA development options to meet IRS requirements and next steps after option approval.

VVV CHNA Deliverables:

z Uncover / document basic secondary research and health of county, organized by 10 TABS. z Conduct Town Hall meeting to discuss secondary data and uncover / prioritize county health needs. z Conduct and report CHNA primary research. z Prepare and publish IRS-aligned CHNA report that meets requirements.

19 Mercy Medical Center-Centerville CHNA Work Plan Project Timeline and Roles 2016 Step Date (Start-Finish) Lead Task 1 10/28/2015 VVV Sent VVV quote for review. 2 11/9/2015 Client Select CHNA Option C. Approve to start work 1/15/16. Send out REQCommInvite Excelfile. Hospital andhealthdepartment to fill in primary service area stakeholders names, addresses and e- 3 1/25/2016 VVV mails. Request clienttosend IHA PO101, 102 and PO103 reports to document service area for FFY 12, 13 and 14. In addition, request client to complete three year historical PSA IP/OP/ER/Clinic patient 4 1/25/2016 VVV origin file (Use ZipPSA_3yrPOrigin.xls). Prepare CHNA Option C stakeholder feedback online link.Send text 5 On or before 1/25/2016 VVV link for client review. VVV / Prepare and send out PR story to local media announcing upcoming 6 On or before 1/25/2016 Client CHNA work. Client to place. Launch and conduct online surveytostakeholders. Client will e-mail 7 2/5/2016 VVV invite to participate to all stakeholders. VVV / Prepare and send outPRstoryto local mediaannouncing online 8 2/5/2016 Client CHNA stakeholder feedback survey. Request public to participate. Assembleand completesecondary research. Find andpopulate 10 9 On or before 2/19/2016 VVV tabs. Create Town Hall PowerPoint for presentation. Prepare and send out community Town Hall invite letter andplace 10 2/19/2016 Client local advertisement. VVV / Prepare and send out PR story to local media announcing upcoming 11 2/19/2016 Client Town Hall. VVV will mock up PR release to media sources. VVV/ Conduct conference call (time TBD) with client andhealth 12 On or before 2/29/2016 Client department to review Town Hall data and flow. Conduct CHNA Town Hall from 11:30a.m.-1:00p.m. at the Majestic Theater. Review and discuss basic health data plus rank health 13 3/15/2016 VVV needs. Complete analysis. Release draftoneand seekfeedbackfrom client 14 On or before 4/30/2016 VVV leaderes and health department. 15 On or before 5/15/2016 VVV Produce and release final CHNA report. Client will post CHNA online. Conduct client Implementation Plan primary service area leadership 16 On or before 5/31/2016 Client meeting. 30 days prior toend of Hold board meetings to discuss CHNA needsand createand adopt 17 client fiscal year Client an Implementation Plan. Communicate CHNA plan to community.

20 To meet IRS CHNA requirements, a four-phase methodology was reviewed and approved as follows:

Phase I—Discovery:

Conduct a 30-minute conference call with the CHNA hospital client and county health department. Review / confirm CHNA calendar of events, explain / coach client to complete required participant database and schedule / organize all Phase II activities.

Phase II—Qualify Community Need:

A) Conduct secondary research to uncover the following historical community health status for the primary service area. Use Iowa Hospital Association (IHA), Vital Statistics, Robert Wood Johnson County Health Rankings, etc. to document current state of county health organized as follows:

TAB 1. Demographic Profile TAB 2. Economic/Business Profile TAB 3. Educational Profile TAB 4. Maternal and Infant Health Profile TAB 5. Hospitalization / Providers Profile TAB 6. Behavioral Health Profile TAB 7. Risk Indicators & Factors TAB 8. Uninsured Profile TAB 9. Mortality Profile TAB 10. Preventative Quality Measures

B) Gather historical primary research to uncover public health needs, practices and perceptions for hospital primary service areas.

Phase III—Quantify Community Need:

Conduct a 90-minute Town Hall meeting with required county primary service area residents. At each Town Hall meeting, CHNA secondary data will be reviewed, facilitated group discussion will occur and a group ranking activity to determine the most important community health needs will be administered.

Phase IV—Complete Data Analysis and Create Comprehensive Community Health Needs Assessment:

Post CHNA report findings to meet IRS-aligned CHNA criteria.

After consideration of CHNA stakeholders (sponsoring hospital and local health department), the CHNA Option C was selected with the following project schedule: Phase I: Discovery…………………………………………………………… January 2016 Phase II: Secondary / Primary Research……………………………… February 2016 Phase III: Town Hall Meeting.……………………………………..…….. March 15th,2016 Phase IV: Prepare / Release CHNA report………………………..….. May 2016

21 Detail CHNA Development Steps Include:

Steps to Conduct Community Health Needs Assessment

Development Steps Determine interest level of area healthcare leaders Step # 1 Commitment (Hospital, Health Dept, Mental Health Centers, Schools, Churches, Physicians etc), hold community meeting.

Prepare brief Community Health Needs Assessment Plan - list goals, objectives, purpose, outcome, roles, Step # 2 Planning community involvement, etc. Hold Community Kick-off meeting.

Collect & Report Community Health Published Facts. Gather data health practice data from published Step # 3 Secondary Research secondary research sources i.e. census, county health records, behavioral risk factors surveillance, etc.

Conduct Community Roundtable (Qualitative Research). Review Secondary Research (Step3) with Community Step # 4a Primary Research Stakeholders. Gather current opinions and identify health needs.

Collect Community Opinions. (Quantitative Research). Gather current opinions (Valid sample size) regarding Step # 4b Primary Research community health needs and healthcare practices. If appropriate, conduct Physician Manpower Assessment to determine FTE Physician need by specialty.

Prepare/Present comprehensive Community Health Needs Assessment report (to community leaders) with Steps # 5 Reporting Recommended Actions to improve health .

VVV Research & Development, LLC 913 302-7264

22 Overview of Town Hall Community Priority Setting Process

Each community has a wealth of expertise to be tapped for CHNA development. For this reason, a Town Hall is the perfect forum to gather community insight and provide an atmosphere to objectively consensus build and prioritize county health issues.

All Town Hall priority-setting and scoring processes involve the input of key stakeholders in attendance. Individuals and organizations attending the Town Halls were critically important to the success of the CHNA. The following list outlines partners invited to Town Hall: local hospital, public health community, mental health community, free clinics, community- based clinics, service providers, local residents, community leaders, opinion leaders, school leaders, business leaders, local government, faith-based organizations and persons (or organizations serving them), people with chronic conditions, uninsured community members, low income residents and minority groups.

Mercy Medical Center—Centerville’s Town Hall was held on Tuesday, March 15th,2016atthe Majestic Theater. Vince Vandehaar and Alexa Backman facilitated this 1 ½ hour session with fifty-seven (57) attendees. (Note: a detailed roster of Town Hall attendees is listed in Section V a).

The following Town Hall agenda was conducted: 1. Welcome and introductions. 2. Review purpose for the CHNA Town Hall and roles in the process. 3. Presentation/review of historical county health indicators (10 tabs). 4. Facilitate Town Hall participant discussion of data (probe health strengths/concerns). Reflect on size and seriousness of any health concerns sited and discuss current community health strengths. 5. Engage Town Hall participants to rank health needs (using four dots to cast votes on priority issues). Tally and rank top community health concerns cited. 6. Close meeting by reflecting on the health needs/community voting results. Inform participants on next steps. At the end of each Town Hall session, VVV encouraged all community members to continue to contribute ideas to both hospital and health department leaders via e-mail or personal conversations.

(NOTE: To review detail Town Hall discussion content, please turn to Section V for detailed notes of session and activity card content reporting of open-end comments).

23 II. Methodology d) Community Profile (A Description of Community Served)

Appanoose County, IA Community Profile

Demographics

The population of Appanoose County was estimated to be 12,529 on July 1, 2015 and had a -2.8% change in population from April 1, 2010–July 1, 2015.1 Its county seat is Centerville, IA. According to the U.S. Census Bureau, the county has a total area of 516 square miles, of which 497 square miles is land and 19 square miles is water. Rathbun Reservoir, created by damming the Chariton River, is its main physical feature.2 Appanoose County’s population density is 26 persons per square mile and its industries providing employment are Agriculture (forestry, fishing and hunting and mining) (37.0%), Construction (21.3%) and Educational (health and social services) (15.4%).3

The major highway transportation is by Iowa Highway 2, Iowa Highway 5 and Iowa Highway 202.4

1 http://www.census.gov/quickfacts/table/PST045215/19007 2 U.S. Census Bureau 3 http://www.city-data.com/county/Appanoose_County-IA.html 4 U.S. Census Bureau

24 Appanoose County Detail Demographic Profile Population Households HH Per Capita ZIP NAME County YR 2014 YR2019Chg YR 2014 YR 2019 Avg Size Income 14 52544 Centerville APPANOOSE 7,696 7,545 -2.0% 3,418 3,362 2.2 $23,082 52549 Cincinnati APPANOOSE 743 728 -2.0% 292 287 2.5 $19,355 52555 Exline APPANOOSE 327 327 0.0% 143 144 2.3 $23,707 52571 Moravia APPANOOSE 1,402 1,380 -1.6% 623 615 2.3 $23,415 52572 Moulton APPANOOSE 1,129 1,113 -1.4% 480 474 2.4 $21,436 52574 Mystic APPANOOSE 936 949 1.4% 392 400 2.4 $20,869 52581 Plano APPANOOSE 283 283 0.0% 135 135 2.1 $28,110 52593 Udell APPANOOSE 125 125 0.0% 53 53 2.4 $26,015 52594 Unionville APPANOOSE 381 391 2.6% 169 174 2.3 $27,855 Totals 13,022 12,841 -3.0% 5,705 5,644 2.3 $23,760

Population YR 2014 Females ZIP NAME County YR 2014 Pop65+ Kids<18 GenY Males Females Age20_35 52544 Centerville APPANOOSE 7,696 1,644 1,825 2,124 3,703 3,993 666 52549 Cincinnati APPANOOSE 743 145 184 194 384 359 57 52555 Exline APPANOOSE 327 65 83 76 170 157 23 52571 Moravia APPANOOSE 1,402 319 315 344 690 712 104 52572 Moulton APPANOOSE 1,129 255 290 277 559 570 88 52574 Mystic APPANOOSE 936 198 197 256 466 470 72 52581 Plano APPANOOSE 283 72 54 63 144 139 17 52593 Udell APPANOOSE 125 25 27 29 64 61 10 52594 Unionville APPANOOSE 381 70 104 93 192 189 30 Totals 13,022 2,793 3,079 3,456 6,372 6,650 1,067

Population Aver HH ZIP NAME County White Black Amer In Hisp HH Inc 14 YR 2014 HH $50K+ 52544 Centerville APPANOOSE 7,406 68 27 153 $51,663 3,418 1,191 52549 Cincinnati APPANOOSE 725 0 3 6 $49,249 292 99 52555 Exline APPANOOSE 311 0 1 4 $54,212 143 56 52571 Moravia APPANOOSE 1,375 4 1 19 $52,694 623 243 52572 Moulton APPANOOSE 1,100 0 3 10 $50,418 480 189 52574 Mystic APPANOOSE 917 8 0 15 $49,829 392 141 52581 Plano APPANOOSE 279 1 0 4 $58,927 135 54 52593 Udell APPANOOSE 124 0 0 1 $61,357 53 24 52594 Unionville APPANOOSE 375 0 0 4 $62,798 169 77 Totals 12,612 81 35 216 $54,572 5,705 2,074 Source: ERSA Demographics

25 III. Community Health Status

[VVV Consultants LLC]

26 III. Community Health Status a) Historical Health Statistics

Health Status Profile

This section of the CHNA reviews published quantitative community health indicators and results of our recent CHNA Town Hall. To produce this profile, VVV Consultants LLC staff analyzed data from multiple sources. This analysis focuses on a set of published health indicators organized by ten areas of focus (10 tabs), results from the 2015 County Health Rankings and conversations from Town Hall primary research. Each table reflects a Trend column, with GREEN denoting growing/high performance indicators, YELLOW denoting minimal change/average performance indicators and RED denoting declining/low performance indicators.

27 Secondary Research

2015 State Health Rankings for Appanoose County, IA

Appanoose IA Rural # IA Rank of 99 Counties Definitions County TREND Norm (14) 1 Physical Environment Environmental quality 21 41 2 Health Factors 98 54 Access to care / Quality of 86 64 2a Clinical Care Care Education, Employment, Income, Family/Social 98 50 support, Community 2b Social & Economic Factors Safety 3HealthOutcomes 99 59 Tobacco Use, Diet/Exercise, Alcohol Use, 95 52 3a Health Behaviors Sexual Activitiy 3b Morbidity Quality of life 99 49 3c Mortality Length of life 94 62 http://www.countyhealthrankings.org, released 2015 Iowa Rural Norm N=14 includes the following counties: Page, Fremont, Ida, Sac, Davis, Appanoose, Marion, Poweshiek, Tama, Madison, Ringgold, Caroll, Lucas and Clayton.

When considering the state of community health, it’s important to review published health data by topic area. Below is a summary of key tabs of information collected:

Tab 1 Demographic Profile

Appanoose State of Rural Tab Health Indicator County Trend Iowa Norm Source

1a a Population, 2014 Estimate 12,661 3,107,126 14,153 People Quick Facts

1a b Population, % Change - April 1, 2010 to July 1, 2014 -1.8% 2.0% -1.7% People Quick Facts

1a c Population, 2010 12,887 3,046,355 14,364 People Quick Facts

1a d Persons Under 5 years, Percent, 2014 6.0% 6.3% 6.0% People Quick Facts

1a e Persons Under 18 years, Percent, 2014 22.4% 23.4% 23.4% People Quick Facts

1a f Persons 65 Years and Over, Percent, 2014 21.4% 15.8% 20.2% People Quick Facts

1a g Female Persons, Percent, 2014 50.6% 50.3% 50.3% People Quick Facts

1a h White Alone, Percent, 2014 97.4% 92.1% 96.6% People Quick Facts

1a i Black or African American Alone, Percent, 2014 0.7% 3.4% 0.7% People Quick Facts

1a j Hispanic or Latino, Percent, 2014 1.5% 5.6% 2.5% People Quick Facts

1a k Foreign Born Persons, Percent, 2009-2013 1.0% 4.5% 1.8% People Quick Facts Language Other than English Spoken at Home, Pct Age 1a l 5+, 2009-2013 2.3% 7.2% 5.2% People Quick Facts

1a m Living in Same House 1 Year & Over, Percent, 2009-2013 86.6% 84.8% 87.5% People Quick Facts

28 Tab 1 Demographic Profile

Appanoose State of Rural Tab Health Indicator County Trend Iowa Norm Source

1b a Veterans, 2009-2013 1,045 226,175 1,173 People Quick Facts

1b b Persons per Square Mile, 2010 25.9 54.5 25.5 Geography Quick Facts

1b c Children in Single-Parent Households, 2015 33.0% 29.0% 25.9% County Health Rankings

1b d Poverty Levels, 2011 16.3% 12.7% 12.7% Iowa Health Fact Book

1b e Limited Access to Healthy Foods, 2015 6.0% 6.0% 5.9% County Health Rankings

U.S. Department of Agriculture - 1b f People 65+ with Low Access to a Grocery Store, 2010 3.2% 3.6% 3.3% Food Environment Atlas

1b g Voter Turnout, 2012 48.5% 53.3% 53.6% Iowa Secretary of State

Tab 2 Economic Profile

Appanoose State of Rural Tab Health Indicator County Trend Iowa Norm Source Per Capita Money Income in Past 12 Months (2013 2adollars), 2009-2013 $21,599 $27,027 $24,657 People Quick Facts

2 b Housing Units in Multi-Unit Structures, Percent, 2009-2013 12.0% 18.4% 10.5% People Quick Facts

2 c Persons per Household, 2009-2013 2.3 2.4 2.4 People Quick Facts

2dSevere Housing Problems, 2015 13.0% 12.0% 10.6% County Health Rankings

2 e Retail Sales per Capita, 2007 $10,331 $13,172 $10,006 Business Quick Facts

2 f Total Number of Firms, 2007 1,428 259,931 1,421 Business Quick Facts

2gUnemployment, 2015 6.4% 4.6% 4.8% County Health Rankings

2 h Child Food Insecurity Rate, 2013 14.4% 12.6% 12.4% Feeding America U.S. Department of Agriculture - 2 i Grocery stores / 1,000 pop, 2012 0.4 0.3 0.3 Food Environment Atlas U.S. Department of Agriculture - 2 j Low-Income and Low Access to a Grocery Store, 2010 3.2% 3.6% 3.3% Food Environment Atlas U.S. Department of Agriculture - 2 k SNAP participants (% eligible pop), 2010* 88.0% 88.0% 88.0% Food Environment Atlas Mean Travel Time to Work (Minutes), Workers Age 16+, 2l2009-2013 19.0 18.8 19.8 People Quick Facts

2mLong Commute - Driving Alone, 2009-2013 20.0% 19.0% 24.9% County Health Rankings

29 Tab 3 Public Schools Health Delivery Profile

Currently, school districts are providing on-site primary health screenings and basic care.

Appanoose State of Rural Tab Health Indicator County Trend Iowa Norm Source

U.S. Department of Agriculture - 3 a Students Eligible for Free Lunch (%), 2010 35.7% 30.0% 29.4% Food Environment Atlas

3 e 4-Year High School Graduation Rates, 2011-2012 123 30,357 145 Iowa Health Fact Book Bachelor's Degree or Higher, Percent of Persons Age 25+, 3f2009-2013 18.3% 25.7% 18.7% People Quick Facts

Tab 3 Public Schools Health Delivery Profile

# CHNA 2016 Indicators Centerville Moulton 1 Total Public School Nurses 1.7 (3 afternoons/week, one nurse working) 1 2 School Nurse is part of the IEP Team Yes Yes 3 Active School Wellness Plan Yes, committee chaired by administrator meets 1-2x per year Yes VISION: # Screened / Referred to Prof 4 PK: 41/4/1, K-1: 13/6/2 (Iowa Kid None (will be done this / Seen by Professional Sight/Local Lions Club) month) HEARING: # Screened / Referred to 5 PK+7-12: 172/4, K-6: 13/7 85 screened, 1 referred Prof / Seen by Professional (Great Prairie AEA) (HS,K,1,2,4,5&6) 9th: 80/93 screened, 37 referred ORAL HEALTH: # Screened / Referred K: 103/34/NA (I-Smile Program 6 to Prof / Seen by Professional provided fluoride brush & dental 13/31 screened by prof (K sealants to 325) &9th) Not a requirement since 2004. No SCOLIOSIS: # Screened / Referred to 7 longer recommended by USPSTF Prof / Seen by Professional or school health officials. 0 Students Served with No Identified 8 PK: 49, K-6: 653, 7-8: 183, 9-12: Chronic Health Concerns 312 233/241 School has a Suicide Prevention MH counseling services and crisis 9 intervention available through Program CHCSI. Yes Compliance on Required 10 PL: 98%, K-6: 96%, 7-8: 99%, 9-12: Vaccinations 99.9% 94%

30 TAB 4 Maternal and Infant Health Profile

Tracking maternal and infant care patterns are vital in understanding the foundation of family health.

Appanoose State of Rural Tab Health Indicator County Trend Iowa Norm Source Mothers Who Began Prenatal Care in First Trimester, 2010- 4a2011 242 62,857 253 Iowa Health Fact Book Iowa Department of Health and 4 b Annual Birth Outcome % Preterm, 2014 9.2% 7.3% 8.3% Environment

4 c Low Birth Weight (<2500 Grams), 2010-2011 21 NA 21 Iowa Health Fact Book

4 d Mothers Who Smoked During Pregnancy, 2010-2011 80 12,398 62 Iowa Health Fact Book

4 e Mothers under Age 20, 2010-2011 36 5,763 28 Iowa Health Fact Book

4fOut-of-Wedlock Births, 2010-2011 131 26,106 104 Iowa Health Fact Book

TAB 4 Maternal and Infant Health Profile

Appanoose State of Tab Vital Satistics Trend County Iow a 4aTotal Live Births, 2010-2011 310 76,718 4aTotal Live Births, 2012-2013 299 77,699

TAB 5 Hospitalization/Provider Profile

Understanding provider access and disease patterns are fundamental in healthcare delivery. Listed below are several vital county statistics.

Appanoose State of Rural Tab Health Indicator County Trend Iowa Norm Source

5aPrimary Care Physicians per 1, 2015 1270 1,375 1,987 County Health Rankings

5bPreventable Hospital Stays, 2015 65 56 65 County Health Rankings

Patients Who Gave Their Hospital a Rating of 9 or 10 on a CMS Hospital Compare, 1/1/14- 5cScale from 0 (Lowest) to 10 (Highest) 72.0% 76.0% 74.3% 12/31/14 Patients Who Reported Yes, They Would Definitely CMS Hospital Compare, 1/1/14- 5dRecommend the Hospital 63.0% 75.0% 72.6% 12/31/14 Average Time Patients Spent in the Emergency Department Before They Were Seen by a Healthcare CMS Hospital Compare, 1/1/14- 5eProfessional NA 26 29 12/31/14 Medicare Hospital Spending per Patient (Medicare CMS Hospital Compare, 1/1/14- 5fSpending per Beneficiary) NA $0.92 $0.85 12/31/14

31 TAB 5 Hospitalization/Provider Profile

Appanoose County # IA Hospital Association PO103 FFY2013 FFY2014 FFY2015p TREND 1 Total Discharges 1,792 1,738 1,776 2 Total IP Discharges-Age 0-17 Ped 216 251 286 3 Total IP Discharges-Age 18-44 310 294 304 4 Total IP Discharges-Age 45-64 382 389 398 5 Total IP Discharges-Age 65-74 330 282 270 6 Total IP Discharges-Age 75+ 554 522 518 Mercy Medical Center-Centerville # IA Hospital Association PO103 FFY2013 FFY2014 FFY2015p TREND 1 Total Discharges 797 703 748 2 Total IP Discharges-Age 0-17 Ped 93 119 148 3 Total IP Discharges-Age 18-44 97 87 104 4 Total IP Discharges-Age 45-64 119 118 114 5 Total IP Discharges-Age 65-74 152 92 84 6 Total IP Discharges-Age 75+ 336 287 298

*FFY2015 has been prorated based on 2Q of data

Mercy Medical Center-Centerville # Internal Records FFY2013 FFY2014 FFY2015p TREND 1 ER Visits 6,975 6,393 7,049 2 OP Visits 60,663 57,071 61,382 3 Clinic Visits 15,818 14,618 15,030

TAB 6 Social & Rehab Services Profile

Behavioral healthcare provides another important indicator of community health status.

Appanoose State of Rural Tab Health Indicator County Trend Iowa Norm Source

Centers for Medicare and 6 a Depression: Medicare Population, 2012 15.4% 14.9% 14.0% Medicaid Services Alcohol-Impaired Driving Deaths, 2015 (3 of 6 Total Driving 6bDeaths) 18.0% 23.0% 22.9% County Health Rankings

6dPoor Mental Health Days, 2015 3.3 2.6 2.7 County Health Rankings

32 TAB7HealthRiskProfiles

Knowing community health risk factors and disease patterns can aid in the understanding next steps to improve health. Being overweight / obese; smoking, drinking in excess, not exercising, etc. can lead to poor health.

Appanoose State of Rural Tab Health Indicator County Trend Iowa Norm Source

7a a Adult Obesity, 2015 30.0% 30.0% 31.0% County Health Rankings

7a b Adult Smoking, 2015 28.0% 18.0% 19.0% County Health Rankings

7a c Excessive Drinking, 2015 23.0% 20.0% 19.8% County Health Rankings

7a f Physical Inactivity, 2015 31.0% 24.0% 26.4% County Health Rankings

7a g Poor Physical Health Days, 2015 5.4 2.8 2.9 County Health Rankings

7a h Sexually Transmitted Infections, 2015 181 370 226 County Health Rankings

TAB7HealthRiskProfiles

Appanoose State of Rural Tab Health Indicator County Trend Iowa Norm Source

Centers for Medicare and 7b a Hypertension: Medicare Population, 2012 57.6% 51.2% 52.8% Medicaid Services Centers for Medicare and 7b b Hyperlipidemia: Medicare Population, 2012 40.3% 40.2% 41.0% Medicaid Services Centers for Medicare and 7b c Heart Failure: Medicare Population, 2012 16.7% 12.8% 14.0% Medicaid Services Centers for Medicare and 7b d Chronic Kidney Disease: Medicare Population, 2012 16.2% 13.4% 13.7% Medicaid Services Centers for Medicare and 7b e COPD: Medicare Population, 2012 15.2% 10.5% 11.0% Medicaid Services Centers for Medicare and 7b f Atrial Fibrillation: Medicare Population, 2012 6.8% 8.6% 8.8% Medicaid Services Centers for Medicare and 7b g Cancer: Medicare Population, 2012 6.3% 7.3% 7.4% Medicaid Services Centers for Medicare and 7b h Osteoporosis: Medicare Population, 2012 3.0% 5.4% 5.9% Medicaid Services Centers for Medicare and 7b i Asthma: Medicare Population, 2012 3.7% 3.5% 2.7% Medicaid Services Centers for Medicare and 7b j Stroke: Medicare Population, 2012 2.2% 2.6% 2.6% Medicaid Services

33 TAB 8 Uninsured Profiles Based on state estimations, the number of insured is documented below. Also, the amount of charity care (last three years of free care) from area providers is trended below.

Appanoose State of Rural Tab Health Indicator County Trend Iowa Norm Source

8aUninsured (Under 65), 2010 12.7% 10.7% 12.0% Iowa Health Fact Book

TAB 8 Uninsured Profiles

# MercyMedical Center - Centerville YR13 YR14 YR15 TREND

1 BadDebt- Write off $2,263,311 $1,899,865 $1,251,196

2 Charity Care - Free Care Given $558,372 $454,606 $416,430

TAB 9 Mortality Profile

The leading causes of county deaths are listed below. Areas of higher than expected are so noted.

Appanoose State of Rural Tab Health Indicator County Trend Iowa Norm Source

Institute for Health Metrics and 9aLifeExpectancy for Females, 2009 80.3 82.0 81.3 Evaluation Institute for Health Metrics and 9 b Life Expectancy for Males, 2009 75.2 77.3 76.4 Evaluation

9 c Infant Deaths, 2007-2011 NA 998 9 Iowa Health Fact Book

9 d Heart Disease Mortality, 2006-2010 370 35154 215 Iowa Health Fact Book Chronic Obstructive Pulmonary Disease Mortality, 2006- 9e2010 28 NA 46 Iowa Health Fact Book

9fSuicides, 2007-2011 11 1843 12 Iowa Health Fact Book

34 TAB 9 Mortality Profile

Causes of Death by County of Residence, Appanoose State of # Trend % % Iowa Health Fact Book 2013 County Iowa All Causes 916 100.0% 138,412 100.0% 1 Heart Disease 15.0% 370 40.4% 35,154 25.4% 2 All Cancer 0.8% 218 23.8% 31,766 23.0% 3 LungCancer 0.5% 63 6.9% 8,838 6.4% 4 Stroke 4.1% 47 5.1% 1,422 1.0% 5 Accidents and Adverse Effects -0.6% 36 3.9% 6,233 4.5% 6 Chronic Obstructive Pulmonary Disease 1.7% 28 3.1% 1,824 1.3% 7 Diabetes Mellitus 0.2% 27 2.9% 3,770 2.7%

TAB10PreventiveHealthProfile

The following table reflects future health of the county. This information also is an indicator of community awareness of preventative measures.

Appanoose State of Rural Tab Health Indicator County Trend Iowa Norm Source

10 a Access to Exercise Opportunities, 2015 68.0% 79.0% 69.9% County Health Rankings 2-Year-Old Coverage of Individual Vaccines and Selected 10 b Vaccination Series, 2012 48.0% 71.0% 67.0% Iowa Immunization Program

10 d Diabetic Monitoring, 2015 83.0% 89.0% 88.4% County Health Rankings

10 e Mammography Screening, 2015 60.5% 66.4% 62.9% County Health Rankings

10 f Limitied Access to Healthy Food, 2015 6.0% 6.0% 5.9% County Health Rankings

10 g PercentAnnual Check-Up Visitwith PCP NA NA NA TBD

10 h Percent Annual Check-Up Visit with Dentist NA NA NA TBD

10 i Percent Annual Check-Up Visit with Eye Doctor NA NA NA TBD

35 Community Feedback Research

For a CHNA, it also important to gather community perspective from key stakeholders on their views of progress to address the baseline CHNA needs documented three years ago. Below are findings of this online community primary research:

Question 1—Overall Quality of Healthcare Delivery

Mercy Medical Center - Centerville (Primary Service Area) Appanoose Co, IA N=263 1. Three years ago, a Community Health Needs Assessment was completed. This assessment identified a number of health needs for our community. Today, we are updating this assessment and would like to know how you rate the "Overall Quality" of healthcare delivery in our community? Answer Options VeryGood Good Fair Poor VeryPoor ValidN

Appanoose County N=263 43 138 70 11 1 263 Top 2 Boxes (Very Good / Good) 68.8% Option C Stakeholders Round #2 580 1292 479 65 12 2428 Top 2 Boxes (Very Good / Good) 77.1%

Question 5—Rating of Healthcare Services

Mercy Medical Center - Centerville (Primary Service Area) Appanoose Co, IA N=263

Option C 5. How would our community rate each Stakeholders Appanoose TREND of the following ? Round #2 Bottom Co N=263 2Boxes Ambulance Services 3.7% 2.1% Child Care 15.8% 9.8% Chiropractors 5.5% 1.1% Dentists 15.2% 31.4% Emergency Room 5.7% 10.7% Eye Doctor / Optometrist 8.9% 23.9% Family Planning Services 16.9% 20.7% Home Health 12.2% 8.8% Hospice 7.6% 1.7% Inpatient Services 3.8% 3.2% Mental Health Services 30.8% 31.4% Nursing Home 12.7% 9.0% Outpatient Services 2.9% 4.7% Pharmacy 2.6% 2.2% Primary Care 4.9% 5.8% Public Health Department 4.2% 7.9% School Nurse 7.7% 12.6% Visiting Specialists 7.7% 14.4%

36 Question 7—Healthcare Services Outside of PSA

Mercy Medical Center - Centerville (Primary Service Area) Appanoose Co, IA N=263

7. Over the past 2 years, did you or do Option C you know someone who received Stakeholders Appanoose Co TREND health care services outside of our Round #2 Bottom N=263 community? 2Boxes Yes 79.3% 82.7% No 13.0% 12.9% Don't know 7.7% 4.5% TOTALS 100.0% 100.0%

Question 8—Requested Discussion Items for Town Hall Agenda

Mercy Medical Center - Centerville (Primary Service Area) Appanoose Co, IA N=263

Option C 8. Are there any other health needs Stakeholders Appanoose Co that we need to discuss at our TREND Round #2 Bottom N=263 upcoming CHNA Town Hall meeting? 2 Boxes Abuse / Violence 4.8% 6.0% Alcohol 5.0% 6.1% Cancer 5.4% 4.4% Diabetes 4.9% 4.6% Drugs / Substance Abuse 7.8% 10.8% Family Planning 2.9% 3.8% Heart Disease 3.8% 2.9% Lead Exposure 0.7% 0.5% Mental Illness 7.9% 9.6% Nutrition 5.0% 4.2% Obesity 7.9% 6.4% Ozone 0.8% 0.3% Physical Exercise 5.9% 4.0% Poverty 5.2% 8.5% Respiratory Disease 2.3% 1.7% Sexual Transmitted Diseases 2.2% 2.3% Suicide 4.5% 5.2% Teen Pregnancy 4.0% 3.6% Tobacco Use 4.1% 4.1% Vaccinations 4.4% 2.0% Water Quality 3.2% 1.5% Wellness Education 6.1% 5.8% Some Other Need (please specify below) 1.3% 1.7% TOTAL 100.0% 100.0%

37 IV. Inventory of Community Health Resources

[VVV Consultants LLC]

38 Inventory of Health Services - Appanoose County, IA Cat Healthcare Services OfferedinCounty:Yes/No Hospital Health Dept Other Clinic Primary Care YES NO YES

Hosp Alzheimer Center NO NO YES Hosp Ambulatory Surgery Centers YES NO NO Hosp Arthritis Treatment Center NO NO NO Hosp Bariatric/Weight Control Services NO NO NO Hosp Birthing/LDR/LDRP Room YES NO NO Hosp Breast Cancer YES NO NO Hosp Burn Care NO NO NO Hosp Cardiac Rehabilitation YES NO NO Hosp Cardiac Surgery NO NO NO Hosp Cardiology Services YES NO NO Hosp Case Management YES YES YES Hosp Chaplaincy/Pastoral Care Services YES NO YES Hosp Chemotherapy YES NO NO Hosp Colonoscopy YES NO NO Hosp Crisis Prevention NO NO YES Hosp CTScanner YES NO NO Hosp Diagnostic Radioisotope Facility NO NO NO Hosp Diagnostic/Invasive Catheterization NO NO NO Hosp Electron Beam Computed Tomography (EBCT) NO NO NO Hosp Enrollment Assistance Services YES NO YES Hosp Extracorporeal Shock Wave Lithotripter (ESWL) NO NO NO Hosp Fertility Clinic NO NO NO Hosp FullField Digital Mammography (FFDM) YES NO NO Hosp Genetic Testing/Counseling NO NO NO Hosp Geriatric Services YES NO YES Hosp Heart YES NO NO Hosp Hemodialysis NO NO YES Hosp HIV/AIDS Services NO NO NO Hosp Image-Guided Radiation Therapy (IGRT) NO NO NO Hosp Inpatient Acute Care - Hospital services YES NO NO Hosp Intensity-Modulated Radiation Therapy (IMRT) 161 NO NO NO Hosp IntensiveCareUnit YES NO NO Hosp Intermediate Care Unit YES NO YES Hosp Interventional Cardiac Catherterization NO NO NO Hosp Isolation room YES NO NO Hosp Kidney YES NO NO Hosp Liver YES NO NO Hosp Lung YES NO NO Hosp Magnetic Resonance Imaging (MRI) YES NO NO Hosp Mammograms YES NO NO Hosp Mobile Health Services NO NO YES Hosp Multislice Spiral Computed Tomography (<64 slice CT) YES NO Hosp Multislice Spiral Computed Tomography (<64+ slice CT) NO NO NO Hosp Neonatal YES NO NO Hosp Neurological Services YES NO NO Hosp Obstetrics YES NO NO Hosp Occupational Health Services YES NO NO Hosp Oncology Services YES NO NO Hosp Orthopedic Services NO NO NO Hosp Outpatient Surgery YES NO NO Hosp Pain Management YES NO NO Hosp Palliative Care Program YES YES YES Hosp Pediatric YES NO YES Hosp Physical Rehabilitation YES NO YES Hosp Positron Emission Tomography (PET) YES NO NO Hosp Positron Emission Tomography/CT (PET/CT) YES NO NO Hosp Psychiatric Services NO NO YES

39 Inventory of Health Services - Appanoose County, IA Cat Healthcare Services OfferedinCounty:Yes/No Hospital Health Dept Other Hosp Radiology, Diagnostic YES NO NO Hosp Radiology, Therapeutic NO NO NO Hosp Reproductive Health NO NO YES Hosp Robotic Surgery NO NO NO Hosp Shaped Beam Radiation System 161 NO NO NO Hosp Single Photon Emission Computerized Tomography NO NO NO Hosp Sleep Center YES NO NO Hosp Social Work Services YES NO YES Hosp Sports Medicine YES NO YES Hosp Stereotactic Radiosurgery YES NO NO Hosp Swing Bed Services YES NO YES Hosp Transplant Services NO NO NO Hosp Trauma Center -Level IV NO NO NO Hosp Ultrasound YES NO NO Hosp Women's Health Services YES NO YES Hosp Wound Care YES NO YES

SR Adult Day Care Program NO NO YES SR Assisted Living NO NO YES SR Home Health Services NO YES YES SR Hospice NO YES YES SR LongTerm Care YES NO YES SR Nursing Home Services YES NO YES SR Retirement Housing NO NO YES SR Skilled Nursing Care YES NO YES

ER Emergency Services YES NO NO ER Urgent Care Center NO NO NO ER Ambulance Services YES NO YES

SERV Alcoholism-Drug Abuse NO NO YES SERV Blood Donor Center NO NO YES SERV Chiropractic Services NO NO YES SERV Complementary Medicine Services NO NO YES SERV Dental Services NO NO YES SERV Fitness Center NO NO YES SERV Health Education Classes YES NO NO SERV Health Fair (Annual) YES NO NO SERV Health Information Center YES NO NO SERV Health Screenings YES NO YES SERV Meals on Wheels NO NO YES SERV Nutrition Programs YES NO NO SERV Patient Education Center YES NO NO SERV Support Groups YES NO NO SERV Teen Outreach Services NO NO YES SERV Tobacco Treatment/Cessation Program YES NO NO SERV Transportation to Health Facilities YES NO YES SERV Wellness Program YES NO YES

40 Providers Delivering Care in Appanoose County, IA Mercy Medical Center-Centerville Primary Service Area - YR 2016 FTE Physicians FTE Allied Staff PSA Based PSA Based FTE Providers Working in County DRs Visting DRs* PA / NP Primary Care: Family Practice 7.0 5.0 Internal Medicine/Geriatrician 1.0 Obstetrics/Gynecology 1.0 Pediatrics 1.0

Medicine Specialists: Allergy/Immunology 1.0 Audiology 2.0 Cardiology 2.0 Dermatology 1.0 Endocrinology Gastroenterology Oncology/Radiology 2.0 Infectious Diseases Nephrology 1.0 Neurology Psychiatry Pulmonary Rheumatology Podiatry 1.0 Surgery Specialists: General Surgery/Colon/Oral 2.0 Neurosurgery Ophthalmology 1.0 Orthopedics Otolaryngology (ENT) 1.0 Plastic/Reconstructive Thoracic/Cardiovascular/Vascular Urology 1.0

Hospital Based: Anesthesia/Pain Emergency 7.0 Radiology 2.0 Pathology 1.0 Hospitalist Neonatal/Perinatal Physical Medicine/Rehab Occupational Medicine Podiatry Chiropractor 3.0 Optometrist 1.0 Dentist 3.0 TOTALS 32.0 10.0 5.0 *Total FTE Specialists serving community with offices outside PSA.

41 Visiting Specialists to Mercy Medical Center- Centerville Office Annual Specialty Physician Name/Group Location Schedule Days (City/State) Allergy Ravinder Agarwal, M.D. Des Moines, IA 52 3rd Monday

Audiology Douglas Leonard Atlantic, IA 52 3rd Monday

Audiology Greg Moore Ottumwa, IA 52 3rd Tuesday

Cardiology Thomas Brown, M.D. Des Moines, IA 156 2nd, 3rd, 4th Tues

Cardiology Beth Chia, A.R.N.P. Des Moines, IA 104 1st & 3rd Thurs

Dermatology Linda Shilling, A.R.N.P. Des Moines, IA 156 1st, 2nd & 4th Wed

ENT Phillip Linquist, M.D. Des Moines, IA 104 1st & 3rd Monday

Oncology Ahmad Wehbe, M.D. Des Moines, IA 104 2nd & 4th Wed

Oncology Angela Sandre, D.O. Des Moines, IA 104 1st & 3rd Wed 1st Thursday and following Nephrology Jobinson Thomas, M.D. Des Moines, IA 102 Friday Ophthalmology Senthil Krishnasama, M.D. Des Moines, IA 52 4th Wednesday

Podiatry Susan Warner, D.P.M. Bloomfield, IA 104 1st & 3rd Friday

Urology Fawad Zafar, M.D. Des Moines, IA 52 Every Tuesday

42 Appanoose County, Iowa Healthcare Area Service Directory

Emergency Numbers

Police/Sheriff 911

Fire 911

Ambulance 911

Non-Emergency Numbers

Appanoose County Sheriff (641) 437-7100 Appanoose County EMS (641) 437-1133

Municipal Non-Emergency Numbers

Police/Sheriff Fire Centerville (641) 437-7100 (641) 856-2314 Unionville (660) 947-3200 (641) 000-1111

43 General Online Healthcare Resources

Doctors and Dentists--General AMA Physician Select: Online Doctor Finder (American Medical Association) DocFinder (Administrators in Medicine) Find a Dentist (Academy of General Dentistry) Find a Dentist: ADA Member Directory (American Dental Association) Physician Compare (Centers for Medicare & Medicaid Services)

Hospitals and Clinics--General Find a Health Center (Health Resources and Services Administration) Find a Provider: TRICARE Provider Directories (TRICARE Management Activity) Hospital Quality Compare (Centers for Medicare & Medicaid Services)

Doctors and Dentists--Specialists ACOG's Physician Directory (American College of Obstetricians and Gynecologists) ACR: Geographic Membership Directory (American College of Rheumatology) American College of Surgeons Membership Directory (American College of Surgeons) American Osteopathic Association D.O. Database (American Osteopathic Association) ASGE: Find a Doctor (American Society for Gastrointestinal Endoscopy) Cancer Genetics Services Directory (National Cancer Institute) Child and Adolescent Psychiatrist Finder (American Academy of Child and Adolescent Psychiatry) Dystonia: Find a Health Care Professional (Dystonia Medical Research Foundation) Expert Locator: Immunologists (Jeffrey Modell Foundation) Find a Dermatologic Surgeon (American Society for Dermatologic Surgery) Find a Dermatologist (American Academy of Dermatology) Find a Gastroenterologist (American College of Gastroenterology) Find a Gynecologic Oncologist (Society of Gynecologic Oncologists) Find a Hand Surgeon (American Society for Surgery of the Hand) Find a Hematologist (American Society of Hematology) Find a Neurologist (American Academy of Neurology) Find a Pediatric Dentist (American Academy of Pediatric Dentistry) Find a Pediatrician or Pediatric Specialist (American Academy of Pediatrics) Find a Periodontist (American Academy of Periodontology) Find a Physical Medicine & Rehabilitation Physician (American Academy of Physical Medicine and Rehabilitation) Find a Plastic Surgeon (American Society of Plastic Surgeons) Find a Podiatrist (American Podiatric Medical Association) Find a Thyroid Specialist (American Thyroid Association) Find a Urologist (American Urological Association) Find an ACFAS Physician (American College of Foot and Ankle Surgeons) Find an Allergist/Immunologist: Search (American Academy of Allergy, Asthma, and Immunology) Find an Endocrinologist (Hormone Health Network) Find an Eye M.D. (American Academy of Ophthalmology) Find an Interventional Radiologist (Society of Interventional Radiology) Find an Oncologist (American Society of Clinical Oncology) Find an Oral and Maxillofacial Surgeon (American Association of Oral and Maxillofacial Surgeons) Find an Orthopaedic Foot and Ankle MD (American Orthopaedic Foot and Ankle Society) Find an Otolaryngologist (ENT) (American Academy of Otolaryngology--Head and Neck Surgery) Finding an Eye Care Professional (National Eye Institute) GI Locator Service (American Gastroenterological Association)

Other Healthcare Providers AMTA's Find a Massage Therapist (American Massage Therapy Association) Cancer Genetics Services Directory (National Cancer Institute) Find a Diabetes Educator (American Association of Diabetes Educators) Find a Genetic Counselor (National Society of Genetic Counselors) Find a Midwife (American College of Nurse-Midwives) Find a Nurse Practitioner (American Academy of Nurse Practitioners) Find a Physical Therapist (American Physical Therapy Association) Find a Professional: Online Directory of Audiology and Speech-Language Pathology Programs (American Speech-Language-Hearing Association) Find a Registered Dietitian (Academy of Nutrition and Dietetics) Find a Therapist (Anxiety Disorders Association of America) Find an Audiologist (American Academy of Audiology) Manual Lymphatic Drainage Therapists (National Lymphedema Network) National Register of Health Service Providers in Psychology (National Register of Health Service Providers in Psychology) NCCAOM: Find Nationally Certified Practitioners (National Certification Commission for Acupuncture and Oriental Medicine) Search for an Emergency Contraception Provider in the United States (Princeton University, Office of Population Research)

44 Hospitals and Clinics--Specialized Accredited Birth Centers (Commission for the Accreditation of Birth Centers) Alzheimer's Disease Research Centers (National Institute on Aging) Cystic Fibrosis Foundation: Find a Chapter (Cystic Fibrosis Foundation) Cystic Fibrosis Foundation: Find an Accredited Care Center (Cystic Fibrosis Foundation) Dialysis Facility Compare (Centers for Medicare & Medicaid Services) FDA Certified Mammography Facilities (Food and Drug Administration) Find a Free Clinic (National Association of Free Clinics) Find an Indian Health Service Facility (Indian Health Service) Find Treatment Centers (American Cancer Society) Genetics Clinic Directory Search (University of Washington) Locate a Sleep Center in the United States by Zip Code (American Academy of Sleep Medicine) MDA ALS Centers (Muscular Dystrophy Association) Mental Health Services Locator (Substance Abuse and Mental Health Services Administration) NCI Designated Cancer Centers (National Cancer Institute) Neurofibromatosis Specialists (Children's Tumor Foundation) Post-Polio Directory 2011: Post-Polio Clinics, Health Professionals, Support Groups (Post-Polio Health International including International Ventilator Users Network) Spina Bifida Clinic Directory (Spina Bifida Association of America) Substance Abuse Treatment Facility Locator (Substance Abuse and Mental Health Services Administration) Transplant Center Search Form (BMT InfoNet) U.S. NMDP Transplant Centers (National Marrow Donor Program) VA Health Care Facilities Locator & Directory (Veterans Health Administration) Where to Donate Blood (AABB) Where to Donate Cord Blood (National Marrow Donor Program)

Other Healthcare Facilities and Services Alzheimer's Disease Resource Locator (Fisher Center for Alzheimer's Research Foundation) American College of Radiology Accredited Facility Search (American College of Radiology) APA District Branch / State Association Directory (American Psychiatric Association) Directory of Organizations (Deafness and Communication Disorders) (National Institute on Deafness and Other Communication Disorders) Dog Guide Schools in the United States (American Foundation for the Blind) Eldercare Locator (Dept. of Health and Human Services) Find a Hospice or Palliative Care Program (National Hospice and Palliative Care Organization) Find Services (for People with Vision Loss) (American Foundation for the Blind) Find Urgent Care Centers by State (Urgent Care Association of America) Genetic Testing Laboratory Directory (University of Washington) Home Health Compare (Centers for Medicare & Medicaid Services) Medicare: Helpful Contacts (Centers for Medicare & Medicaid Services) Muscular Dystrophy Association Clinics and Services (Muscular Dystrophy Association) National Foster Care and Adoption Directory Search (Children's Bureau) Nursing Home Compare (Centers for Medicare & Medicaid Services) Organizations That Offer Support Services (National Cancer Institute) Poison Control Centers (American Association of Poison Control Centers) Resources and Information for Parents about Braille (American Foundation for the Blind) State-Based Physical Activity Program Directory (Centers for Disease Control and Prevention) TSA Chapters in the USA (Tourette Syndrome Association) Violence against Women: Resources by State (Dept. of Health and Human Services, Office on Women's Health) Where to Find Hair Loss Accessories and Breast Cancer Products (American Cancer Society) SOURCE: MedlinePlus provides links to directories to help you find libraries, health professionals, services and facilities. NLM does not endorse or recommend the organizations that produce these directories, nor the individuals or organizations that are included in the directories.

45 GeneralHealthResources Iowa State Patrol Emergency 1-800-525-5555 Action Now 1-800-622-5168 Medicare 1-800-MEDICARE Al-Anon “Free to Be Me” (515) 462-4253 Mental Health Information and Referral 1-800-562-4944 Alcoholics Anonymous 641-856-6689 National Alcohol Hotline 1-800-252-6465 Alzheimer’s Disease Helpline 1-800-272-3900 National Center for Missing & Exploited Children American Cancer Society 1-800-THE LOST 1-800-227-2345 National Institute on Drugs American Red Cross 1-800-662-4537 1-641-682-4484 Poison Control Arthritis Foundation 1-800-222-1222 1-866-378-0636 Sr Health Ins Info Program (Shiip) Battered Women 1-800-351-4664 1-800-433-SAFE Substance Abuse Information & Treatment Child Abuse Hotline 1-800-662-HELP 1-800-795-9606 Suicide Prevention Hotline Dependent Adult Abuse Hotline 1-800-SUICIDE 1-800-362-2178 Teen Line (Red Cross) Dependent Adult and Child Abuse 1-800-443-8336 1-800-652-9516 Chiropractors Domestic Abuse Hotline 1-800-942-0333 Lawrence E Heffron DC Heffron Chiropractic Office First Call for Help 116 E Jackson St (515) 246-6555 Centerville, IA 52544 6414374278 Foundation Through Crisis 1-800-332-4224 WAHeffronDC Heffron Chiropractic Office Gambling Hotline 116 E Jackson St 1-800-238-7633 Centerville, IA 52544 6414374278 Iowa Arson/Crime Hotline 1-800-532-1459 Jaren R Tubaugh DC Tubaugh Family Chiropractic Iowa Child Abuse Reporting Hotline 1114 N Haynes Ave 1-800-362-2178 Centerville, IA 52544 6414374433

46 Clinics Dentists

Sandy Poncy Scott Davis, DDS Centerville Family Care Clinic 112N10thSt PO Box 427 Centerville, IA 52544 Centerville, IA 52544 6418568643 6418565578 Nick Hindley DDS Amy Sweet Hindley Dental Chariton Valley Medical Center 203 W Washington St 707 S Main Centerville, IA 52544 Centerville, IA 52544 6418564103 6414374344 Joseph Whitehead, DDS Janet Peterie 1015 N. 18th St Mercy Cline Family Dialysis Centerville, IA 52544 1040 N 18th St 6418564400 Centerville, IA 52544 6414373515 Ron Harshman DDS PO Box 728 Brenda Hostetler Centerville, IA 52544 Mercy Medical Clinic Centerville 6418565352 19876 Saint Joseph Dr Centerville, IA 52544 Home Health / Hospices 6418568684 Appanoose County Public Health Kevin Bradley 209 E. Jackson Mercy Medical Ctr Radiology Centerville, IA 52544 1SaintJosephDr 6414374332 Centerville, IA 52544 6414373482 Caregivers Homestead of Centerville Staci Larson 19999 St. Joseph's Drive Mercy Rehabilitation Services Centerville, IA 52544 1SaintJosephDr 6414371999 Centerville, IA 52544 6414373454 Kristopher Laurson Appanoose Community Care Svc River Hills Community Health Center 19890 Saint Joseph Dr 1015 N 18th St Centerville, IA 52544 Centerville, IA 52544 6414373474 6418564400 Brian Hargrave Southern Iowa Surgical Assoc Hospice of Sourthern Iowa PO Box 37 103 E Van Buren St Centerville, IA 52544 Centerville, IA 52544 6418568100 6418565502 Ray Tresemer Tresemer Physical Therapy 612 E Franklin St Centerville, IA 52544 6418562515

47 Hospital Physicians & Surgeons

Clint J Christianson Ryan Arnevik, DO Mercy Medical Ctr-Centerville 19876 Saint Joseph Dr 1SaintJosephDr Centerville, IA 52544 Centerville, IA 52544 6418568684 6414374111 David B Fraser MD Mental Health Services 19876 Saint Joseph Dr Centerville, IA 52544 Daniel O’Brien 6418568684 Community Health Ctr-Southern 221 E State St Jennifer Haden, DO Centerville, IA 52544 19876 Saint Joseph Dr 6418566471 Centerville, IA 52544 6418568684 Jackie Sharp Centerville Community Betterment Erica Collins MD 1111 Haynes Ave. 1SaintJosephDr Centerville, IA 52544 Centerville, IA 52544 6414371051 6418568684

Appanoose County Mental Health Kathleen Lange MD Diane Buss 707 S Main 209 E. Jackson Centerville, IA 52544 Centerville, IA 52544 6414374344 6418562085 or 6418951690 Nancy Barton MD Oak Place 19876 Saint Joseph Dr Crisis Stabilization House Centerville, IA 52544 415 E. Oak 6418568684 Centerville, IA 52544 641-216-8134 Cassie Parrish, ARNP 19876 Saint Joseph Dr Paula Gordy Centerville, IA 52544 6418565382 6418568684

SIEDA Drug & Alcohol N. Sokol, DO 6418563112 19876 Saint Joseph Dr Centerville, IA 52544 NAMI (National Alliance Mental Health) 6418568684 Local Chapter 6418563213 Naren Batra MD 707 S Main Other Centerville, IA 52544 6418568100 Appanoose County Environmental PO Box 399 Paul D Poncy DO MORAVIA, IA 52571 PO Box 427 6417243511 Centerville, IA 52544 6418565578

48 Rajni Batra MD Golden Age Care Ctr 707 S Main 1915 S 18th St Centerville, IA 52544 Centerville, IA 52544 6418566780 6418562757

Richard J Burger MD Maple Grove Senior Living 1SaintJosephDr 1917 S. 18th Centerville, IA 52544 Centerville, IA 52544 6414374111 6418566601

Public Health Cathy Proffitt Proffitt's Residential Care Natasha Myers 615 W Washington St Appanoose County Public Health Centerville, IA 52544 201N12thSt 6418568344 Centerville, IA 52544 6414374332 Tara Koestner Homestead of Centerville Senior Care 19999 St. Joseph's Drive Centerville, IA 52544 Mercy Long Term Care 6414371999 One St. Joseph’s Drive Centerville, IA 52544 Tina Stansberry 6414373300 The Continental on the Square Well Elderly Living Michelle Kerschner 217 N. 13th Centerville Nursing & Rehab Centerville, IA 52544 1208 E Cross St 6414371025 Centerville, IA 52544 6418568651

49 V. Detail Exhibits

[VVV Consultants LLC]

50 Patient Origin and Access

[VVV Consultants LLC]

51 Appanoose County # IA Hospital Association PO103 FFY2013 FFY2014 FFY2015p TREND 1 Total Discharges 1,792 1,738 1,776 2 Total IP Discharges-Age 0-17 Ped 216 251 286 3 Total IP Discharges-Age 18-44 310 294 304 4 Total IP Discharges-Age 45-64 382 389 398 5 Total IP Discharges-Age 65-74 330 282 270 6 Total IP Discharges-Age 75+ 554 522 518 Mercy Medical Center-Centerville # IA Hospital Association PO103 FFY2013 FFY2014 FFY2015p TREND 1 Total Discharges 797 703 748 2 Total IP Discharges-Age 0-17 Ped 93 119 148 3 Total IP Discharges-Age 18-44 97 87 104 4 Total IP Discharges-Age 45-64 119 118 114 5 Total IP Discharges-Age 65-74 152 92 84 6 Total IP Discharges-Age 75+ 336 287 298

*FFY2015 has been prorated based on 2Q of data

Mercy Medical Center-Centerville # Internal Records FFY2013 FFY2014 FFY2015p TREND 1 ER Visits 6,975 6,393 7,049 2 OP Visits 60,663 57,071 61,382 3 Clinic Visits 15,818 14,618 15,030

52 Town Hall Attendees Notes and Feedback

[VVV Consultants LLC]

53 Community Health Needs Assessment Appanoose Co, IA - Strengths (Color Cards) N=57 # Today: What are the strengths of our community that contribute to health? 1 Increased home care services offered 2 Improved mental health options 3 More dentists coming to town 4 On site CAT scan and MRI (MRI used to travel 10 years ago) 5 Excellent nursing care 6 Hospital in Centerville 7 Two new young doctors 8 Hospice 9 Oral health education at schools 10 Good physical environment 11 Access to exercise opportunities 12 Physicians 13 Decreasing bad debt write offs/charity care from 2013-2015 14 IP satisfaction 15 Increased outpatient MH services 16 Dialysis center 17 We have nice facility in the hospital and the clinic dialysis center! 18 A community college that trains 90% of the nurses in the area 19 Veterans support, benefits and incentives 20 Stabilization house 21 Mental health coalition 22 Wellness coalition 23 Mental health 24 Hospital 25 VA help 26 Relationship with patients 27 Community 28 Willingness to change 29 Provider community 30 Variety of health services available to all ages 31 YMCA- rec opportunities available for youth and adults 32 Access to specialist at hospital 33 Variety of services- hospice, home health, emergency, mental, physical therapy 34 Accessforexercisehaveplaces 35 Support groups for chronic illness- Parkinson's and Diabetes 36 Mental health issues addressed 37 Mental illness support- temporary housing and support groups I don't have knowledge efficiencies to express an opinion- this is a learning 38 experience for me

54 Community Health Needs Assessment Appanoose Co, IA - Strengths (Color Cards) N=57 # Today: What are the strengths of our community that contribute to health? I know we have a fine hospital in our community and I intend to do everything I can 39 to support it (except for being a patient- I don't have time for that!) 40 Stabilization house 41 Church involvement for poor and elderly 42 Decrease in unemployment People in the county that care and want to make things better- whatever the 43 concern 44 MH facilities 45 All levels of housing 46 Excellent progress for mental health 47 Community leaderes- interest 48 Administrator actively recruiting docs 49 Mental health stabilizing house and post Oak Place follow up 50 Mental health is improving 51 Unemployment dropping 52 Charity 53 Community college good asset to community 54 Good schools and community college 55 Many people hardworking life long residents who really care about this community 56 Mental health 57 24 hour screenings 58 Mental health coalition 59 New playground equipment 60 Clean up parks 61 New docs 62 New infrastructure- streets, sidewalks, improved clean up 63 Mental health services 64 Good school and college 65 Lifetime people 66 Cleaning up the area 67 On site hospital 68 Increased number of nurse practitioners 69 Efforts 70 Mental health/DOH/Hosp work together 71 Health wellness coalition 72 YMCA 73 Done work on underage and binge drinking- passed ordinance for social host 74 Sustainable agriculture 75 Stabilization house- increased MH providers (2 psych, 2 ARNP) 76 Caring people

55 Community Health Needs Assessment Appanoose Co, IA - Strengths (Color Cards) N=57 # Today: What are the strengths of our community that contribute to health? 77 Community involvement 78 Community resources- meeting 79 Hospice 80 Onsite MRI 81 MH stabilization house 82 Caring people 83 Increased MH providers (2 psychiatrists, 2 ARNPs) 84 Improvement in mental health solutions 85 Senior solutions 86 We have the ability to provide education- schools, newspaper, radio 87 Mental health services are starting to improve 88 Mental health services have improved 89 Crisis stabilization house 90 Emergency mental health pre-screening 91 School mental health counselors in school- just getting started 92 Child care 93 New housing in the county 94 Outdoor activities 95 Strong hospital with resources to bring in outpatient services 96 Good EMS 97 Good doctor/patient care 98 Good infrastructure- water 99 Good physical activity opportunities 100 Emergency mental health services 101 Health coaches in clinic 102 Counselors in school 103 People are willing to come together and hash out needs in the community 104 There have been improvements since our last town meeting! 105 Mental health coalition 106 Wellness coalition Hospital involved in determining community needs and trying to make 107 improvements We have strong hospital administrators working to bring in providers and 108 specialists 109 Wellness coalition 110 Good networking 111 Providers are knowledgeable about area resources 112 Emergency pre-screeneres at hospital 113 Oak Place stabilization house 114 Mental health coalition

56 Community Health Needs Assessment Appanoose Co, IA - Strengths (Color Cards) N=57 # Today: What are the strengths of our community that contribute to health? 115 Senior life solutions 116 Increased mental health services 117 Mental health coalition has been established 118 Caring providers who provide high quality care 119 Strong local hospital that continues to provide diversified services 120 Ambulance 121 Chiropractors 122 Environment 123 New focus/Temco 124 People are trying- involvement 125 Emergency pre-screeners 24/7 126 Second step for mental health 127 Mental health coalition 128 Emergency pre-screener at Law Center (mental health) 129 Mental health coalition 130 Life Serve program 131 Community meals 132 Open enrolled school system 133 River Hills- serve uninsured, under-insured, sliding scale, accept Title XIX dental 134 Quality education K-12 and Indian Hills 135 Senior life solutions 136 Oak Place 137 River Hills 138 YMCA 139 Good water 140 Community health center (good substance abuse provider) 141 Good walking/mountain bike trail- reservoir 142 Good school system- quality teacheres 143 Development of Oak Place- stabilization house 144 Two new physicians within last two years- young doctors 145 Emergency pre-screeners 24/87- ER and Law Center (mental illness) 146 Mental health coalition that meets monthly 147 Senior life solutions development 148 Local doctors stay here Stabilization house in Centerville for mental illness and 24/7 on call screenings for 149 ER and Law Center (mental health coalition group and senior life solutions) Have a hospitalist program which allows HCPs to be available more time at their 150 office 151 Mental health house 152 Coalition for mental health

57 Community Health Needs Assessment Appanoose Co, IA - Strengths (Color Cards) N=57 # Today: What are the strengths of our community that contribute to health? 153 Free mental health screening 24/7 154 Face to face psychiatrist 155 River Hills 156 Oak Place 157 YMCA 158 Mental health group 159 Community meals 160 Crisis stabilization 161 Emergency PC 162 School MH services 163 Schools 164 Good schools- community college 165 Good workers- good community people 166 Mental health strides 167 Good hospital 168 Recreation

58 Community Health Needs Assessment Appanoose Co, IA - Weakness (White Cards) N=57 # Today: What are the weaknesses of our community that contribute to health? 1 Transportation- getting to appointments 2 No local batterers education classes 3 Not enough drug and alcohol counselors 4 Need more inpatient for mental health and chemo department 5 Need dieticians 6 More doctors 7 Community meals 8 More transportation 9 Having fundraisers by serving alcohol 10 Need expanded mental health 11 Inpatient detox or drug rehab 12 Transportation 13 VA care 14 Screenings in schools and factories 15 Expand STD and Hep C screening 16 Mental health that doesn't fit criteria for Oak Place 17 Detox 18 Transportation 19 Specialists 20 Need more doctors- PCP 21 Need more specialists- Ortho, Podiatry 22 More options specialty- wound care 23 Urgent care Ambulance services given all tools to find rural residence (GPS)- ambulance could not find my home in emergency. Ambulance response time not good and didn't 24 know most direct route to Mercy (Moulton ambulance) ER doc not familiar with systems (computerse) in Mercy ER and had to be 25 coached by nurse Follow up on patient surveys! If receive bad survey they should contact person 26 and seek more feedback- follow up! Find out what you can do to improve! 27 Local cancer care and chemo and radiation treatment 28 Need for additional optometrist 29 Expanded dental care- must go out of county for wisdom teeth and orthodontics 30 After house urgent care 31 ER physicians- ER repsonse times 32 Ambulance response to rural areas- updated location maps 33 Reasonable costs 34 Outside of community to seek services 35 Communication with patient after tests performed

59 Community Health Needs Assessment Appanoose Co, IA - Weakness (White Cards) N=57 # Today: What are the weaknesses of our community that contribute to health? 36 More physicians 37 Specialty docs Sexual health and education for teens- increased awareness of long term effects 38 of sex and promiscuity Improve participation and awareness of exercise and good nutrition. Educate 39 about the food and health connection. Personal health accountability- knowing how to care for yourself, when to and not to go to doctor and ER, having private insurance instead of Medicaid, taking 40 ownership of personal health 41 We need doctors- family practice 42 We need all patients to be outpatients 43 We need more people bing active and exercising in Appanoose County 44 We need to communicate better to citizens on health care services Mental health and obesity is a huge issue! A lot of overweight people that leads to 45 heart disease and diabetes and other health issues 46 Individual accountability to health 47 Urgent care clinic 48 Smoking/drinking program 49 Extended hours for clinic 50 Depression/mental health services 51 Single family homes 52 Loss of population 53 Mental health 54 Hospitalist program 55 After hours clinic 56 Depression leads to alcohol, drugs, suicide, etc. 57 Urgent care 58 Hospitalists 59 Suicide- grief therapy and support groups 60 Specialty health- OBGYN 61 Mandatory vaccination- public schools 62 County rankings overall! Ortho surgeon for specialty clinic- residents leave county and don't return for 63 rehab 64 Urgent care clinic/after hours clinic 65 More psychiatry services- long waits for new patients More primary providers, especially second NP for nursing facilities. When current 66 NF-NP is on leave, other PCPs aren't able to provide consistent care 67 Nurse shortage

60 Community Health Needs Assessment Appanoose Co, IA - Weakness (White Cards) N=57 # Today: What are the weaknesses of our community that contribute to health? 68 Poor early life choices lead to early NF status (under 65) 69 Jail diversion- MH counselor in the Appanoose County jail Tele psych in the jails- inmates can have a psych evaluation while in jail and stay 70 on medications if appropriate People's motivation to make changes to their lives to improve health- smoking, eat 71 better, get jobs 72 Urgent care facility 73 Poor housing for low income families 74 Mentor program for teens or community facility Classes at food pantry to educate people on food choices or how to store/make 75 food last 76 We need more interested parties from different entities 77 Change people's motivation levels to make improvements 78 After or before hours clinic and urgent care 79 Transportation- need more options 80 Need more activities for elderly and families 81 Employment opportunities 82 After hours clinic 83 Mental health 84 Community healthcare doctor 85 Mental health 86 Mental illness 87 Quality of care needs to improve- ER perception 88 Image management 89 More BH providers 90 More inpatient mental health 91 Need for detox centers 92 Transportation to specialty care 93 More public transportation for medical appointments 94 Domestic violence 95 Mental health 96 Decrease poverty 97 Health 98 Habits 99 Training 100 Education 101 Jobs 102 Attend 18-80 club 103 Return to community from hospital for elders

61 Community Health Needs Assessment Appanoose Co, IA - Weakness (White Cards) N=57 # Today: What are the weaknesses of our community that contribute to health? 104 Transportation for elders 105 Decrease Medicaid 106 Psychiatric care Only complaint I have ever heard about our hospital is the food isn't good. My opinion is this is a hospital, not a restaurant and we are in the healing business 107 which includes not induldging some foods or seasonings 108 General wellness education for kids and parents 109 Few walk/ride bike to school 110 Access to providers 111 After hour access to provider other than the emergency room 112 Additional jobs/improve income levels- reduce poverty level 113 Immediate need of patients wanting to be seen the same day 114 Knowledge of mental health services to community 115 Access to exercise knowledge and where can go 116 Physical activity initiatives/opportunities 117 We have information on lead exposure but not radon gas 118 More MH 119 More resources for single parents 120 More jobs and higher pay 121 After hours healthcare 122 Continue mental health services- pediatric 123 Extend hours of schools nurses 124 Eye doctors 125 Walk in clinic 126 Ask a nurse number 127 Adolescence mental health 128 After hour healthcare- urgent care 129 Need more room at hospital and doctor's office 130 Poverty 131 Obesity 132 Drug/alcohol abuse 133 Marketplace help with setting up coverage 134 More healthcare providers 135 After hours clinic 136 More general practice physicians and dentists 137 More affordable activity in the community to promote health and wellness 138 Need more walk in clinics, people utilize the ER too much Need more businesses brought in town to bring in the young people and keep the 139 young people that already live here

62 Community Health Needs Assessment Appanoose Co, IA - Weakness (White Cards) N=57 # Today: What are the weaknesses of our community that contribute to health? 140 Easy to access entitlement programs and stay on these programs 141 More doctors 142 More mental health 143 Walk in clinics 144 Make assistance hard to get- a lot get it and shouldn't have it Decrease entitlement programs to force people to get up and become motivated 145 physically and mentally More focus on education, more money, more opportunities for younger generation to learn a life of being a motivated and responsible citizen and living a long and 146 productive life 147 Increase general practitioners in area 148 "Affordable" healthcare Too many people use ER for office visits because of decreased access to doctors 149 and visits 150 Increase law enforcement training of mental illness training 151 Public transit 152 Need increase of physicians/urgent care facilities 153 Poverty- need more better paying jobs 154 After hours clinic 155 Poverty- more better paying jobs 156 Activities for children to do 157 Communication! 158 Jobs- decrease poverty 159 Jobs- increase self-worth, decrease domestic violence and MH issues 160 Public transportation 161 Urgent care- after hours clinic 162 All mapping 163 Obesity, nutrition, poverty, family planning 164 Communication- drugs, abuse, alcohol, poverty, wellness eduation 165 Community garden, improve farmer's market- hospital or DOH host it? 166 Depression 167 Greater/better access to local providers either extended hours or urgent care 168 More home health services

63 Appanoose County Community Health Needs Assessment Meeting 3.15.16 N=57

Community Members Present: x Providers- Doctors and Nurse Practitioners x Business Owners x Farmers x Law Enforcement x Parents x Senior Caregivers x Schools- Superintendent and Principal x Elected Officials- Board of Supervisors, Mayor and Township Clerk

TAB 1: Demographic Profile x We are losing people in our county

TAB 2: Economic/Business Profile x We think the unemployment rate has gone down

TAB 3: Educational Profile x Someone from schools believe free and reduced lunch rate should be about 45%

TAB 10: Preventive Quality Measures Profile x We have Amish in our area

Primary Research: x “I think there have been improvements in the Mental Health area that people are not aware of.”

Recent Happenings in the Community: x Mental illness stabilization house opened x Emergency room pre-screeners now available 24/7 for mental illness x Mental health coalition group started meeting monthly x Senior Life Solutions (Geriatric Mental Health) opened

STRENGTHS: x On-siteCTScanandMRI x Have a hospital in our community x Mental health services are starting to improve due to new access x Health and wellness coalition at the hospital x Community involvement in health x River Hills- offers services to the under-served x New, young providers in the community x Local hospice

64 x EMS services x Support groups (Parkinson’s and diabetes) x Providers are engaged, trustworthy and build relationships x All levels of care are available in our community x Good schools x Good VA health x Improved home care services x YMCA x Availability of healthcare education to the public x Hospitalist program x Community Resources meeting every two months x Outdoor activities x Church involvement for poor and elderly x Focus on oral health in elementary schools x Oak Place- Mental health stabilization house x Sustainable agriculture program at the Community College x Social hosting ordinance was passed

WEAKNESSES: x After hours clinic/urgent care x Ambulance services- 911 mapping to rural areas x Depression x Healthier lifestyles- personal health accountability x Nutrition x Senior activities x Inpatient detox x Teen sex education x Provider recruitment- starting in schools x Poverty x Pediatric mental health x Specialists- Orthopedic, Wound Care, Oncology, Podiatry, Pain Management, Cardiac, Rheumatology x Healthcare transportation x Economic development x Marking/communication of services x Lack of DHS presence x Radon x Activities/jobs for the handicapped x Cost of healthcare services x Family planning

65 Public Notice and Invitation

[VVV Consultants LLC]

66 Mercy Medical Center One St. Joseph’s Drive Centerville, IA 52544 www.mercycenterville.org (641) 437-4111 • FAX (641) 437-3304

Media Contact: PRESS RELEASE Ann Young Vice President - Community Relations FOR IMMEDIATE RELEASE (641) 437-3434 • FAX (641) 437-3304 [email protected] February 2, 2016

Hospital to Conduct Community Health Needs Assessment

Over the next three months, Mercy Medical Center-Centerville will be updating the 2013 Appanoose County (Centerville, IA) Community Health Needs Assessment (CHNA).

The 2013 survey identified Mental Health as the community’s number one health issue. Since that time the hospital working with a broad coalition of community partners including the county, mental health providers, law enforcement and court system have worked to create access to timely emergency mental health assessment and follow up within the community. As a result of this work, a mental health crisis stabilization house was created in 2014.

The goal of the follow up assessment update is to evaluate progress in addressing community health needs cited in the 2013 CHNA report and to collect up-to-date community health perceptions. To accomplish this work, a short online survey has been developed: https://www.surveymonkey.com/r/MMCC_CHNA2016. All community residents and business leaders are encouraged to complete the 2016 online CHNA survey by March 1st.

Residents and business leaders are also invited and encouraged to attend the upcoming scheduled Town Hall on Tuesday, March 15th from 11:30-1:00pm at the Majestic in Centerville.

“We hope that the community and health professionals will take advantage of this opportunity to provide input into the future of healthcare delivery in our county,” comments Clint Christianson, President.

This assessment update is a follow-up to meet final IRS regulations, requiring all 501(c)(3) hospitals to conduct a community health needs assessment and adopt an implementation strategy at least once every three years. Vince Vandehaar, MBA (VVV Consultants LLC, an independent research firm from Olathe, Kansas) has been retained to conduct this countywide research. ###

67

To: All Appanoose County Residents From: Clint Christianson, President

Mercy Medical Center-Centerville is conducting an update to the 2013 Community Health Needs Assessment.

Your feedback and suggestions regarding community health de- livery are very important to collect in order to complete the 2016 Community Health Needs Assessment and implementation plan updates.

We invite you to take a short online survey that has been devel- oped at the following link: https://www.surveymonkey.com/r/MMCC_CHNA2016

Due date for survey completion is March 1. All responses are confidential.

Thank you in advance for your time and support in participating with this important request.

68 From: Clint Christianson, President Date: Feb. 1, 2016 To: Community Leaders, Health Services Personnel Subject: Community Health Needs Assessment

Mercy Medical Center-Centerville is conducting an update to the 2013 Community Health Needs Assessment. (Note: This assessment update is a follow-up to meet final IRS regulations released on 01/02/2015, requiring all 501(c)(3) hospitals to conduct a Community Health Needs Assessment and adopt an implementation strategy at least once every three years).

Your feedback and suggestions regarding community health delivery are very important to collect in order to complete the 2016 Community Health Needs Assessment and implementation plan updates.

To accomplish this work, a short online survey has been developed: https://www.surveymonkey.com/r/MMCC_CHNA2016

Due date for survey completion is March 1. All responses are confidential. Thank you in advance for your time and support in participating with this important request.

69 To: Area Health Experts, Community & Business Leaders

From: Clint Christianson, CEO

Date: February 14, 2016

RE: Community Health Needs Assessment Town Hall Meeting

Mercy Medical Center Centerville is in the process of updating the 2013 Community Health Needs Assessment by collecting community views regarding healthcare delivery for our area. As leaders and health care advocates, you represent a broad spectrum of the community and are all uniquely qualified to help identify the most critical health issues facing our citizens.

As part of this process, we invite you to participate in a Community Health Town Hall meetingtobeheld: March 15, 2015 11:30 A.M. – 1:00 PM Majestic Ballroom Centerville

A light lunch will be served and we ask that you R.S.V.P. on the enclosed/return address stamped postcard if you plan to join us.

Feedback & suggestions are very important to collect in order to update our community health needs assessment and implementation plan. If you haven’t already, I would invite you to complete a confidential online survey by March 1 at the following address:

https://www.surveymonkey.com/r/MMCC_CHNA2016 or link directly from the homepage of our website at www.mercycenterville.org

Thank you in advance for your participation and support. I hope to see you on March 15th and look forward to working with you to identify and address our community’s top health issues.

70 COMMUNITY CALENDAR: Public Invited to Attend Town Hall to Improve Healthcare in Appanoose County

WHAT: Mercy Medical Center-Centerville will host a town hall meeting to gather the public’s input about identifying unmet community health needs and improving the delivery of healthcare in Appanoose County (Centerville, IA). A light lunch will be provided.

WHO: All members of the community interested in the future of healthcare delivery are invited to attend. Vince Vandehaar of VVV Consultants LLC from Olathe, Kansas, will facilitate the meeting.

WHEN: Tuesday, March 15th, 11:30-1:00pm.

WHERE: The Majestic Theater.

HOW: RSVP by contacting Ann Young at (641) 437-3434.

71 Community Health Needs Assessment Appanoose County, IA Community Town Hall Meeting

Mercy Medical Center-Centerville and Appanoose County Public Health will be sponsoring a Town Hall Meeting on Tuesday, March 15th from 11:30 to 1:00 p.m. at The Majestic Theater. Public is invited to attend. A light lunch will be provided

Please join us for this opportunity to share your opinions and suggestions to improve health care delivery in Appanoose County, IA.

Thank you in advance for your participation.

72 Detail Primary Research Primary Service Area

[VVV Consultants LLC]

73 Community Health Needs Assessment Round #2 Community Feedback

Methodology

A community feedback survey was created on behalf of the CHNA client to gather primary service area stakeholder feedback on health perception and progress in addressing previous CHNA community needs. All community residents were encouraged to take the survey online by entering the following address into personal browser: https://www.surveymonkey.com/r/MMCC_CHNA2016.

In addition, an invite letter was sent to all primary service area stakeholders (i.e. Schools, County, City, Clergy, Public Health Leaders).

Below is a summary of public response:

Mercy Medical Center - Centerville (Primary Service Area) Appanoose Co, IA N=263

Option C 10. For reporting purposes, are you Appanoose Co Stakeholders Round involved in or are you a... N=263 #2 Bottom 2 Boxes Board Member 4.1% 4.0% Business / Merchant 5.6% 6.7% Case Manager / Discharge 0.6% 0.3% Civic Club / Chamber 4.3% 4.5% Charitable Foundation 2.5% 1.9% Clergy / Congregational Leader 1.1% 1.9% College / University 1.7% 1.1% Consumer Advocate 1.1% 2.4% Consumers of Health Care 8.5% 8.8% Dentist 0.2% 0.3% Economic Development 1.2% 1.1% Education Official / Teacher 4.3% 5.1% Elected Official (City / County) 1.6% 0.8% EMS / Emergency 1.7% 4.0% Farmer / Rancher 4.3% 3.2% Health Department 1.6% 1.3% Hospital 13.2% 11.8% Housing / Builder 0.4% 0.5% Insurance 0.7% 0.3% Labor 1.4% 1.3% Law Enforcement 0.5% 0.3% Low Income / Free Clinics 0.6% 1.3% Mental Health 1.4% 2.9% Nursing 9.2% 9.4% Other Health Professional 6.4% 4.5% Parent / Caregiver 11.1% 6.4% Pharmacy 0.5% 0.0% Physician (MD / DO) 0.5% 0.8% Physician Clinic 1.3% 1.1% Press (Paper, TV, Radio) 0.3% 0.8% Senior Care / Nursing Home 1.5% 2.1% Social Worker 0.8% 1.1% Veteran 1.8% 1.6% Welfare / Social Service 0.6% 0.8% Other (please note below) 3.4% 5.6% TOTAL 100.0% 100.0%

74 KEY - CHNA Open End Comments CODE Physician Specialty CODE Physician Specialty

ALLER Allergy/Immunology ONC Oncology/Radiation Oncology

AES Anesthesia/Pain OPTH Ophthalmology

CARD Cardiology ORTH Orthopedics

DERM Dermatology ENT Otolaryngology (ENT)

EMER Emergency PATA Pathology

ENDO Endocrinology PEDS Pediatrics

FP Family Practice (General) PHY Physical Medicine/Rehabilitation

GAS Gastroenterology PLAS Plastic/Reconstructive

SUR General Surgery PSY Psychiatry

GER Gerontology PUL Pulmonary

HEM Hemotology RAD Radiology

IFD Infectious Diseases RHE Rheumatology

IM Internal Medicine VAST Thoracic/Cardiovascular/Vascular

NEO Neonatal/Perinatal URL Urology

NEP Nephrology MDLV Mid-Level

NEU Neurology SURG Surgery

NEUS Neurosurgery TEL Telemedicine OBG Obstetrics/Gynecology (Delivery)

KEY - CHNA Open End Comments Code Healthcare Themes Code Healthcare Themes VIO Abuse/Violence NURSE More Nurse Availibility ACC Access to Care NEG Neglect AGE Aging (Senior Care/Assistance) NH Nursing Home AIR Air Quality NUTR Nutrition ALC Alcohol OBES Obesity ALT Alternative Medicine ORAL Oral Surgery ALZ Alzheimers ORTHD Orthodontist AMB Ambulance Service OTHR Other ASLV Assisted Living OP Outpatient Services/Surgeries AUD Auditory OZON Ozone BACK Back/Spine PAIN Pain Management BD Blood Drive PARK PARKING BRST Breastfeeding PHAR Pharmacy CANC Cancer DOCS Physicians CHEM Chemotherapy FLU Pneumonia / Flu KID Child Care FOOT Podiatrist CHIR Chiropractor POD PODIATRIST CHRON Chronic Diseases POV Poverty CLIN Clinics (Walk-In, etc.) PNEO Prenatal

75 KEY - CHNA Open End Comments Code Healthcare Themes Code Healthcare Themes COMM Communication PREV Preventative Healthcare CORP Community Lead Healthcare PRIM Primary Care: CONF Confidentiality PROS Prostate DENT Dentists DOH Public Health Department DIAB Diabetes QUAL Quality of care DIAL Dialysis REC Recreation DUP Duplication of Services RESP Respiratory Disease ECON Economic Development NO Response "No Changes," etc. EMER Emergency Room SANI Sanitary Facilities EMS EMS SNUR School Nurse EYE Eye Doctor/Optometrist STD Sexually Transmitted Diseases FAC Facility SMOK Smoking FAM Family Planning Services SS Social Services FEM Female (OBG) SPEC Specialist Physician care FINA Financial Aid SPEE Speech Therapy FIT Fitness/Exercise STRK Stroke ALL General Healthcare Improvement DRUG Substance Abuse (Drugs/Rx) GEN General Practice SUIC Suicide GOV Government TPRG Teen Pregnancy HRT Heart Care THY Thyroid HIV HIV/AIDS TOB Tobacco Use HH Home Health TRAN Transportation HSP Hospice TRAU Trauma HOSP Hospital TRAV Travel MAN Hospital Management ALCU Underage Drinking INFD Infidelity INSU Uninsured/Underinsured IP Inpatient Services URG Urgent Care/After Hours Clinic LEAD Lead Exposure VACC Vaccinations

BIRT Low Birth Weight VETS Veteran Care LOY Loyalty WAG Wages MAMO Mammogram WAIT Wait Times MRKT Marketing H2O Water Quality STFF Medical Staff WELL Wellness Education/Health Fair BH Mental Health Services WIC WIC Progam

76 CHNA Community Feedback 2016 Mercy Medical Center - Centerville Primary Service Area, N= 263 Are there healthcare services in the Mercy MedicalCenter - Overall HC Centerville service area that you feel need to be improved and/or ID Zip Rating c1 c2 c3 changed? (Please be specific.) More access to theclinicasthere was times it took awhile toget in so people were going to ER for illnesses that could be 1173 52537 Good ACC CLIN EMER addressed in a clinic setting 1167 52544 Fair ACC DOCS SPEC More access to healthcare providers, including specialists. 1119 52572 Very Good ACC DOCS More timely access to appointments with physcians. Access toweekend care other than ER. I miss having Saturday morning hours. Now we have to wait until Monday afternoon 1127 52544 Good ACC EMER URG before we can be seen. An urgent care would be helpful. Timely access to health care providers. An urgent care/walk-in 1070 52544 Good ACC URG CLIN clinic would be good. Access to urgent care Pain Management would be beneficial 1197 52590 Very Good ACC URG PAIN Orthopedics ALTME Provide more alternative type treatments - such as use of 1060 52544 Good D essential oils and options for birthing. Mercy Medical offers blood test at a huge discount for seniors MARKE BUT not enough people KNOW about this or take advantage of 1102 52549 Good AWARE T it. Maybe a monthly mention of services in the paper?? In the 1079 52544 Good CARD AWARE Increased heart health awareness in the community Cardiac is one area that needs to have another Dr besides Dr. 1146 52544 Very Good CARD DOCS UROL Bown and Chia. Another Dr in Urology. 1218 52544 Fair CLIN DOCS We need a walk in clinic and more physicians... yes -- patientsneedto beworkedinto theclinicvsbeing told to come to the ER for simple issues such as ear aches, colds, can't sleep, medication refills, etc... It would be nice to have an urgent 1220 63548 Good CLIN EMER URG care clinic in Appanoose County. 1253 52544 Good CLIN EMER A clinic that was open early evening hours and weekends for The Clinicshould bemoreaccessible. It isveryhardtogetin quicklywhenyouaresick.Itwouldbenicetohaveadeskright at the door for the ER area to make it easier for emergency 1249 52544 Very Good CLIN EMER patients. There is a big need for a walk in clinic...the only option here is 1248 52544 Fair CLIN EMER the ER. we need an after hours walk in clinic as an alternative to the 1240 52544 Very Good CLIN EMER emergency room. Extended hours at the clinic, expanded specialty clinic, Urgent 1252 52531 Good CLIN SPEC URG Care Longer clinic hours - weekendhours Recruitment ofdoctors More events that promote healthy living (5k events, YMCA 1082 52544 Good CLIN URG DOCS programs, etc.) After hours clinicservices during theweek and weekends. Hospital needs to bring back their home care service. Access to more specialists locally. Updated medical facilities - hospital and 1108 52544 Very Good CLIN URG HH clinics. 1191 52544 Very Good CLIN URG extended clinic hours for urgent/walk in care 1076 52544 Good CLIN URG Still difficult for patients to get in to the clinic in a semi urgent 1104 52544 Good CLIN URG Walk-in Clinics evening and weekends 1106 52544 Good CLIN URG Walk-in Clinics not only for daytime but evenings and weekends Clinic issometimes hardtoget an appointment. Some things can wait but others you really need to see a doctor and emergency 1100 52544 Good CLIN WAIT EMER room is not an option. Too expensive. 1067 52544 Good CLIN availability of clinic appointments 1150 52549 Good COST WAIT EMER Cost of treatment and wait time in ER 1046 52555 Very Good DOCS CLIN EMER more doctors in clinics if not people goes to the er More providers are needed,extended clinic hours, weekend operation of clinics, urgent care so ED is not overwhelmed with non-emergent patients. Mental health services are lacking in this 1072 52544 Poor DOCS CLIN URG area. Need for more physicians, family practice and specialty. Also need more staff, if you can't provide enough staff to take care of the physician's local patients how does that effect local services when they have to be transferred to another hospital because MMC is not taking any admits due to not enough staff to care for 1233 52571 Fair DOCS FP SPEC them.

77 CHNA Community Feedback 2016 Mercy Medical Center - Centerville Primary Service Area, N= 263 Are there healthcare services in the Mercy MedicalCenter - Overall HC Centerville service area that you feel need to be improved and/or ID Zip Rating c1 c2 c3 changed? (Please be specific.) 1077 52549 Fair DOCS MH SPEC Provider availability, Mental Health, more Speciality services. There doesn't seem to be enough Drs. in our area. Mental 1099 52544 Fair DOCS MH healthcare services also seem to be short on caregivers We have a DEFINITE shortage of family medical providers in Centerville. It seems that all recruited practitioners, including Nurse Practitioners, etc., are recruited or placed in the Centerville Medical clinic facility. There needs to be a variety of providers so that the public feels that they have some choice in where they received medical treatment. Chariton Valley and Centerville Family Care have cut their physician hours to the 1155 52544 Poor DOCS NP CLIN point of Need more doctors. Need doctors who want to work and accomodate patients, not ones who are always on vacation. There is also a huge problem with continuity of care when your primary physician is out of the office. The 'on-call' doctors are lame ducks in that they will not/cannot accomodate a patient's needs during that time. Huge problem since the doctors are 1199 52544 Fair DOCS PRIM WAIT FREQUENTLY out of the office. Yes, more doctors. Being able togetintoseethe doctor of your choice in a shorter period of time. Last two time I have went to 1239 52544 Fair DOCS PRIM WAIT see my primary care giver is too me two - four weeks to get in. 1133 52583 Fair DOCS SPEC More physicians local and specialist. 1262 52544 Good DOCS URG CLIN provider There isaneedfor more availability to Doctors. Needfor an Urgent Care clinic with extended hours, 6:00 am to 10:00 pm. 1235 52544 Good DOCS URG CLIN Greater access to specialty practices. Centerville er is used as an urgent care clinic. Dr. Langes office is a joke, misdiagnoses, misses a lot of issues associated with health of patients, has a horrible response time with reporting back labs e.t.c. Lack of mental health services. Town needs urgent care clinic (more accessible hours). This is not the place for this but since this will be viewed by hospital officials they may want to check into the reputation of the office ladies-Tonya Clawson and Sherry Doggett. I have heard on several occasions a nurse who puts in her notice will be called by these individuals before her last shift to be told she (the nurse) does not need to come in to finish her shift and then by them (tonya and or sherry) be put on the do not rehire list because they did not show up for their last shift. Call some ex employees (ask around) this has happened several times that I have heard of. Mercy hospital Centerville as also has the reputation that it depends on your social status or last name if you will be hired on as an employee. Not the knowledge, education, or experience you would add to 1012 52544 Very Poor DOCS URG MH the facility. not being able to see a doctor at the clinic when you work at 1084 52544 Fair DOCS WAIT CLIN mercy Physician office hours needto beextended evening and weekends! There are more than enough doctors in town. Your 1056 52544 Very Good DOCS WAIT URG doctors need to work! More physicians so that the wait time to see a physician is not so 1040 52549 Fair DOCS WAIT long. Sometimes you have to wait weeks for the next available 1163 52544 Very Good DOCS It would be helpful to have more doctors on staff. 1142 52544 Good DOCS more doctors We have some escellent doctors, but they are overworked. We 1221 52544 Very Good DOCS need more. 1103 52544 Fair DOCS we need Doctors 1263 52544 Very Good DOCS We need more providers Additional G.Ps. as we have had and will have some retirements. 1185 52544 Good DP OBG CLIN Additional OB/Gyn. Sleep clinic. Ibelieve there should beadifferent waiting room for ER patients, rather than mixed with patients for the clinic who are some times 1097 52544 Good EMER CLIN CANC cancer patients with suppressed immune systems

78 CHNA Community Feedback 2016 Mercy Medical Center - Centerville Primary Service Area, N= 263 Are there healthcare services in the Mercy MedicalCenter - Overall HC Centerville service area that you feel need to be improved and/or ID Zip Rating c1 c2 c3 changed? (Please be specific.) The ER needs enlarged, hallways are too crowded with 1037 52572 Good EMER EQUIP equipment and some of the rooms are too small. We lacktechnical medical support. The E.R. is timely. The facility seems dated. Confidence in personnel to take action 1190 52544 Poor EMER FAC STAFF required to save a persons life... I hope so. Medical appointments for individualsarenot readilyavailable, if people can't get into their provider when they need to they show up in the ER and verbalize that is exactly what they are doing. 1212 52544 Poor EMER MH PEDS we also need MH services for kids to be more readily available. Personally I and my family do not have many healthcare needs so I cant answer on a personal level but from comments from the community or post I have saw on facebook I think we need better quality care in the ED dept and sometimes when being transferred to the floor. I have heard responses of lack of professionalism and what patient thought was delay of care. From what I understand it was more a nurse issue than a physician but have heard some past comments about the physicians in the ED not accessing patients well and not giving them the meds they need because they say the are a narcotic 1216 52544 Good EMER STAFF SUB and very addicting when patient is in extreme pain and does not 1205 52555 Fair EMER STAFF Emergency Room assessment and approach from staff Registration Clerk needs to be closer or in ER, would be great help when needing to fax, direct traffic, assist Physician with calls, ect. Safety issues, one nurse in ER at nights, ER doors not locked, Night nurse alone on nights with Mental Health/Meth patients. Times ER Nurse don't see House Supervisor. After hours for Clinic be extended to assist patients when don't need Level of Emergency care/and consider their cost of Clinic vs ER. Physicians for Ortho and Pain Management in our Speciality 1009 52574 Good EMER URG CLIN Clinics needed. Thank You

There is no where to go (except the ER) on evenings, weekends, and holidays if we, or especially, a child becomes ill. We need 1251 52544 Good EMER URG CLIN an urgent care or walk-in clinic with evening and weekend hours. Alarger Emergency Departmentisneededtoservice theneeds of this community. Our citizens face a variety of health challenges. Also a consideration for an urgent care area, to sort out those patients that need to be seen but are not true 1036 52572 Very Good EMER URG emergencies. 1148 52581 Fair EMER WAIT Emergency room. Takes too much time. 1111 52574 Good EMER WAIT Faster ER service. 1138 52544 Good EMER e r Would be nice to have some simple gym equipment to exercise 1068 52544 Good EQUIP EXER before/after work. Generaldoctoring. It'sapain togetinto doctors, and many other doctors seem too complacent and unwilling to spend proper 1182 52544 Poor GP amount of time with patients. More behavioral health providers, more dentists, more 1172 52544 Fair MH DENT DOCS physicians 1175 52544 Good MH EMER Mental health and emergency room visits. access to inpatient/outpatient mentalhealth services. There has been improvement but still a gap. Pain management, rheumatology, dermatology, orthopedics, more providers for 1246 52590 Good MH PAIN DERM optometry, and I go out of town for dental services. 1176 52544 Fair MH PAIN mental health/ pain management Mental health care in our community is still very lacking. We do have adult care available, however, when it comes to children we have a great need for a child psychiatrist in our community. We tend to get nurse practitioner’s in this area of health care. I am not saying they are not competent; I just feel that when it comes 1109 52544 Fair MH PEDS NP to children we need a psychiatrist. 1229 52537 Fair MH PEDS mental health services, more pediatrics All of them; and a great need for more effective mental health 1120 52549 Poor MH SUB and substance abuse services

79 CHNA Community Feedback 2016 Mercy Medical Center - Centerville Primary Service Area, N= 263 Are there healthcare services in the Mercy MedicalCenter - Overall HC Centerville service area that you feel need to be improved and/or ID Zip Rating c1 c2 c3 changed? (Please be specific.) 1058 52549 Good MH SUB issue. 1095 52574 MH SURG Mental Health Treatment Option and another Surgeon 1250 52555 Good MH TRANS Mental health and transportion Ifeel we have made theright steps in the MentalHealth area but there is still a huge shortage. I believe an Urgent care Clinic is a 1128 52544 Fair MH URG CLIN necessity here as well. 1092 52544 Fair MH URG TRANS mental health urgent care services for youth transportation 1010 52590 Good MH mental health 1065 52544 Fair MH Mental Health 1005 52544 Fair MH mental healthcare 1101 52544 Fair MH Psychiatric 1144 52581 Good MH There is a need for more mental health providers. 1088 52544 Fair OBG Women's health

*oncology clinic area *infusion area is too far away from parking *Med/surg rooms too small to maneuver in *Front desk personel not as friendly and don't seem to make phone tranfers correctly 1048 52544 Good ONC SURG STAFF for patients or customers who call in. *Security is non-existent More space needs to beprovidedfor those coming in for outpatient services, such as Cancer treatments, quick care, and 1085 68124 Very Good OP CANC URG consultations. 1244 52544 Fair OPHTH Yes - we need an ophthalmologist 1064 52544 Fair ORTHO DERM FP Orthopedics, Dermatology, FP, It would be nice to be able to see an ortho surgeon in Mercy 1090 52544 Fair ORTHO SURG instead of having to drive to Ottumwa or Des Moines 1211 52544 Very Good PAIN CLIN Pain management clinic 1066 52544 Fair PAIN CLIN We need a pain clinic

1098 52544 Good PAN MH DENT A Couple of areas Pain control, Mental Health and even dentistry 1180 52544 Good PRIM ACC Increased Primary Care access. 1112 52549 Good PRIM URG IM More PCP. Urgent Care. Internal Medicine. 1200 52544 Good PULM SPEC CLIN Would love to see pulmonology in specialty clinic I was recently hospitalized for more than a week and based on that experience, I believe that Centerville Mercy has excellent nursing care and I was pleased there was an onsite CAT scan machine. Having the new kidney center and an MRI are great assets in our community. What I do not know, is if there is any services from Chemo and Radiation. We often hear people having to travel daily out of town for treatments. If not currently available, I think those services should be a priority for new 1223 52544 Very Good QUAL EQUIP CHEMO treatment facilities and staff. Many peoplearedischargedfrom the hospitaltoo soon and are not medically stable. Sometimes the underlying medical issue 1217 52544 Fair QUAL STAFF was not even addressed or diagnosed. I had several incidences where the hospital didn't read my 1137 52549 Good QUAL doctor's orders carefully and weren't ready when I arrived for 1020 52544 Very Good SPEC CLIN DOCS Additions in the specialty clinics. Wealways need specialists tocometo Centerville. It isvery difficult for many people to travel to Des Moines if they are already in poor health. Also additional transportation needs to be 1116 52544 Good SPEC TRANS available. 1041 52544 Good STAFF 8 hour shifts for those interested in them This is not directly service related but, when I receive a phone call from Mercy Medical Center-Centerville, my caller-ID shows "Out of Area" and I'm unable to know who is calling. I get many telemarketing phone calls each day and some do not provide caller ID. I would like the hospital to provide caller ID, otherwise I must wait to see if a message has been left and if so, I phone 1214 52544 Good STAFF them back.

80 CHNA Community Feedback 2016 Mercy Medical Center - Centerville Primary Service Area, N= 263 Are there healthcare services in the Mercy MedicalCenter - Overall HC Centerville service area that you feel need to be improved and/or ID Zip Rating c1 c2 c3 changed? (Please be specific.) I feel that sometimes in Centerville with people having lower socioeconomic status and there being a major drug problem in this area that something more needs done with young children to educate them of drug situations and what to do to stay sober, healthy, and happy. Especially those children who are growing 1179 52544 Fair SUB ED up with parents who use drugs. 1196 52544 Poor SUB GP Substance abuse treatment. Overall general care for families. 1. Transportation requiredfor patientswho have same day procedures e.g., colonoscopy, endoscopy, as they have relatives that live out of out time, that makes it inconvenient for them to come to provide them a ride home. 2. Recreation room for the 1001 52544 Good TRANS PEDS SURG pediatric patients at the hospital. 3. More bathroom require at Walk-in after hours clinic staffed by same doctors that are there 1053 53544 Fair URG CLIN DOCS regularly. Not just a nurse. Urgent care services so thatifyou get sick after clinic hours or on the weekend you have an option other than the emergency 1086 52544 Good URG CLIN EMER room.

There needs to be some type of urgent care clinic. Many times, patients are unable to get an appointment at a regular doctor's office, but the complaint isn't an emergency. An urgent care 1140 52544 Good URG CLIN WAIT clinic would also serve a need for evening care in the community. Urgent Care and Saturday Clinic times. Also - the Clinic needs to be attached to the hospital. I know this is in the works - but the Clinic looks TERRIBLE and very concerning to patients - and those patients are making concerning comments in the public. I'm not sure we can wait for 2+ years in the Clinic's current 1123 52544 Good URG CLIN WAIT condition. Need an urgent care clinic. Need clinic to be open later hours to 1254 52544 Fair URG CLIN serve the community. 1094 52544 Good URG CLIN urgent care, or a walk in clinic ;urgent care isextremely limited.physician recruitmentto replace retiring practioners and those leaving general practice environment. shortage of dentists. mental health service 1129 52544 Fair URG DOCS MH shortage Acute care needs after usual business hours, other than use of the emergency room. Mental health including psychiatric services, psychological services, and counseling services for all ages, but particularly youth. Improved adherence to state and federal regulations and recommendations regarding regular child developmental assessments and immunizations, along with routine entry into IRIS for all immunizations. Timely referrals for 1245 52544 Fair URG EMER MH further evaluation of suspected developmental delays and/or Would like to have week-endDr. for care thatdoesn't needER. If you get sick on Thursday probably can't see a Dr. until Monday. If you have sick children, it makes a long week-end, or for anyone to have to go that long without medicine. ER is so 1059 52544 Good URG EMER WAIT expensive and sometimes you are there 6-7 hrs. 1033 52544 Good URG EMER a urgent care or another option other than emergency room after care hours...having an urgent care---checking into the ER is 1247 52544 Fair URG EMER an expensive option. The services are excellent, we just need extended hours and 1227 52544 Good URG EMER hours on the weekend besides the emergency room urgent care mental health care options home health care 1093 52544 Good URG MH HH services

81 CHNA Community Feedback 2016 Mercy Medical Center - Centerville Primary Service Area, N= 263 Are there healthcare services in the Mercy MedicalCenter - Overall HC Centerville service area that you feel need to be improved and/or ID Zip Rating c1 c2 c3 changed? (Please be specific.) 1) We need access to an urgent care clinic. 2) It would be beneficial if there was an Ortho surgeon that came to the specialty clinic. Unfortunately, several community members have to have this service performed elsewhere - typically Des Moines. After that, the ACO culture is steering them to stay in Des Moines for any post-op rehabilitation/therapy. This is a lot of loss for several entities in the community. 3) The on-call physician tends to 'dump' items they don't want to deal with on the weekends. They say 'let's observe' or 'let's wait until Monday' 1241 52544 Fair URG ORTHO SURG This often leaves the patient with a deteriorating condition and 1087 52544 Good URG WAIT DOCS urgent care/after hour physician services 1004 52544 Good URG WAIT Access to urgent care or extended clinic hours. 1264 52544 Good URG Addition of urgent care - access 7 days a week. 1049 52544 Good URG Need an urgent care 1091 52544 Good URG Urgent Care services 1115 52544 Good URG Urgent Care; Nights and weekend availability vascular provider in specialty clinic, podiatry, psychiatry in 1206 52581 Very Good VASC CLIN POD specialty clinic, expand infusion center hours. Ibelieve it needs to beeasier for patients togetintoseeaDr. Pts are waiting 3 to 4 days to get in for a URI. We need a walk in 1257 52544 Fair WAIT CLIN URG clinic or urgent care for weekends also. Availabilityof same day appointments. If you are sick on Monday, but can't been seen until Wed., or Thursday, are you kidding me? Urgent Care Clinic. We can drive to Des Moines to 1149 52544 Poor WAIT URG see Urgent Care 7 days a week, and weeknights until 7. 1089 52544 Fair WAIT wait times Quality of general practice providers. Mental health care 1107 52544 Fair WAUL GP MH facilities. 1260 52544 Good WELL COST EXER Make the YMCA more affordable

82 CHNA Community Feedback 2016 Mercy Medical Center - Centerville Primary Service Area, N= 263 Throughout thepasttwo years, did you or someone you know Overall HC receive healthcare services outside of Mercy Medical Center - ID Zip Rating c1 c2 c3 Centerville's service area? If Yes, what service? 1214 52544 Good CANC DM Cancer treatment, Mercy Cancer Center Des Moines 1195 52581 Good CANC DM Neighbor cancer treatment in Des Moines 1118 52544 Good CANC MH SURG Cancer treatments, mental health services, surgery 1020 52544 Very Good CANC SURG RAD cancer surgery and radiation treatments 1151 52549 Good CANC Follow up on Cancer 1167 52544 Fair CARD COLON OPTOM Heart surgeries, colon surgery, eye care (for glaucoma) 1157 52544 Good CARD DERM SURG Heart surgery, dermatological surgery 1010 52590 Good CARD DM cardiac, DM Mercy 1053 53544 Fair CARD ORTHO OPTOM Heart knee eye hearing Heart surgery, Specialist services not available locally, DENTIST 1056 52544 Very Good CARD SPEC DENT - major problem. 1137 52549 Good CARD SPEC saw heart specialist 1012 52544 Very Poor CARD SURG MH Cardiac, surgical procedures, mental health 1103 52544 Fair CARD cardiac 1115 52544 Good CARD Cardiology 1029 52544 Good COLON ORTHO Colonoscopy, hip replacement, 1190 52544 Poor CORY OBG traveled to Corydon, IA for child's delivery. 1173 52537 Good DAVIS URG OTTUM DAvis County Hospital; urgent care in ottumwa 1224 52537 Good DAVIS Davis County Hospital 1246 52590 Good DENT ENDO OBG dental, endocrinology,OB, vision, chiropractic, urgent care 1251 52544 Good DENT OPTOM DERM Dentist, eye Dr., dermotologist, gynocologist 1180 52544 Good DENT Dental 1186 52544 Good DENT dental 1044 52569 Good DENT Dentist 1102 52549 Good DERM ENT Dermatology ENT 1116 52544 Good DERM ORTHO Dermatologist, Broken leg, 1035 52549 Good DERM dermatology 1070 52544 Good DERM Dermatology 1088 52544 Fair DERM dermatology 1098 52544 Good DISAB Center of Disabilities 1257 52544 Fair DM IACTY mercy desmoines and iowa city 1234 52549 Fair DM DES MOINES 1236 52544 Good DM Mercy - Des Moines 1133 52583 Fair DM Mercy Des Moines 1253 52544 Good DM Methodist Hospital in Des Moines 1192 52572 Very Good DM Transferred to Mercy in Des Moines 1030 52531 Very Good DOC ALBIA My husband his Doctor is in Albia closer to home. 1031 52531 Very Good DOC ALBIA My husband with his Doctor in Albia, closer to home. 1032 52531 Very Good DOC ALBIA My husband's doctor in Albia closer to home for him. 1172 52544 Fair DOCS ACC lack of providers, access 1075 52544 Good EMER ENDO COLON er care for gi bleed had endo and colonoscopy done 1176 52544 Fair EMER ER 1089 52544 Fair EMER er visit 1237 52544 Very Good ENDO DM endocrinology in Mercy Des Moines 1225 52544 Good ENDO Endocrine 1040 52549 Fair ENDO Endocrinologist 1046 52555 Very Good ENT ears Because of sub-standardfacilities andlack of providers, our family has taken 90% of our medical business outside of 1155 52544 Poor FAC DOCS Centerville. 1051 52544 Good GALL Gall stone removed 1182 52544 Poor GP OBG General doctoring, survey, child delivery 1094 52544 Good IAHRT iowa heart 1244 52544 Fair IM OPHTH Internist, ophthalmology 1039 52544 Good MAYO Mayo Clinic 1117 52544 Fair MH ORTHO SURG Mental health & joint replacement surgery 1048 52544 Good NEPH nephrology procedure that can't be completed here Neurology, orthopedic, psycology, TBI rehab, pain management, 1081 52544 Good NEURO ORTHO MH ENT, Audiology, EEG, MRI, NCV, Trauma. 1191 52544 Very Good NEURO ORTHO RHEU neurology,orthopedics,rheumatology 1263 52544 Very Good NEURO SURG Neurosurgical services 1124 52544 Good NEURO Neurologist

83 CHNA Community Feedback 2016 Mercy Medical Center - Centerville Primary Service Area, N= 263 Throughout thepasttwo years, did you or someone you know Overall HC receive healthcare services outside of Mercy Medical Center - ID Zip Rating c1 c2 c3 Centerville's service area? If Yes, what service? 1139 52544 Fair NEURO Neurologist 1260 52544 Good NEURO Neurology 1162 52544 Fair OBG ENT maternity; ent 1212 52544 Poor OBG FPLAN DENT OBGYN, family planning, dentist, pediatrician 1067 52544 Good OBG SURG OB, surgery 1049 52544 Good OBG WAYNE Delivery at Wayne County hospital I personally called several times to make an appt with the ob/gyn by calling the main clinic number they would transfer me to vicki and I always got a voicemail. I left a voicemail and it was well over a week before I heard back from anyone and I had already found a new dr. out of town where I will continue to go because 1097 52544 Good OBG the service is fabulous 1200 52544 Good OBG ob-gyn 1171 52574 Good OBG pap and mammogram 1096 52544 Good OP EMER outpatient and ER 1123 52544 Good OP SPEC CLIN Outpatient services/Speciality Clinic 1216 52544 Good OP Outpatient testing 1144 52581 Good OPTOM CARD eye laser procedure, heart stress test 1037 52572 Good OPTOM DENT eye care & dental 1252 52531 Good OPTOM DENT Optometry, Dental 1240 52544 Very Good OPTOM eye care 1120 52549 Poor OPTOM Optometry 1108 52544 Very Good ORTHO CARD DENT Orthopedics, heart care, dental joint replacement surgery, cardiac care, oncology services, mental health services, primary care services, obstetric services, 1245 52544 Fair ORTHO CARD ONC dental care 1064 52544 Fair ORTHO DERM OPTOM Ortho, Derm, eye, OB 1238 52544 Good ORTHO DM Orthopedist in Des Moines 1129 52544 Fair ORTHO FP orthopedic and family practice 1217 52544 Fair ORTHO MH GAST Orthopedic, mental health, geriatric psych, Gastroenterology Reconstructive Ankle Surgery with cadaver transplant, I also use 1220 63548 Good ORTHO PRIM a primary care physician in another county -- due to where I live. 1235 52544 Good ORTHO PULM Knee replacement, hospitaliztion for lung infection 1199 52544 Fair ORTHO SURG CORY Orthopedic surgery in Corydon, IA 1099 52544 Fair ORTHO SURG EMER Orthopedic surgeries, emergency care 1004 52544 Good ORTHO SURG Orthopedic surgery 1109 52544 Fair ORTHO SURG Orthopedical care and Orthopedical surgery 1025 52571 Very Good ORTHO UROL orthopedic and urologist 1027 52571 Very Good ORTHO UROL orthopedic and urologist 1175 52544 Good ORTHO orthapedic 1185 52544 Good ORTHO Orthepedic 1100 52544 Good ORTHO Ortho 1164 52544 Good ORTHO orthopedic 1087 52544 Good ORTHO orthopedics 1161 52544 Fair OTTUM DM OBG Ottumwa OBGYN - Mercy DSM OBGYN,NICU, & Neurology 1205 52555 Fair OTTUM IACTY DM Ottumwa, Iowa City, Des Moines 1077 52549 Fair OTTUM Ottumwa Regional 1066 52544 Fair PAIN CLIN Pain Clinic 1036 52572 Very Good PAIN Pain Management 1211 52544 Very Good PAIN Pain managment 1166 52544 Very Good PEDS there kids 1248 52544 Fair PELLA CLIN Pella Regional Clinic 1196 52544 Poor PRIM DENT medical and dental 1247 52544 Fair PRIM SPEC SURG Check-Ups, Routine Checks, Specialist, Surgery 1149 52544 Poor PRIM routine office calls, cold, flu, injury 1218 52544 Fair PULM pulmonology 1086 52544 Good RAD EMER x-ray/ER 1148 52581 Fair RHEU ORTHO OPTOM rheumatologist, orthopedic services, optometrist 1093 52544 Good SPEC DENT OBG specialty services of all kinds; dentistry; OB 1111 52574 Good SPEC DM Specialists in Des Moines 1095 52574 SPEC OBG Specialized in GYN services 1113 52544 Fair SPEC PAIN specialist / pain management

84 CHNA Community Feedback 2016 Mercy Medical Center - Centerville Primary Service Area, N= 263 Throughout thepasttwo years, did you or someone you know Overall HC receive healthcare services outside of Mercy Medical Center - ID Zip Rating c1 c2 c3 Centerville's service area? If Yes, what service? 1092 52544 Fair SPEC PRIM all the specialties and some primary care 1140 52544 Good SPEC PRIM Specialists, primary care 1264 52544 Good SPEC SURG DENT Specialized sugery, dental services, internal medicine 1243 52544 Fair SPEC specialist 1114 52544 Fair SPEC specialist 1126 52544 Fair SPEC Specialty appointments 1250 52555 Good SPEC specialty care 1091 52544 Good SURG CANC DM Surgery for cancer in Des Moines 1014 52544 Good SURG DM Surgery at Mercy Des Moines 1239 52544 Fair SURG DM Surgery at Mercy West in Des Moines 1256 52574 Fair SURG IP Surgery and inpatient hospital stay 1082 52544 Good SURG Surgery 1007 52544 Good SURG Surgery 1249 52544 Very Good SURG surgical 1072 52544 Poor UI University of Iowa Hospitals and Clinics Ottumwa Urgent Care Clinic vs use of ER. Consider cost and 1009 52574 Good URG COST WAIT wait time 1104 52544 Good URG Urgent care 1106 52544 Good URG Urgent Care 1059 52544 Good VA KNOX CANC VA Knoxville. Cancer Treatments. 1138 52544 Good VA va 1069 52544 Fair VA Veterans affairs 1107 52544 Fair WAYNE Wayne County 1233 52571 Fair WOUN Wound care

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90 CHNA Report Contact :

Vince Vandehaar, MBA VVV Consultants LLC Adjunct Professor / Professional Healthcare Marketing and Strategic Planning Consulting Services

601 N Mahaffie, Olathe, KS 66061 (913) 302-7264 (C) [email protected]

LinkedIn: vandehaar Website: VandehaarMarketing.com

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