Fargo, Noorth Dak Oo Ta June 18, 2013

Commmunnity HHealt hh Neee ds AA ssesssment Essenttia Healthh West, F Fargo, Noorth Dak oo ta June 18, 2013

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Essentia Health West, Fargo, ND Community Health Needs Assessment

Table of Contents

Executive Summary ...... iv 1. Introduction ...... 6 2. Community Served by the Hospital Facility ...... 9 2.1. Description/Definition and Determination ...... 9 2.2. Demographics ...... 10 2.3. Additional Demographic Data ...... 16 3. Process and Methods Used to Conduct the Assessment ...... 17 3.1. Sources and Dates of the Data and Other Information Used in the Assessment ...... 17 3.2. Analytical Methods Applied/Process Used to Identify Community Health Needs ...... 21 3.3. Information gaps that impact ability to assess the health needs of the community served by the hospital facility ...... 21 3.4. Coordination with Other Hospitals and Collaboration with Other Organizations ...... 22 3.5. Contracted Third Parties ...... 23 4. Community Health Profile ...... 24 5. Input from Persons Who Represent the Broad Interests of the Community Served by the Hospital Facility ...... 37 5.1. When and How These Persons Were Consulted ...... 37 5.2. Organizations Consulted ...... 37 5.3. Individuals with Special Knowledge of or Expertise in Public Health ...... 38 5.4. Federal, Tribal, Regional, State, or Local Health or Other Departments or Agencies with Current Data or Other Information Relevant to the Health Needs of the Community ...... 38 5.5. Individuals Who are Leaders, Representatives, or Members of Medically Underserved, Low‐Income, and Minority Populations and Populations with Chronic Disease Needs .. 38 6. Community Health Needs Identified Through the CHNA ...... 39 6.1. Process and Criteria Used in Prioritizing the Needs ...... 39 6.2. Standardization and Prioritized Description of Identified Health Needs ...... 39 7. Existing Healthcare Facilities and Other Resources Within the Community Available to Meet the Community Health Needs Identified Through the CHNA ...... 42 7.1. Process for Identifying and Prioritizing Resources/Services to Meet the Community Health Needs ...... 42 8. Making the CHNA Report Widely Available to the Public ...... 42 References ...... 43 Acknowledgments ...... 44 Appendix A – Implementation Strategy ...... 45 Appendix B – Intervention Protocols for First Health Need ...... 53 Appendix C – Compendium of Resources ...... 72

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List of Figures Figure 1. Population Health Links ACOs, PCMHs, and Community Benefit (CHNA)...... 6 Figure 2. Institute of Medicine Community Health Improvement Process...... 8 Figure 3. Intervention Timeline ...... 9 Figure 4. Hospital Location ...... 10 Figure 5. UWPHI County Health Rankings Social and Economic Factors Ranks, Cass County .. 14 Figure 6. UWPHI County Health Rankings Social and Economic Factors Ranks, Clay County... 15 Figure 7. UWPHI County Health Rankings Model...... 19 Figure 8. UWPHI County Health Rankings Health Outcomes Ranks, Cass County ...... 24 Figure 9. UWPHI County Health Rankings Health Outcomes Ranks, Clay County ...... 25 Figure 10. UWPHI County Health Rankings Health Behaviors Ranks, Cass County...... 26 Figure 11. UWPHI County Health Rankings Health Behaviors Ranks, Clay County ...... 27 Figure 12. UWPHI County Health Rankings Clinical Care Ranks, Cass County ...... 31 Figure 13. UWPHI County Health Rankings Clinical Care Ranks, Clay County...... 31 Figure 14. UWPHI County Health Rankings Physical Environment Ranks, Cass County ...... 35 Figure 15. UWPHI County Health Rankings Physical Environment Ranks, Clay County...... 35

List of Tables Table 1. Population Demographics for States Where Essentia Health Has a Presence...... 11 Table 2. Population Demographics for States Where Essentia Health Has a Presence Stratified by Geographic Locale (Rural/Non‐Rural) ...... 12 Table 3. Population Demographics for States Where Essentia Health Has a Presence Stratified by Race/Ethnicity ...... 13 Table 4. UWPHI County Health Rankings Social and Economic Factors Data ...... 15 Table 5. Cass and Clay County Demographic Data...... 17 Table 6. UWPHI County Health Rankings Health Outcomes Data...... 25 Table 7. UWPHI County Health Rankings Health Behaviors Data ...... 27 Table 8. Population Risk Factors and Disease Status for States Where Essentia Health Has a Presence...... 28 Table 9. Population Risk Factors and Disease Status for States Where Essentia Health Has a Presence Stratified by Geographic Locale (Rural/Non‐Rural)...... 29 Table 10. Population Risk Factors and Disease Status for States Where Essentia Health Has a Presence Stratified by Race/Ethnicity...... 30 Table 11. UWPHI County Health Rankings Clinical Care Data ...... 32 Table 12. Population Health Service Information for States Where Essentia Health Has a Presence...... 32

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Table 13. Population Health Service and SES Information for States Where Essentia Health Has a Presence Stratified by Geographic Locale (Rural/Non‐Rural)...... 33 Table 14. Population Health Service and SES Information for States Where Essentia Health Has a Presence Stratified by Race/Ethnicity...... 34 Table 15. UWPHI County Health Rankings Physical Environment Data...... 36 Table 16. Examination of a Specific Health Issue: The Case of Smoking...... 36

Companion Reports 2012 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents 2012 Greater Fargo‐Moorhead Community Health Needs Assessment of Community Leaders

iii

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Essentia Health West, Fargo, ND Executive Summary

Executive Summary

Innovis Health, LLC, doing business and hereafter referred to as Essentia Health West, is required to conduct a Community Health Needs Assessment (CHNA) and adopt an implementation strategy to meet the community health needs identified through the CHNA at least once every three years. The following document and past and future activities described therein serve to meet that requirement. The implementation strategy included in Appendix A was approved by the Essentia Health West Region Board of Directors on May 30, 2013.

The majority of the hospital facility’s CHNA process occurred from May 2011 to May 2013. The process began with the hospital facility’s participation in the Fargo‐Moorhead Community Health Needs Assessment Collaborative (i.e. the Collaborative), a group composed of representatives from several community organizations and partnered with the Center for Social Research (CSR) at North Dakota State University. The Collaborative and CSR conducted a survey of residents in the greater Fargo‐Moorhead area to learn about the perceptions of area residents regarding the prevalence of disease and health issues in their community. A breakfast meeting was also held for community leaders during which they had an opportunity for discussion and completed a survey to explore their views regarding the resident population’s health and the prevalence of disease and health issues within the community. Other community leaders who were not able to attend the breakfast meeting completed the survey via an Internet‐based survey tool. Based on results of these surveys and a two‐round voting process in October 2012, the Collaborative ranked the community’s health priorities.

On February 1, 2013, the hospital facility joined a coordinated CHNA process that was ongoing among fourteen other Essentia Health hospital facilities and was facilitated by the Essentia Institute of Rural Health, a center for research and education. For the fourteen other hospital facilities, community health profile data had been compiled and presented to Community/Patient Focus Groups that were asked to identify and prioritize their community’s health needs based on the data. The health needs for each community fell into similar thematic categories so were subsequently standardized across the communities in order to leverage the value of a coordinated process across a health system. The top three priorities ranked by the Collaborative for the greater Fargo‐Moorhead area aligned with the standardized health needs of the fourteen other Essentia Health hospital facilities and thus were merged.

The three highest‐priority health needs for the community served by Essentia Health West are 1) obesity, physical activity, and nutrition as risk factors for chronic diseases, such as type 2 diabetes, 2) access to mental healthcare, and 3) access to healthcare, defined as enhanced healthcare for the local population. Each of these health needs will be addressed by a three

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Essentia Health West, Fargo, ND Executive Summary

year intervention, the first of which will begin in 2013 with the others beginning in subsequent years. The first intervention will be enhanced type 2 diabetes prevention and education. Interventions addressing the second two health needs will be selected by participants at Town Hall Meetings to be held in late 2013/early 2014 and late 2014/early 2015. Intervention Planning Meetings will be held prior to implementation of each intervention in order to make concrete plans for implementing the selected interventions and to identify individuals who are accountable for the implementation. The first Intervention Planning Meeting for Essentia Health West will occur on July 8, 2013. All interventions will be monitored over time to determine whether the community health needs are being met and to add to the evidence on intervention effectiveness.

We truly believe this CHNA and associated implementation strategy will benefit community health, thus supporting Essentia Health’s mission to make a healthy difference in people’s lives.

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Essentia Health West, Fargo, ND Community Health Needs Assessment

1. Introduction

This Community Health Needs Assessment (CHNA) was cconducted in response to the enactment through The Patient Protection and Affordable Care Act, Public Law 111‐148 (124 Stat. 119 (2010)), of section 501(r) of the Internal Revenue Code.1 According to REG‐106499‐ 12, “Section 501(r)(3) requires a hospital organization to conduct a CHNA at least once every three years and adopt an implementation strategy to meet the community health needs identified through the CHNA.”1

In addition to the CHNA being a legal requirement, the CHNA and associated implementation strategy support population health‐related goals of Essentia Health. First and foremost, Essentia Health’s mission is to make a healthy difference in people’s lives. As the CHNA is ultimately designed to provide community benefit by improving community/population health, meeting CHNA requirements helps Essentia Health pursue that mission. Second, Essentia Health is one of the first accredited Accountable Care Organizations (ACOs) in the nation.2 This accreditation is part of Essentia Health’s pursuit of the Triple Aim of “improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.”3 Finally, Essentia Health is working on a Patient Centered Medical Home (PCMH) primary care delivery model project. As described by the Agency for Healthcare Research and Quality, PCMHs coordinate care among different partts of the healthcare system, such as hospitals and community services and supports,, and assure quality through activities such as population health management.4 Community/population health consequently links several of Essentia Health’s goals (Figure 1).

Figure 1. Population Health Links ACOs, PCMHs, and Community Benefit (CHNA)

Accountable Care Organization

Population Heal Patient Centered Medical Home

To meet the CHNA requirement, fifteen Essentia Health hospital facilities participated in a coordinated process that was facilitated by the Essentia Institute off Rural Health (EIRH), a center for research and education. In addition to furthering the goals listed above, a

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coordinated CHNA process presents research opportunities to EIRH through methodical evaluation of processes for and outcomes of health interventions developed in response to each community’s health needs. EIRH researchers will contribute to the evidence on intervention effectiveness, as well as quantify provision of community benefit for the IRS.

A substantial portion of the CHNA process was completed prior to the April 5, 2013 release of additional CHNA guidance via REG‐106499‐12.1 Consequently, the following CHNA report and accompanying implementation strategy conform to requirements outlined in Notice 2011‐525 with one exception and one addition resulting from guidance provided in REG‐106499‐12. The exception taken to Notice 2011‐52 relates to the following excerpt from REG‐106499‐12: “…these proposed regulations do not specifically require the CHNA report to contain the names or titles of any individuals contacted within an organization. In addition, the proposed regulations specify that a CHNA report does not need to name or otherwise individually identify any individuals participating in community forums, focus groups, survey samples, or similar groups.” Consequently, names and titles of individuals providing input in the hospital facility’s CHNA are suppressed. In order to conform to Notice 2011‐52, names and titles will be made available upon request. The addition made to this CHNA based on guidance provided in REG‐ 106499‐12 is the opportunity for public comment on the CHNA and implementation strategy. REG‐106499‐12 requires a hospital facility to take into account input from “written comments received on the hospital facility’s most recently conducted CHNA and most recently adopted implementation strategy.” Thus, comments on this CHNA and accompanying implementation strategy can be emailed to Essentia Health in order to meet this regulation for the next CHNA ([email protected]).

The following report is divided into sections and subsections as prescribed by Notice 2011‐52. Additional sections and subsections were included by the authors as needed. The conceptual model guiding the CHNA process is the Institute of Medicine’s Community Health Improvement Process6 (Figure 2). The “Problem Identification and Prioritization Cycle” culminated in identification and prioritization of three health needs for the community served by the hospital facility. These health needs, described in Section 6, will each be addressed by a 3‐year intervention, the first of which will begin in 2013 with the other two beginning in subsequent years (Figure 3). The “Analysis and Implementation Cycle” is currently underway. An inventory of resources is provided in Appendix C. Development of a health improvement strategy has already occurred for the highest priority health need (see Appendix A for greater detail). For the second and third priority health needs, intervention options will be presented at Town Hall Meetings to individuals representing the broad interests of the community who will be asked to select one for implementation. Town Hall Meetings for the second and third priority health needs will occur in late 2013/early 2014 and late 2014/early 2015, respectively. The remaining steps in the “Analysis and Implementation Cycle” will occur in the future. Intervention Planning

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Meetings will be held in order to make concrete plans for implementing the interventions and to identify individuals who are accountable for the implementation. Once the interventions are underway, their effectiveness will be monitored over time in order to determine whether the community health needs are being met and for researchers at EIRH to contribute to scientific evidence on intervention effectiveness.

Figure 2. Institute of Medicine Community Health Improvement Process

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I1nventQ1Y Resources

An aliy,ets and lmplementatlon Cycle,

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Figure 3. Intervention Timeline

Health Need 1 Health Need 2 Health Need 3 000 l Intervention 3 -----~ Intervention 2 -----~ Intervention 1

6/2013 6/2014 6/2015 6/2016 6/2017 6/2018

2. Community Served by the Hospital Facility

2.1. Description/Definition and Determination

Essentia Health West is located in Fargo, North Dakota (Figure 4) and serves Cass County, North Dakota and Clay County, Minnesota. This definition of the community served was determined by collective agreement of the Fargo‐Moorhead Community Health Needs Assessment Collaborative (i.e. the Collaborative). See Section 3 for more detail on the Collaborative. In the following report, data are presented at the county and state level to ensure stability of the estimates.

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Figure 4. Hospital Location ------,.------, Crltlcal Access Hospital Group I ~ Essentia Health ·cw-.....- ~ :..______, Hospital, Clinic & Other Facility Locations f ~ =- West, Central, East & Critical Access Hospital Group Regions

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2.2. Demographics

Population demographics for the four states in which Essentia Health has a presence are displayed below. See Subsection for 3.1 for detail on methods. As shown in Table 1, compared to the other states, Minnesota has the highest percentaage of individuals with annual household income ≥ $35,000 and who are college graduates. These differences translate into Minnesota having the highest proportion of individuals with high socioeconomic status (SES). North Dakota has the second highest percentage of individuals with annual household income ≥ $35,000 and who are college graduates, but these percentages are more similar to those of Idaho and Wisconsin than Minnesota. Consequently, North Dakota’s percentage of individuals with high SES is equal to that of Wisconsin and lower than Minnesotta. In North Dakota, 50.4% of individuals had at least one health service deficit (HSD), defined as lacking health insurance, lacking a healthcare provider, deferring medical care because of cost, or failing to obtain a routine medical exam, all within the last twelve months. Despite the relatively high SES and although lower than the other three states, 42.8% of Minnesotans had at least one HSD. 10

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Table 1. Population Demographics for States Where Essentia Health Has a Presence.

2009 BRFSS* Data (%) Measure North Idaho Minnesota Dakota Wisconsin Male 50.0 49.4 49.9 49.3 Sex Female 50.0 50.6 50.1 50.7 18‐34 Years 32.8 30.1 32.9 29.5 Age Ranges 35‐64 Years 50.8 53.3 47.8 52.8 >=65 Years 16.5 16.6 19.2 17.7 Annual Household <$35,000 40.7 26.0 33.3 37.9 Income >=$35,000 59.3 74.0 66.7 62.1

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As displayed in Table 2, there is a higher percentage of females in rural Minnesota compared to non‐rural Minnesota. All four states have a higher percentage of individuals ≥ 65 years of age in rural versus non‐rural areas, but the difference across rurality is more pronounced in Minnesota. All four states also have a lower percentage of college graduates in rural areas compared to non‐rural areas; this difference across rurality is larger in Minnesota than the other three states. A higher percentage of rural versus non‐rural individuals in all states have an annual household income < $35,000. There is a higher percentage of Caucasians in non‐rural versus rural North Dakota; this difference across rurality is reversed in Minnesota.

Table 2. Population Demographics for States Where Essentia Health Has a Presence Stratified by Geographic Locale (Rural/Non‐Rural)

% Idaho % Minnesota % North Dakota % Wisconsin Measure Non‐Rural Rural Non‐Rural Rural Non‐Rural Rural Non‐Rural Rural Sex Male 49.7 50.5 50.0 47.8 50.2 49.8 49.2 49.4 Female 50.3 49.5 50.0 52.2 49.8 50.2 50.8 50.6 >=65 Years 15.8 17.7 14.5 21.7 17.9 20.0 16.7 20.2 Household Income <$35,000 36.9 47.4 22.7 34.4 27.7 37.0 35.3 43.8 Education

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Stratification by race/ethnicity, as shown in Table 3, highlights other demographic factors in the four states. There is a sharply decreasing gradient across age in the percentage of North Dakotans and Minnesotans who are non‐Caucasian in that 55.6% and 53.9%, respectively, are 18‐34 years of age compared to the 30.4% and 27.9%, respectively, of Caucasians in that age range. In all states, a higher percentage of non‐Caucasians earn <$35,000 annually and a lower percentage are college graduates compared to Caucasians. These racial/ethnic differences in indicators of SES, however, are less pronounced in Minnesota versus the other three states. In all four states, a higher percentage of non‐Caucasians than Caucasians are unmarried and not living with a partner and have at least one child living in the household. These differences across race/ethnicity are more pronounced in North Dakota than in the other states.

Table 3. Population Demographics for States Where Essentia Health Has a Presence Stratified by Race/Ethnicity % Idaho % Minnesota % North Dakota % Wisconsin Measure Non‐ Non‐ Non‐ Non‐ Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Male 49.1 56.5 49.2 51.2 50.2 48.0 49.5 47.4 Sex Female 50.9 43.5 50.8 48.8 49.8 52.0 50.5 52.6 18‐34 Years 31.1 45.5 27.9 53.9 30.4 55.6 27.4 46.3 Age Ranges 35‐64 Years 51.7 43.2 54.6 39.3 49.3 34.5 54.3 40.6 >=65 Years 17.1 11.3 17.5 6.8 20.3 9.9 18.3 13.1 Household Income <$35,000 37.3 67.9 24.4 43.7 30.5 60.0 34.9 62.4

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Figure 5 includes the University of Wisconsin Population Health Institute (UWPHI) County Health Rankings7 for Social and Economic Factors for Cass County compared to other counties in North Dakota. Figure 6 includes Social and Economic Factors ranks for Clay County compared to other counties in Minnesota. A rank of one is the best. Seven counties in North Dakota were not ranked (Divide, Oliver, Golden Valley, Sheridan, Slope, Billings, and Steele), and three counties in Minnesota were not ranked (Kittson, Lake of the Woods, and Traverse). The underlying data for these ranks are included in Table 4 which also includes error margins and state averages, as well as national benchmarks, the point at which only 10% of counties in the nation do better. Cass County’s overall Social and Economic Factors rank is moderate. The lowest component rank is for Community Safety. As evidenced in Table 4, Cass County’s violent crime rate is higher than the North Dakota average, and both rates are higher than the national benchmark. Clay County’s overall Social and Economic Factors rank is high; however, Clay County is ranked low for Family and Social Support. The percent of adults without social/emotional support is higher in Clay County than the Minnesota average and the national benchmark.

Figure 5. UWPHI County Health Rankings Social and Economic Factors Ranks, Cass County Social & Economic Family & Social Community Factors Education Employment Income Support Safety 0 2 4 6 2 8 10 12 14 11 16 18 15 20 22 24 20 20 Rank 26 28 30 32 34 36 38 40 42 44 46 46

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Figure 6. UWPHI County Health Rankings Social and Economic Factors Ranks, Clay County Social & Economic Family & Social Community Factors Education Employment Income Support Safety 0 1 12

24 17 25 36 29 37 Rank 48

72 72 84

Table 4. UWPHI County Health Rankings Social and Economic Factors Data Social & North Dakota Minnesota Economic National Social & Economic Measure Factors Clay County Benchmark Cass County State State Category High school graduation, % of ninth grade cohort that graduates in 4 years, 93% 88% 78% 76% ‐ 2008‐2009 (ND), 2009‐2010 (MN) Education Some college, % of adults aged 25‐44 years with some post‐secondary 79% (76‐81%) 73% 74% (69‐78%) 72% 68% education, 2006‐2010 Unemployment, % of population age Employment 16+ unemployed but seeking work, 3.9% 3.9% 4.8% 7.3% 5.4% 2010 Children in poverty, % of children under Income 13% (10‐15%) 16% 15% (11‐18%) 15% 13% age 18 in poverty, 2010 Inadequate social support, % of adults without social/emotional support, 14% (12‐15%) 16% 17% (12‐23%) 14% 14% Family/Social 2005‐2010 Support Children in single‐parent households, % of children that live in household 25% (22‐28%) 25% 26% (22‐31%) 26% 20% headed by single parent, 2006‐2010 Community Violent crime rate per 100,000 237 203 91 254 73 Safety population, 2007‐2009

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2.3. Additional Demographic Data

Additional demographic data for Cass and Clay Counties are included in Table 5. The populations were estimated at just over 156,000 and 60,000 persons, respectively, in the most recent census with 10‐12% over age 65. Females constitute 49.6% (Cass County) and 50.6% (Clay County) of the populations. By race and ethnicity, the populations are not very diverse, with Caucasians constituting approximately 90% of the populations overall. Clay County has a high household ownership rate averaging 70.8% over a 4‐year timeframe, but Cass County’s household ownership rate is only 53.8%. Ninety‐three percent or more of the population aged 25 and older are high school graduates, and over 30% of this same group are college graduates (4‐year degree). Thirteen percent of the population lives below the federal poverty level. The per capita income averaged over a 4‐year timeframe was $29,518 (Cass County) and $23,771 (Clay County), and the median household income for this same time frame was $49,429 (Cass County) and $52,108 (Clay County). Cass and Clay Counties are considered non‐rural counties because Fargo, ND‐MN is a metropolitan area that is geographically part of both counties. According to the 2012 UWPHI County Health Rankings data, Cass County is 13.4% rural, and Clay County is 29.9% rural.

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Table 5. Cass and Clay County Demographic Data Demographic Variables Cass County, ND Clay County, MN Population, 2012 156,157 60,155 Persons under 5 years, percent, 2011 6.8% 6.7% Persons under 18 years, percent, 2011 21.5% 22.9% Persons 65 years and over, percent, 2011 9.9% 11.9% Female persons, percent, 2011 49.6% 50.6%

White persons not Hispanic, percent, 2011 90.3% 90.4% Black persons, percent, 2011 (a) 2.4% 1.5% Persons of Hispanic or Latino Origin, percent, 2011 (b) 2.2% 3.6% American Indian and Alaska Native persons, percent, 2011 (a) 1.4% 1.4% Other 3.7% 3.1%

Living in same house 1 year & over, percent, 2007‐2011 76.9% 83.4% Foreign born persons, percent, 2007‐2011 5.0% 2.9% Language other than English spoken at home, percent of persons age 5+, 2007‐2011 6.7% 5.4% High school graduate or higher, percent of persons age 25+, 2007‐2011 94.3% 93.0% Bachelor's degree or higher, percent of persons age 25+, 2007‐2011 36.5% 30.4%

Homeownership rate, 2007‐2011 53.8% 70.8% Median value of owner‐occupied housing units, 2007‐2011 $150,700 $149,900 Households, 2007‐2011 63,901 21,928 Persons per household, 2007‐2011 2.23 2.45 Per capita money income in the past 12 months (2011 dollars), 2007‐2011 $29,518 $23,771 Median household income, 2007‐2011 $49,429 $52,108 Persons below poverty level, percent, 2007‐2011 13.2% 13.0%

Land area in square miles, 2010 1,764.94 1,045.37 Persons per square mile, 2010 84.9 56.4 Federal Information Processing Standard (FIPS) Code 17 27 Rural No Source: US Census Bureau State & County QuickFacts

3. Process and Methods Used to Conduct the Assessment

3.1. Sources and Dates of the Data and Other Information Used in the Assessment

Essentia Health West’s CHNA process began with participation in the Fargo‐Moorhead Community Health Needs Assessment Collaborative (i.e. the Collaborative), a group composed of representatives from several community organizations and partnered with the Center for Social Research (CSR) at North Dakota State University (NDSU). All descriptions of CHNA 17

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activities prior to February 2013 are paraphrased or reproduced from work produced by these entities.

The Collaborative and CSR conducted a survey of residents in the greater Fargo‐Moorhead area to learn about the perceptions of area residents regarding the prevalence of disease and health issues in their community. Residents completing the survey were to return it by April 20, 2012. A breakfast meeting was also held in early May 2012 with community leaders during which they had an opportunity for discussion and completed a survey to explore their views regarding the resident population’s health and the prevalence of disease and health issues within the community. Other community leaders who were not able to attend the breakfast meeting completed the survey via an Internet‐based survey tool. Full reports on the surveys of residents and community leaders are included in this document’s companion reports titled “2012 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents” and “2012 Greater Fargo‐ Moorhead Community Health Needs Assessment of Community Leaders.”

A community health profile consisting of state and county service area demographic, health‐ related behaviors, health services, and health outcomes data was compiled for the hospital facility and is included in Subsection 2.2 and Section 4. Data for the community health profile were obtained from two sources: the UWPHI County Health Rankings7 and the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS).8

Primary and chronic disease needs of minority groups were assessed through stratification of BRFSS data on race/ethnicity, as well as administering a generalizable survey to residents of the greater Fargo‐Moorhead area. Primary and chronic disease needs and other health issues of uninsured persons and low‐income persons were also assessed through administration of a generalizable survey to residents. Additionally, BFRSS data were stratified on rurality, a factor that is relevant to 13.4% of Cass County and 29.9% of Clay County according to the 2012 UWPHI County Health Rankings data. The following excerpt9 authored by researchers at EIRH describes the health disparities experienced by rural populations:

“In addition to being a medically underserved population, U.S. rural residents experience more disease and greater health and healthcare disparities than urban residents.10,11 Specifically, compared to the urban population, rural populations have higher prevalence of uninsured adults, adults with chronic conditions such as diabetes and cardiovascular disease, adolescent and adult smoking, and below‐guideline consumption of fruits and vegetables.10‐17 Other important disparities in social determinants of health have also been detected for rural U.S. residents including higher poverty levels and lower levels of attained education.”

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UWPHI County Health Rankings7 data from 2012 were utilized in this assessment. These data are compiled by the County Health Rankings team from a variety of sources including, but not limited to, BFRSS, The Dartmouth Institute, the National Center for Health Statistics, the United States Census, and the United States Department of Agriculture. For this assessment, both the county rankings and the data underlying the rankings weere utilized ffrom the fulll County Health Rankings Model (Figure 7). The data presented here were downloaded in May 2013. Ranks are not shown if all underlying data are missing or unreliablee. As described earlier, a rank of one is best. Seven counties in North Dakota were not ranked (Billings, Divide, Golden Valley, Oliver, Sheridan, Slope, and Steele), and three counties in Minnesota were not ranked (Kittson, Lake of the Woods, and Traverse). The national benchmark is “the point at which only 10% of counties in the nation do better, i.e., the 90 th percentile or 10th percentile, depending on whether the measure is framed positively (e.g., high school graduation) or negatively (e.g., adult smoking).” Readers are directed to the County Health Rankings website7 for further information on data and methods. Figure 7. UWPHI County Health Rankings Model

Mortality ( length of life ) 50% Health Outcomes Morbidity (quality of life) 50%

Tobacco use

Diet & exercise Health behaviors (~) Alcohol use

Sexual activity

Access to care Clinical care (2°") Quality of care

Health Factors Education

Employment Social and economic factors Income (40%) Family& social support

Community safety

Physical Environmental quality environment Policies and Programs ( lO'K. l Built environment

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As the 2012 County Health Rankings used years of data ranging from 2002 to 2011, with several measures, such as diet and exercise, using 2009 data,7 BRFSS data from 2009 were utilized for congruency. These data were also the most recently available BRFSS data during the initial stages of Essentia Health’s CHNA.

BRFSS is the largest surveillance system in the world. BRFSS data are collected using a random‐ digit dial telephone survey targeting adults 18 through 99 years of age. These data are collected under the aegis of the CDC in collaboration with all US states and most US territories. Once collected, BRFSS data are weighted by state or territory to represent the non‐ institutionalized US adult population. BRFSS data are cross‐sectional and are focused on health risk factors and behaviors, as well as chronic diseases. All analyses were performed on weighted data as is recommended by the CDC. The weighting, calculated by the CDC, uses the most recently available census data to provide a stratified representation of the nation’s non‐ institutionalized population.

BRFSS data collected in 2009 and made available in 2010 were analyzed for this CHNA. These data were the most recently available BRFSS data during the initial stages of Essentia Health’s CHNA and correspond to the County Health Rankings data. In the analyses presented here, a number of variables were either re‐coded or computed. All re‐coding entailed collapsing categories and removing the responses don’t know and refused. The following variables were computed: health service deficits (HSD), socio‐economic status (SES), and race/ethnicity. HSD was computed from the response categories of four different variables (health insurance status, personal healthcare provider, deferment of medical care because of cost, and routine medical exam). These variables were chosen because they all impact how individuals interact with and access the health care system. The specific response categories were: did not have health insurance, did not have a healthcare provider, deferred medical care because of cost, and did not have a routine medical exam, all within the last 12 months. Having one or more of these constituted having a HSD.

SES is comprised of two categorical variables: education and income. In keeping with convention, data categories from each of these individual variables were coded as low, mid‐ range, or high and numbered 1, 2, or 3, respectively. The variables with numbered factors or categories were then added together to create the composite variable of SES. Categories for education included: low = less than high school (coded as 1), mid‐range = high school graduate (coded as 2), and high = at least some college (coded as 3). Categories for income were: low = <$25,000 (coded as 1), mid‐range = $25,000 ‐ <$50,000 (coded as 2), and high = > $50,000 (coded as 3). The possible range for the SES variable was 2 – 6 points. Subsequently, these points were indexed in the following manner: low = 2‐3 points, mid‐range = 4‐5 points, and high = 6 points. These cut‐points were purposive. For the lowest range of the index, 2 points

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was the floor (smallest possible point assignment). For the mid‐range of the index, 4 points was the floor, and for the high range of the index, 6 points was the floor. Any points below the floor for the mid‐range were assigned to the lowest index category just as any points below the floor for the highest index category were assigned to the mid‐range index category.

The race/ethnicity variable was calculated from participant responses to two separate survey questions—one regarding race and the other regarding Latino/Hispanic ethnicity. Caucasian, non‐Hispanic was coded as Caucasian, and all other racial/ethnic categories were coded as non‐ Caucasian.

The Metropolitan Statistical Area (MSA) variable included in BRFSS was used to define geographic locale. MSA was re‐coded by collapsing categories into those of rural and non‐rural. Rural residents were defined as persons living either within an MSA that had no city center or outside an MSA. Non‐rural residents included all respondents living in a city center of an MSA, outside the city center of an MSA but inside the county containing the city center, or inside a suburban county of the MSA.

3.2. Analytical Methods Applied/Process Used to Identify Community Health Needs

Results of the surveys of community residents and leaders were used to identify the community health needs. Survey statements about which respondents rated the highest levels of concern were ranked and categorized. The categories were: mental health, physical health, dental/vision, substance use and influence, health costs, elder care, illness and disease, health care, violence and safety, and child care. See Section 6 for further detail on health need identification and prioritization.

3.3. Information gaps that impact ability to assess the health needs of the community served by the hospital facility

Of the 1,500 randomly selected households to which the survey of residents was sent, 236 completed surveys were returned which provides a generalizable sample with a confidence level of 95% and an error rate of plus or minus 6 percent.

In the future, we intend to work directly with the state‐level BRFSS staff to ensure that rural populations are sufficiently sampled to provide adequate data. When possible, we will attempt to ensure that the data collected are sufficient for further county‐level analyses. In this iteration of the CHNA, we analyzed state‐level data according to a rural/non‐rural stratification. This was done to ensure stable estimates. County‐level data were not always available and when available were not always stable.

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3.4. Coordination with Other Hospitals and Collaboration with Other Organizations

Members of the Collaborative included: Blue Cross Blue Shield of North Dakota, the Center for Rural Health at the University of North Dakota, Clay County Public Health, Dakota Medical Foundation, Essentia Health, Family HealthCare Center, Fargo Cass Public Health, First Link, North Dakota State University, Sanford Health, Southeast Human Services Center, United Way of Cass‐Clay, and Urban Indian Health and Wellness Center of Fargo‐Moorhead. This list is slightly expanded from that included in the companion reports to this document as new members joined the Collaborative in later stages. The Collaborative partnered with CSR at NDSU.

In the interest of efficiency, cost effectiveness, and alignment with Essentia Health population health strategies, the hospital facility’s CHNA was conducted in a coordinated process with fourteen other Essentia Health hospital facilities since February 1, 2013. While still allowing for tailoring to each particular hospital facility, procedures were standardized to the extent possible across hospital facilities. The hospital facilities included in this coordinated process are: Bridges Medical Center, doing business as (DBA) Essentia Health Ada in Ada, MN; Clearwater Valley Hospital and Clinics, Inc. in Orofino, ID; Deer River Healthcare Center, Inc., DBA Essentia Health Deer River in Deer River, MN; Essentia Health Virginia, LLC, DBA Essentia Health Virginia in Virginia, MN; Graceville Health Center, DBA Essentia Health Holy Trinity Hospital in Graceville, MN; Innovis Health, LLC, DBA Essentia Health West in Fargo, ND; Minnesota Valley Health Center, Inc. in Le Sueur, MN; Northern Pines Medical Center, DBA Essentia Health Northern Pines in Aurora, MN; Pine Medical Center, DBA Essentia Health Sandstone in Sandstone, MN; SMDC Medical Center, DBA Essentia Health Duluth in Duluth, MN; St. Joseph’s Medical Center, DBA Essentia Health St. Joseph’s Medical Center in Brainerd, MN; St. Mary’s Hospital of Superior, DBA Essentia Health St. Mary’s Hospital‐Superior in Superior, WI; St. Mary’s Hospital, Inc. in Cottonwood, ID; St. Mary’s Medical Center, DBA Essentia Health St. Mary’s Medical Center in Duluth, MN; and St. Mary’s Regional Health Center, DBA Essentia Health St. Mary’s‐Detroit Lakes in Detroit Lakes, MN.

Additional collaboration with organizations outside of Essentia Health is planned during intervention implementation. Details such as the research and evaluation protocol for the selected interventions will be presented at Intervention Planning meetings to potential collaborators and hospital facility employees with authority to commit resources to implement the interventions. At the Intervention Planning meetings, selected interventions will be further tailored to the particular hospital facility and community’s programs and resources. The hospital facility’s first Intervention Planning Meeting is scheduled for July 8, 2013. In addition to individuals affiliated with Essentia Health, representatives from other organizations, such as the Dakota Medical Foundation, will be included. Other potential invitees to future

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Intervention Planning Meetings include social service and service organization representatives, city and county government officials, tribal government/leadership/representatives and/or other minority population group members/representatives, primary care and other healthcare providers, lead county public health officials, industry/business leaders/representatives, educators/educational administrators, and other relevant entities.

3.5. Contracted Third Parties

The Collaborative contracted with the CSR at NDSU to assist in conduct of the CHNA. The CSR team, consisting of Richard Rathge, Ph.D., Karen Olson, Ramona Danielson, and Kay Schwarzwalter, assisted with survey development and secondary research and also generated reports of their findings. Funding was provided by Collaborative member organizations, which included Essentia Health West. The CSR team’s qualifications include demography, research methodology, and rural sociology expertise of Dr. Rathge who has a joint teaching/research appointment in the Departments of Sociology/Anthropology and Agribusiness and Applied Economics at NDSU and is the Director of the North Dakota State Data Center. The CSR team’s qualifications also include Karen Olson’s research scientist experience and Ramona Danielson’s and Kay Schwarzwalter’s research assistance experience at NDSU’s Department of Agribusiness and Applied Economics.

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4. Community Health Profile

Demographic and social and economic data are included in Subsection 2.2. The following tables and figures include the remainder of the Community Health Profile.

Figure 8 and Figure 9 include the Health Outcomes, Mortality, and Morbidity ranks for Cass and Clay Counties. The ranks for Cass County are moderately‐high to high, but the ranks for Clay County are all moderately‐low to low. The mortality rank is based on 2006‐2008 premature death, defined as years of potential life lost before age 75 per 100,000 population (age‐ adjusted) and is 5,374 for Cass County versus 6,305 for North Dakota and is 6,427 for Clay County versus 5,248 for Minnesota. The national benchmark is 5,466. Table 6 includes the underlying data for the morbidity ranks.

Figure 8. UWPHI County Health Rankings Health Outcomes Ranks, Cass County

Health Outcomes Mortality Morbidity 0 2 4 6 8 4 10 7 12 14 16 18 20 22 18 24 Rank 26 28 30 32 34 36 38 40 42 44 46

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Figure 9. UWPHI County Health Rankings Health Outcomes Ranks, Clay County Health Outcomes Mortality Morbidity 0

Rank 48

60 55 64 64 72

Table 6. UWPHI County Health Rankings Health Outcomes Data North Dakota Minnesota National Measure of Morbidity Cass County State Clay County State Benchmark Poor or fair health, % of adults reporting fair or poor health (age‐ 10% (9‐11%) 12% 8% (6‐11%) 11% 10% adjusted), 2004‐2010 Poor physical health days, average number of physically unhealthy days 2.6 (2.3‐2.8) 2.7 2.6 (1.9‐3.3) 3.0 2.6 reported in past 30 days (age‐ adjusted), 2004‐2010 Poor mental health days, average number of mentally unhealthy days 2.3 (2.1‐2.6) 2.5 2.7 (1.8‐3.5) 2.7 2.3 reported in past 30 days (age‐ adjusted), 2004‐2010 Low birthweight, % of live births with low birthweight (< 2500 grams), 6.6% (6.2‐7.0%) 6.5% 6.9% (6.2‐7.6%) 6.5% 6.0% 2002‐2008

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The overall Health Factors ranks are 3 of 46 for Cass County and 22 of 84 for Clay County. Four types of health factors are ranked: Health Behaviors, Clinical Care, Social and Economic, and Physical Environment. The Health Behaviors ranks are shown in Figure 10 and Figure 11 with accompanying data included in Table 7. Cass County’s overall Health Behaviors rank is high. Cass County’s lowest Health Behaviors component rank is for Sexual Activity. Cass County’s chlamydia rate is near the North Dakota state average. Clay County’s overall Health Behaviors rank is moderate. Clay County’s lowest Health Behaviors component rank is for Diet and Exercise, and Table 7 indicates Clay County’s adult obesity and physical inactivity percentages are higher than the Minnesota averages, as well as the national benchmarks.

Figure 10. UWPHI County Health Rankings Health Behaviors Ranks, Cass County Health Behaviors Tobacco Use Diet & Exercise Alcohol Use Sexual Activity 0 2 4 6 3 8 10 6 12 14 16 18 20 22 19 24 Rank 26 22 28 30 32 34 36 32 38 40 42 44 46

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Figure 11. UWPHI County Health Rankings Health Behaviors Ranks, Clay County Health Behaviors Tobacco Use Diet & Exercise Alcohol Use Sexual Activity 0

24 22 36

Rank 48 49 51 60 55 62 72

Table 7. UWPHI County Health Rankings Health Behaviors Data Health North Dakota Minnesota National Behavior Health Behavior Measure Cass County State Clay County State Benchmark Category Adult smoking, % of adults that report Tobacco smoking ≥ 100 cigarettes and currently 18% (16‐19%) 19% 18% (13‐23%) 18% 14% Use smoking, 2004‐2010 Adult obesity, % of adults that report a 28% (26‐30%) 30% 30% (25‐36%) 26% 25% body mass index ≥ 30 kg/m2, 2009 Diet & Physical inactivity, % of adults aged 20 Exercise and over reporting no leisure time 22% (20‐24%) 26% 23% (18‐28%) 19% 21% physical activity, 2009 Excessive drinking, binge plus heavy 23% (21‐25%) 22% 20% (14‐26%) 19% 8% Alcohol drinking, 2004‐2010 Use Motor vehicle crash deaths per 100,000 9 (7‐11) 19 11 (8‐15) 13 12 population, 2002‐2008 Sexually transmitted infections, chlamydia 299 305 240 272 84 Sexual rate per 100,000 population, 2009 Activity Teen birth rate per 1,000 female 21 (19‐22) 28 16 (14‐17) 27 22 population, ages 15‐19, 2002‐2008

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BRFSS data indicate Minnesota tends to have a better health profile than the other states in which Essentia Health has a presence, and North Dakota tends to have a moderate health profile with respect to the other states (Table 8). Minnesota has the lowest prevalence of not having had a seasonal flu shot, diabetes, hypertension, high cholesterol, asthma, arthritis, and angina or cardiovascular disease (CVD) but the highest prevalence of inadequate consumption of fruits and vegetables. North Dakota has the highest prevalence of inadequate physical activity and arthritis. More than half of Minnesotans and North Dakotans are overweight or obese.

Table 8. Population Risk Factors and Disease Status for States Where Essentia Health Has a Presence 2009 BRFSS (%) Measure Idaho Minnesota North Dakota Wisconsin No Seasonal Flu Shot 64.5 49.8 57.4 57.4 BMI 25‐<30 36.2 37.9 37.8 36.4 Overweight or Obese I I BMI >=30 25.1 25.4 28.4 29.2 Less Than Moderate Physical Activity 42.5 47.3 47.7 47.2 Diabetes 8.0 6.4 7.5 8.2 Hypertension 26.1 22.3 27.1 28.1 High Cholesterol 37.2 33.9 34.8 35.8 Asthma 12.7 9.6 12.0 13.7 Arthritis 23.7 20.9 27.4 25.2 Angina or CVD 3.9 3.5 3.6 4.3 Binge Drinking 12.6 20.1 20.9 22.9 Consume Fruit & Vegetables < 5 Times Daily 75.4 78.1 77.5 77.3

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In all states in which Essentia Health has a presence, there is a higher prevalence of fair or poor self‐defined health status among individuals living in rural versus non‐rural areas (Table 9). Further examination of population risk factors and disease status in these states stratified by geographic locale supports the poorer self‐defined health status in rural areas. In all states, the prevalence of diabetes, hypertension, arthritis, myocardial infarction, and stroke is higher in rural areas compared to non‐rural. In Minnesota and North Dakota, the prevalence of obesity, inadequate physical activity, binge drinking, high cholesterol, no seasonal flu shot, and inadequate consumption of fruits and vegetables is higher in rural versus non‐rural areas (Table 9). Differences across rurality are particularly large for North Dakota compared to the other three states for obesity and binge drinking. In Minnesota, differences across rurality are particularly large compared to the other three states for inadequate physical activity, diabetes, hypertension, high cholesterol, arthritis, and angina or CVD.

Table 9. Population Risk Factors and Disease Status for States Where Essentia Health Has a Presence Stratified by Geographic Locale (Rural/Non‐Rural) % Idaho % Minnesota % North Dakota % Wisconsin Measure Non‐ Non‐ Non‐ Non‐ Rural Rural Rural Rural Rural Rural Rural Rural Good To Excellent 86.2 82.4 91.1 86.8 90.2 87.2 88.7 86.9 Self‐Defined Health Status Fair To Poor 13.8 17.6 8.9 13.2 9.8 12.8 11.3 13.1 BMI 25‐<30 35.6 37.3 38.0 37.5 38.7 37.2 36.3 36.8 Overweight or Obese BMI >=30 24.9 25.5 23.7 29.3 23.8 31.3 29.7 28.2 Less Than Moderate Physical Activity 42.5 42.5 45.7 51.2 47.0 48.1 47.3 46.9 Binge Drinking 12.7 12.6 19.5 21.4 18.3 22.6 22.8 23.0 Diabetes 7.7 8.4 5.8 7.7 6.6 8.1 8.1 8.6 Hypertension 25.4 27.5 20.8 26.0 24.9 28.5 27.3 29.8 High Cholesterol 36.5 38.7 32.7 36.8 34.5 34.9 36.2 34.8 Asthma 12.8 12.5 10.3 7.7 11.2 12.5 14.8 11.4 Arthritis 22.2 26.4 18.7 26.3 25.1 28.9 24.3 27.1 Myocardial Infarction 3.3 4.2 2.2 4.5 3.7 4.0 3.1 4.1 Angina or CVD 3.5 4.5 2.7 5.3 3.8 3.5 4.2 4.4 Stroke 2.3 2.7 2.0 2.9 2.3 3.2 1.8 3.0 No Seasonal Flu Shot 62.1 68.6 48.6 52.5 53.6 59.8 57.5 57.2 Fewer Than 5 Servings Daily of Fruit and Vegetables 74.0 77.8 77.2 80.3 77.4 77.5 76.6 78.9

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Stratifying various population risk factors and disease statuses by race/ethnicity in states where Essentia Health has a presence indicates a higher prevalence of fair to poor self‐defined health among non‐Caucasians versus Caucasians in all states (Table 10). Likewise, the prevalence of obesity, asthma, and not having had a seasonal flu shot is higher among non‐Caucasians than Caucasians. The prevalence difference across race/ethnicity is particularly large for obesity in North Dakota. In Minnesota, the prevalence of inadequate physical activity is also higher among non‐Caucasians than Caucasians.

Table 10. Population Risk Factors and Disease Status for States Where Essentia Health Has a Presence Stratified by Race/Ethnicity % Idaho % Minnesota % North Dakota % Wisconsin Measure Non‐ Non‐ Non‐ Non‐ Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Good To 86.4 72.9 90.0 88.7 89.4 79.6 88.7 83.8 Self‐Defined Health Status Excellent Fair To Poor 13.6 27.1 10.0 11.3 10.6 20.4 11.3 16.2 BMI 25‐<30 36.5 33.4 37.5 41.4 38.5 31.6 36.6 34.9 Overweight or Obese BMI >=30 24.5 30.6 25.0 29.2 27.2 39.2 28.1 38.5 Less Than Moderate Physical Activity 41.7 48.5 47.0 49.8 48.2 43.7 47.1 48.2 Diabetes 7.7 10.0 6.4 6.4 7.2 10.0 8.3 7.6 Hypertension 26.2 25.5 22.5 20.7 27.4 24.9 28.3 26.0 High Cholesterol 37.6 34.1 34.5 27.2 35.8 24.5 35.9 34.1 Asthma 12.5 14.0 8.9 16.6 11.3 17.7 12.9 20.4 Arthritis 24.3 19.6 21.5 14.9 27.5 26.9 25.8 20.0 Angina or CVD 3.9 3.7 3.7 1.4 3.7 2.9 4.5 2.6 No Seasonal Flu Shot 64.2 66.6 49.5 53.1 57.0 60.6 56.3 67.0 Fewer Than 5 Servings Daily F&V 75.4 75.0 78.3 75.7 78.0 72.7 77.2 78.3

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The County Health Rankings for Clinical Care are high for Cass County (Figure 12). Clay County’s overall Clinical Care Rank is moderately high, but the Access to Care Rank is moderately low (Figure 13). Clay County’s population to primary care physicians ratio is much higher than the Minnesota average and national benchmark (Table 11).

Figure 12. UWPHI County Health Rankings Clinical Care Ranks, Cass County Clinical Care Access to Care Quality of Care 0 2 4 1 6 2 8 10 6 12 14 16 18 20 22 24 Rank 26 28 30 32 34 36 38 40 42 44 46

Figure 13. UWPHI County Health Rankings Clinical Care Ranks, Clay County Clinical Care Access to Care Quality of Care 0 4 12

24 23 36

Rank 48

60 62 72

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Table 11. UWPHI County Health Rankings Clinical Care Data Clinical North Dakota Minnesota National Care Clinical Care Measure Cass County State Clay County State Benchmark Category Uninsured, % of population under age 65 without health 11% (9‐12%) 12% 11% (9‐12%) 10% 11% Access to insurance, 2009 Care Primary care physicians, ratio of population to primary care 646:1 1009:1 3981:1 930:1 945:1 physicians, 2010‐2011 Preventable hospital stays, hospitalization rate for ambulatory‐care sensitive 46 (42‐50) 64 38 (33‐44) 53 49 conditions per 1,000 Medicare enrollees, 2009 Quality Diabetic screening, % of diabetic of Care Medicare enrollees that receive 89% (83‐95%) 85% 86% (76‐96%) 86% 89% HbA1c screening, 2009 Mammography screening, % of female Medicare enrollees that 79% (72‐85%) 72% 81% (69‐91%) 75% 74% receive mammography screening, 2009

Table 12 includes data on population health services for states where Essentia Health has a presence. North Dakota has the lowest prevalence of deferring medical care because of cost compared to the other states. Minnesota performs better than the other states in terms of the prevalence of having had a recent routine medical exam, self‐defined health status, and having health insurance.

Table 12. Population Health Service Information for States Where Essentia Health Has a Presence 2009 BRFSS (%) Measure Idaho Minnesota North Dakota Wisconsin Do not Have Personal Healthcare Provider 27.0 20.8 23.9 15.2 Last Routine Medical ≤12 Months Ago 56.3 70.9 62.7 64.5 Check‐up >12 Months Ago 43.7 29.1 37.3 35.5 Self‐Defined Health Good To Excellent 84.8 89.9 88.4 88.1 Status Fair To Poor 15.2 10.1 11.6 11.9 Do Not Have Health Insurance 18.7 8.0 10.7 10.3 Deferred Medical Care Because Of Cost 14.2 10.3 6.2 10.0

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Stratifying population health service and SES data by geographic locale indicates that the prevalence of having at least one HSD is higher in rural versus non‐rural North Dakota, but is lower in rural Minnesota versus non‐rural Minnesota (Table 13). In all states, there is a higher prevalence of not having health insurance and low SES in rural versus non‐rural areas. The prevalence of not having a personal healthcare provider is higher in rural versus non‐rural North Dakota, and the difference across rurality is larger in North Dakota than in the other states.

Table 13. Population Health Service and SES Information for States Where Essentia Health Has a Presence Stratified by Geographic Locale (Rural/Non‐Rural) % Idaho % Minnesota % North Dakota % Wisconsin Measure Non‐ Non‐ Non‐ Non‐ Rural Rural Rural Rural Rural Rural Rural Rural Do Not Have Personal Healthcare Provider 26.2 28.4 21.3 19.6 20.6 26.1 14.2 17.5 Do Not Have Health Insurance 16.8 22.0 7.6 8.9 8.3 12.3 9.0 13.2 Last Routine Medical ≤12 Months Ago 57.5 54.3 70.0 73.1 64.0 61.8 65.3 62.7 Check‐up >12 Months Ago 42.5 45.7 30.0 26.9 36.0 38.2 34.7 37.3 Deferred Medical Care Because of Cost 13.3 15.9 10.9 8.8 5.3 6.8 9.8 10.4 At Least 1 Health Service Deficit* 55.4 59.1 43.6 40.7 46.7 52.9 42.4 48.3 Low 33.8 42.8 19.0 29.8 23.0 33.1 32.7 41.7 Socioeconomic Status Middle 50.0 48.7 50.6 56.4 54.9 56.0 48.9 50.0 High 16.3 8.4 30.4 13.8 22.0 10.9 18.4 8.3 * Defined as lacking health insurance, lacking a healthcare provider, deferring medical care because of cost, or failing to obtain a routine medical exam, all within the last twelve months.

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In Table 14, disparities across race/ethnicity with respect to population health service and SES become apparent. In all four states, there is a higher prevalence of not having a personal healthcare provider, having had a routine medical check‐up more than twelve months ago, not having health insurance, and deferring medical care because of cost among non‐Caucasians compared to Caucasians. Consequently, the prevalence of having at least one HSD is higher among non‐Caucasians than Caucasians in all four states. Furthermore, low SES is more prevalent among non‐Caucasians than Caucasians in all four states.

Table 14. Population Health Service and SES Information for States Where Essentia Health Has a Presence Stratified by Race/Ethnicity % Idaho % Minnesota % North Dakota % Wisconsin Measure Non‐ Non‐ Non‐ Non‐ Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Caucasian Do Not Have a Personal 25.0 42.2 19.8 31.5 22.5 36.5 13.9 25.9 Healthcare Provider ≤12 Months 57.3 48.7 71.4 65.8 62.9 61.0 64.7 62.8 Last Routine Ago Medical Check‐ >12 up Months 42.7 51.3 28.6 34.2 37.1 39.0 35.3 37.2 Ago No Health Insurance 16.5 35.9 7.6 11.8 9.0 26.3 9.2 19.1 Deferred Medical Care 13.3 21.8 8.9 24.3 5.2 14.7 8.6 21.6 Because of Cost Low SES 33.3 67.4 20.8 35.5 26.4 54.2 32.8 57.2 Socioeconomic Middle SES 52.1 28.2 53.1 42.9 57.5 37.8 51.0 34.6 Status High SES 14.5 4.5 26.0 21.6 16.1 8.1 16.1 8.2 At Least 1 Health Service 55.1 69.5 41.5 56.3 48.9 64.0 43.4 50.6 Deficit* * Defined as lacking health insurance, lacking a healthcare provider, deferring medical care because of cost, or failing to obtain a routine medical exam, all within the last twelve months.

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The overall Physical Environment rank is moderate for Cass County (Figure 14) and moderately low for Clay County (Figure 15). Clay County’s Built Environment rank is especially low. Clay County has more limited access to healthy food than the Minnesota average, which, in turn, is more limited than the national benchmark (Table 15). Table 15 also shows Clay County has a higher percentage of fast food restaurants than the Minnesota average, which is higher than the national benchmark.

Figure 14. UWPHI County Health Rankings Physical Environment Ranks, Cass County Physical Environment Environmental Quality Built Environment 0 2 4 1 6 8 10 12 14 16 18 20 22 24 20 21 Rank 26 28 30 32 34 36 38 40 42 44 46

Figure 15. UWPHI County Health Rankings Physical Environment Ranks, Clay County Physical Environment Environmental Quality Built Environment 0 1 12

Rank 48

60 60 72 73 84

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Table 15. UWPHI County Health Rankings Physical Environment Data Physical North Dakota Minnesota National Environment Physical Environment Measure Cass Clay State State Benchmark Category County County Air pollution – particulate matter days, annual number of unhealthy air quality 0 0 0 0 0 Environmental days due to fine particulate matter, 2007 Quality Air pollution – ozone days, annual number of unhealthy air quality days due 0 0 0 0 0 to ozone, 2007 Access to recreational facilities, rate of recreational facilities per 100,000 13 13 11 12 16 population, 2009 Built Limited access to healthy foods, % of Environment population who are low‐income and do 5% 11% 11% 6% 0% not live close to a grocery store, 2006 Fast food restaurants, % of all restaurants 49% 41% 55% 48% 25% that are fast‐food establishments, 2009

While the tables and figures above considered several health outcomes and risk factors by geographic locale and race/ethnicity, Table 16 breaks down a particular health risk factor, smoking, by other measures. In all four states, the prevalence of smoking is higher among non‐ Caucasians than Caucasians, individuals living in rural versus non‐rural areas, and individuals with at least one HSD versus zero. The most striking relation, however, is the gradient in current smoking across SES wherein the prevalence of current smoking increases as SES decreases. These data exemplify how relations can exist among health‐related factors, such as smoking and SES. These data, however, do not denote causality.

Table 16. Examination of a Specific Health Issue: The Case of Smoking % Idaho % Minnesota % North Dakota % Wisconsin Measure Current Do Not Current Do Not Current Do Not Current Do Not Smoker Smoke Smoker Smoke Smoker Smoke Smoker Smoke Overall 16.3 83.7 16.8 83.2 18.6 81.4 18.8 81.2 Caucasian 16.1 83.9 16.1 83.9 16.1 83.9 17.8 82.2 Race/Ethnicity Non‐Caucasian 17.5 82.5 23.6 76.4 40.6 59.4 26.6 73.4 Geographic Non‐Rural 15.1 84.9 16.5 83.5 13.3 86.7 18.5 81.5 Locale Rural 18.4 81.6 17.4 82.6 22.0 78 19.4 80.6 Low 27.7 72.3 31.8 68.2 30.8 69.2 29.6 70.4 SES Middle 11.2 88.8 15.7 84.3 16.6 83.4 16.3 83.7 High 4.3 95.7 6.2 93.8 7.7 92.3 4.8 95.2 Health Service No HSD 10.6 89.4 12.7 87.3 13.5 86.5 13.4 86.6 Deficit* At Least 1 HSD 20.3 79.7 22.4 77.6 23.6 76.4 25.6 74.4 * Defined as lacking health insurance, lacking a healthcare provider, deferring medical care because of cost, or failure to obtain a routine medical exam, all within the last twelve months. 36

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5. Input from Persons Who Represent the Broad Interests of the Community Served by the Hospital Facility

5.1. When and How These Persons Were Consulted

As described in subsection 3.1, persons representing the broad interests of the community were consulted on two occasions. A generalizable survey was administered to residents of the greater Fargo‐Moorhead area. Residents completing the survey were to return it by April 20, 2012. A breakfast meeting was also held in early May 2012 for community leaders during which they had an opportunity for discussion and also completed a survey. Other community leaders who were not able to attend the breakfast meeting completed the survey via an Internet‐based survey tool. Full reports on the surveys of residents and community leaders are included in this document’s companion reports titled “2012 Greater Fargo‐Moorhead Community Health Needs Assessment of Residents” and “2012 Greater Fargo‐Moorhead Community Health Needs Assessment of Community Leaders.”

In the future, persons will be consulted at Town Hall Meetings, which will be the first step in addressing the second and third prioritized health needs. During the Town Hall Meetings, intervention options for meeting the relevant health need will be presented, and participants will select the option best suited to their community. Town Hall Meetings for the second and third priorities will occur in late 2013/early 2014 and late 2014/early 2015, respectively. Further consultation with potential collaborators will occur prior to intervention implementation at Intervention Planning Meetings (see Subsection 3.4).

5.2. Organizations Consulted

Organizations represented by the community leaders who attended the breakfast meeting or completed the online survey include: Alzheimer’s Association, Arthritis Foundation, Cass Clay Healthy People Initiative of the Dakota Medical Foundation, Churches United for the Homeless, City of Fargo, City of West Fargo, Clay County Collaborative, Clay County Public Health, Clay County Sheriff’s Office, Dakota Medical Foundation, Essentia Health West Region, Essentia Health West, Family HealthCare Center, Fargo Cass Public Health, Fargo City Commission, Fargo School Board, First Link, Healthy North Dakota Worksite, Lutheran Social Services, March of Dimes, Minnesota State University Moorhead, Moorhead City Council, North Dakota Disability Health, North Dakota State University, Prairie St. John’s, Sanford Health Fargo, Sanford Medical Center Fargo, Senator Rick Berg’s North Dakota Office, ShareHouse, Southeast Human Services Center, United Way, and West Fargo School Board.

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Possible prospective Town Hall Meeting participants for the second and third priority health needs include: the Community/Patient Focus Group participants, social service and service organization representatives, city and county government officials, tribal government/leadership/representatives and/or other minority population group members/representatives, primary care and other healthcare providers, lead county public health officials, industry/business leaders/representatives, educators/educational administrators, and other relevant entities.

5.3. Individuals with Special Knowledge of or Expertise in Public Health

Clay County Public Health and Fargo Cass Public Health (names and titles available upon request) were members of the Collaborative, and representatives from these organizations also completed the survey of community leaders. These individuals’ special knowledge or expertise in public health derives from their employment with county public health offices. These individuals and/or other Public Health representatives will be invited to future Town Hall and Intervention Planning Meetings.

5.4. Federal, Tribal, Regional, State, or Local Health or Other Departments or Agencies with Current Data or Other Information Relevant to the Health Needs of the Community

Subsection 5.3 describes input provided by Clay County Public Health and Fargo Cass Public Health.

5.5. Individuals Who are Leaders, Representatives, or Members of Medically Underserved, Low‐Income, and Minority Populations and Populations with Chronic Disease Needs

The survey sent to community residents was designed to be generalizable to the community, which includes members of medically underserved, low‐income, and minority populations and populations with chronic disease needs.

Several organizations represented by community leaders who completed the survey of community leaders focus on the needs of medically underserved, low‐income, or minority populations or populations with chronic disease needs. These include, but are not limited to: Alzheimer’s Association, Arthritis Foundation, Churches United for the Homeless, Lutheran Social Services, North Dakota Disability Health, Prairie St. John’s, ShareHouse, Southeast Human Services Center, and United Way. The Collaborative also included the Center for Rural Health at

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the University of North Dakota and the Urban Indian Health and Wellness Center of Fargo‐ Moorhead.

6. Community Health Needs Identified Through the CHNA

6.1. Process and Criteria Used in Prioritizing the Needs

In October 2012, members of the Collaborative conducted a two‐round voting process to prioritize the topics and general categories of the survey statements about which respondents rated the highest levels of concern. The categories were, in order of priority: physical health, mental health, health care, substance use and influence, health costs and elder care (tied), violence and safety, illness and disease and child care (tied), and dental/vision. In order to streamline these categories into categories with more clear intervention options and to begin standardizing them with the health needs of the other Essentia Health hospital facilities, these categories were collapsed into the following prioritized list: physical health, mental health, health care, substance use and influence, and violence and safety. The top three categories (physical health, mental health, and health care) will be addressed by an intervention. The top‐ voted survey statement topics within these three categories were obesity, poor nutrition/eating habits, and inactivity and/or lack of exercise for physical health; availability of mental health services for mental health; and availability of prevention programs or services and coordination of care for health care.

6.2. Standardization and Prioritized Description of Identified Health Needs

Upon identification and prioritization of health needs for the fourteen other Essentia Health hospital facilities participating in the coordinated CHNA process, it became apparent that the prioritized health needs for each community fell into similar thematic categories. These health needs were subsequently standardized across the communities in order to leverage the value of a coordinated process across a health system by, for example, sharing resources and processes for addressing similar health needs.

Some health needs were inherently standardized across the communities. As none of these health needs were the highest‐priority in communities served by hospital facilities participating in Essentia Health’s coordinated CHNA process, interventions to address these health needs have not yet been selected. These health needs include:

 Reduction of excessive/binge drinking  Tobacco use primary prevention/cessation  Immunizations

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Other health needs were composed of clusters of related concepts that only slightly varied across communities. These clusters were aggregated into four health needs. All communities served by hospital facilities participating in Essentia Health’s coordinated CHNA process identified one of two of these aggregated health needs as their highest‐priority. Consequently, interventions addressing these two health needs have been selected. The aggregated health needs include:

 Health needs selected as highest‐priority by communities and for which interventions have been selected o Obesity, physical activity, and nutrition as risk factors for chronic diseases, including type 2 diabetes: Community members at almost all Community/Patient Focus Groups held for the fourteen other Essentia Health hospital facilities identified obesity, physical activity, and nutrition as health needs. This constellation of risk factors is pertinent to development of a variety of chronic diseases, including type 2 diabetes, which was one of the chronic conditions discussed by several communities. As evidenced in Table 9, the prevalence of diabetes is higher in rural areas in all states in which Essentia Health has a presence. Furthermore, individuals in rural areas are more likely to receive inadequate diabetic care than their non‐rural counterparts.18,19 Consequently, type 2 diabetes is a particularly apt health outcome to focus on with respect to addressing negative outcomes of obesity, physical inactivity, and poor nutrition. All hospitals identifying this health need as their highest priority will implement an enhanced type 2 diabetes prevention and education intervention, as described in Appendix B, to address it. o Access to healthcare: Community members at Community/Patient Focus Groups held for the fourteen other hospital facilities discussed issues related to healthcare cost/insurance, availability and assignment of primary care providers, provision of mental healthcare, and transportation for healthcare. These various issues were aggregated into the health need of access to healthcare, defined as enhanced healthcare for the local population. The four hospital facilities participating in the coordinated CHNA process across Essentia Health that selected access to healthcare as their highest‐priority health need will implement either an enhanced type 2 diabetes prevention and education intervention or a collaborative care for the management of depressive disorders intervention. The former intervention enhances healthcare for the local population by 1) providing diabetes education as community benefit to the extent feasible, 2) involving primary care providers, and 3) either providing a healthcare service that does not currently exist or expanding the impact of existing services. The latter intervention focuses on mental healthcare provision.

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 Health needs selected as lower‐priority by communities and for which interventions have not yet been selected for most hospitals o Preventive care, encompassing primary prevention (e.g. health education, wellness plans, immunizations) and secondary prevention/screening: This health need is an aggregation of general wellness, prevention/wellness, and holistic wellness/primary prevention, which includes issues such as health education, wellness plans, immunizations, and primary and secondary prevention. This health need was the second‐highest priority for Essentia Health St. Mary’s Hospital‐Superior and will be addressed by the enhanced type 2 diabetes prevention and education intervention in 2014. o Secondary prevention/screening: Participants at the Essentia Health St. Mary’s Hospital‐Superior Community/Patient Focus Group while choosing preventive care as their second prioritized health need, selected the sub‐category of secondary prevention/screening as their third prioritized need.

Additional health needs identified for the community served by Essentia Health West include:

 Access to mental healthcare, particularly availability of mental health services  Substance use and influence , particularly alcohol use and abuse  Violence and safety, particularly child abuse and neglect

The ten health needs in the bulleted lists above compose the significant system‐wide health needs identified for the hospital facilities participating in Essentia Health’s coordinated CHNA process. Each hospital facility will address the three highest priority health needs for their community. The hospital facilities will not directly meet the seven unprioritized health needs due to resource constraints. Rather than inadequately addressing all health needs, the hospital facilities will focus resources, financial and otherwise, on their community’s three prioritized health needs in order to foster success in meeting those health needs. Despite not directly meeting the unprioritized health needs, interventions addressing the three prioritized health needs may partially address the unprioritized health needs that overlap with the prioritized health needs. If the unprioritized health needs remain in the next CHNA cycle, they may be directly addressed at that time.

The top three health needs for the greater Fargo‐Moorhead area voted on by members of the Collaborative based on results of surveys of community residents and leaders were similar to and thus merged with the standardized health needs prioritized by the other Essentia Health hospital facilities participating in the coordinated CHNA process. Consequently, the final three priority health needs for the community served by Essentia Health West that will each be addressed, in order, by a 3‐year intervention are (Figure 3):

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1. Obesity, physical activity, and nutrition as risk factors for chronic diseases, such as type 2 diabetes 2. Access to mental health care 3. Access to health care, defined as enhanced health care for the local population

7. Existing Healthcare Facilities and Other Resources Within the Community Available to Meet the Community Health Needs Identified Through the CHNA

Existing healthcare facilities and other resources within the community available to meet the community health needs identified through the CHNA are listed in the Compendium of Resources in Appendix C.

7.1. Process for Identifying and Prioritizing Resources/Services to Meet the Community Health Needs

Existing healthcare facilities and other resources were identified by provision of a template Compendium of Resources to the hospital facility. The template was a grid of the three prioritized health needs crossed with separate resource categories including healthcare facilities, human, financial, programmatic, and infrastructure. A sampling of local events was also requested for the purpose of planning future community outreach. The hospital facility completed the template through internet searching, existing community knowledge, contacting relevant individuals for further information, and referencing the Community Health Needs Assessment Asset Mapping Worksheet: Fargo Moorhead Stakeholders. While some resource types in the Compendium of Resources, such as programmatic resources, are divided by health need, resources included for one health need may be useful in meeting the other health needs as well. Prioritization of resources to meet the community health needs will be based on availability and relevance to planned interventions.

8. Making the CHNA Report Widely Available to the Public

This report was made widely available to the public by the following methods:

 Posting a PDF of the report under the “Community Benefit/CHNA” tab on the hospital facility’s homepage (http://www.essentiahealth.org/Fargo/FindaClinic/Essentia‐HealthFargo‐87.aspx)  Providing paper copies without charge at the hospital facility upon request

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References 1. REG‐106499‐12. Department of Treasury Internal Revenue Service. Community Health Needs Assessments for Charitable Hospitals. 78 FR 20523. 2013. Accessible at: https://federalregister.gov/a/2013‐07959. 2. Essentia Health is one of six U.S. organizations to earn ACO accreditation | COO John Smylie discusses the accreditation process in Wednesday webinar. 2013. Accessible at: http://essentiahealth.org/Main/PressReleases/Essentia‐Health‐is‐one‐of‐six‐US‐ organizations‐to‐242.aspx. 3. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, and Cost. Health Affairs. 2008;27(3):759‐769. 4. Agency for Healthcare Reserach and Quality. Patient Centered Medical Home Resource Center. Accessible at: http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/PCMH_Defining %20the%20PCMH_v2. 5. Notice 2011‐52. Department of Treasury Internal Revenue Service. Notice and Request for Comments Regarding the Community Health Needs Assessment Requirements for Tax‐exempt Hospitals. 2011. Accessible at: http://www.irs.gov/pub/irs‐drop/n‐11‐ 52.pdf. 6. Improving Health in the Community: A Role for Performance Monitoring. The National Academies Press; 1997. Reprinted with permission from Permissions Coordinator, 2013 by the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C. 7. University of Wisconsin Population Health Institute. County Health Rankings 2012. Accessible at: www.countyhealthrankings.org. 8. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. Accessible at: http://www.cdc.gov/brfss/. 9. Lutfiyya MN, McCullough JE, Saman DM, et al. Rural/urban differences in health services deficits among U.S. adults with arthritis: A population‐based study. Journal of Nursing Education and Practice. 2013;3(11):43‐53. 10. Agency for Healthcare Research and Quality. National healthcare disparities report. National Center for Health Statistics. 2007. Accessible at: http://www.ahrq.gov/htm. PMid:23062678. 11. Graves BA. Telehealth for communities: Toward eliminating rural health disparities. Online Journal of Rural Nursing and Health Care. 2010;10(1). 12. Doescher MP, Jackson JE, Jerant A, Gary Hart L. Prevalence and Trends in Smoking: A National Rural Study. The Journal of Rural Health. 2006;22(2):112‐118. 13. Danaei G, Rimm EB, Oza S, Kulkarni SC, Murray CJL, Ezzati M. The Promise of Prevention: The Effects of Four Preventable Risk Factors on National Life Expectancy and Life

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Expectancy Disparities by Race and County in the United States. PLoS Med. 2010;7(3):e1000248. 14. Vander Weg MW, Cunningham CL, Howren MB, Cai X. Tobacco use and exposure in rural areas: Findings from the Behavioral Risk Factor Surveillance System. Addictive Behaviors. 2011;36(3):231‐236. 15. Lutfiyya MN, Shah K, Johnson M, et al. Adolescent daily cigarette smoking: Is rural residency a risk factor? Rural and Remote Health. 2008;8:875. 16. Krishna S, Gillespie KN, McBride TM. Diabetes Burden and Access to Preventive Care in the Rural United States. The Journal of Rural Health. 2010;26(1):3‐11. 17. Lutfiyya MN, Chang LF, Lipsky MS. A cross‐sectional study of US rural adults' consumption of fruits and vegetables: Do they consume at least five servings daily? BMC Public Health. 2012;12:280. 18. Lutfiyya MN, Patel YR, Steele JB, et al. Are there disparities in diabetes care? A comparison of care received by US rural and non‐rural adults with diabetes. Primary Health Care Research & Development. 2009;10(04):320‐331. 19. Lutfiyya MN, McCullough JE, Mitchell L, Dean LS, Lipsky MS. Adequacy of diabetes care for older US rural adults: A cross‐sectional population based study using 2009 BRFSS data. BMC Public Health. 2011;11:940. 20. Elder Services Network. Senior & Caregiver Resource Guide for Northern St. Louis County, 2012‐2013. Duluth, MN: The Senior Reporter Harbor Centers, Inc.

Acknowledgments

Essentia Health thanks members of the Fargo‐Moorhead Community Health Needs Assessment Collaborative, as well as the Center for Social Research at North Dakota State University. Essentia Health also thanks community residents and leaders who provided input to this CHNA. Finally, Essentia Health thanks all participants at future Town Hall and Intervention Planning Meetings and all individuals who will participate in ensuring the success of interventions introduced to meet the community’s health needs.

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Appendix A Essentia Health West, Fargo, ND Implementation Strategy

Appendix A – Implementation Strategy

The following implementation strategy was approved by the Essentia Health West Region Board of Directors on May 30, 2013. The implementation strategy describes the enhanced DSME intervention being delivered primarily by a Certified Diabetes Educator (CDE). As the National Diabetes Prevention Program does not require CDE certification for delivery, an individual with other qualifications may be the primary meeting leader in the finalized intervention. CDEs and/or other health care professionals will be involved in the intervention as needed and as is feasible.

Introduction

As mandated in IRS Notice 2011‐52 Notice and Request for Comments Regarding the Community Health Needs Assessment Requirements for Tax‐exempt Hospitals (1), the following implementation strategy addresses each of the community health needs identified through the Community Health Needs Assessment (CHNA) conducted for the 2013 taxable year for Innovis Health, LLC, doing business and hereafter referred to as Essentia Health West. This implementation strategy begins with a brief description of the general CHNA process. Each of the health needs identified by the CHNA is then listed along with either a description of how the hospital facility plans to meet the health need or an explanation for why the hospital facility does not intend to meet the health need.

General CHNA Process

Coordination among Essentia Health Hospital Facilities

In the interest of efficiency, cost effectiveness, and alignment with Essentia Health population health strategies, fifteen Essentia Health hospital facilities are participating in a coordinated CHNA process. While still allowing for tailoring to each particular hospital facility, procedures are standardized across hospital facilities. These hospital facilities include: Bridges Medical Center, doing business as (DBA) Essentia Health Ada in Ada, MN; Clearwater Valley Hospital and Clinics, Inc. in Orofino, ID; Deer River Healthcare Center, Inc., DBA Essentia Health Deer River in Deer River, MN; Essentia Health Virginia, LLC, DBA Essentia Health Virginia in Virginia, MN; Graceville Health Center, DBA Essentia Health Holy Trinity Hospital in Graceville, MN; Innovis Health, LLC, DBA Essentia Health West in Fargo, ND; Minnesota Valley Health Center, Inc. in Le Sueur, MN; Northern Pines Medical Center, DBA Essentia Health Northern Pines in Aurora, MN; Pine Medical Center, DBA Essentia Health Sandstone in Sandstone, MN; SMDC Medical Center, DBA Essentia Health Duluth in Duluth, MN; St. Joseph’s Medical Center, DBA Essentia Health St. Joseph’s Medical Center in Brainerd, MN; St. Mary’s Hospital of Superior, DBA Essentia Health St. Mary’s Hospital‐Superior in Superior, WI; St. Mary’s Hospital, Inc. in Cottonwood, ID; St. Mary’s Medical Center,

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Appendix A Essentia Health West, Fargo, ND Implementation Strategy

DBA Essentia Health St. Mary’s Medical Center in Duluth, MN; and St. Mary’s Regional Health Center, DBA Essentia Health St. Mary’s‐Detroit Lakes in Detroit Lakes, MN.

Essentia Health West joined the coordinated CHNA process on February 1, 2013. Consequently, not all aspects of the Essentia Health West CHNA are coordinated with those of the other hospital facilities. Prior to February, Essentia Health West participated in the Fargo‐Moorhead Community Health Needs Assessment Collaborative (i.e. the Collaborative), a group composed of representatives from Blue Cross Blue Shield of North Dakota, the Center for Rural Health at the University of North Dakota, Clay County Public Health, Dakota Medical Foundation, Essentia Health, Family HealthCare Center, Fargo Cass Public Health, First Link, North Dakota State University, Sanford Health, Southeast Human Services Center, United Way of Cass‐Clay, and Urban Indian Health and Wellness Center of Fargo‐Moorhead. The Center for Social Research at North Dakota State University assisted with survey development and secondary research and also generated reports. All descriptions of CHNA activities prior to February 2013 are paraphrased or reproduced from work produced by these entities.

Identification and Prioritization of Health Needs

Two groups of individuals from the greater Fargo‐Moorhead area completed surveys with “questions focusing on community assets, general concerns about communities, community health and wellness concerns, and demographic information.” The first group was individuals from randomly selected households in Cass and Clay counties who completed a mailed survey. The second group was community leaders who completed the survey either at a breakfast meeting or via an internet link. Organizations represented by the community leaders include: Alzheimer’s Association, Arthritis Foundation, Cass Clay Healthy People Initiative of the Dakota Medical Foundation, Churches United for the Homeless, City of Fargo, City of West Fargo, Clay County Collaborative, Clay County Public Health, Clay County Sheriff’s Office, Dakota Medical Foundation, Essentia Health West Region, Essentia Health West, Family HealthCare Center, Fargo Cass Public Health, Fargo City Commission, Fargo School Board, First Link, Healthy North Dakota Worksite, Lutheran Social Services, March of Dimes, Minnesota State University Moorhead, Moorhead City Council, North Dakota Disability Health, North Dakota State University, Prairie St. John’s, Sanford Health Fargo, Sanford Medical Center Fargo, Senator Rick Berg’s North Dakota Office, ShareHouse, Southeast Human Services Center, United Way, and West Fargo School Board. Based on the survey results and a two‐round voting process, the top health needs for the community served by Essentia Health West were identified by the Collaborative in October 2012.

At the other hospital facilities participating in Essentia Health’s coordinated CHNA process, community health profiles consisting of state and county service area demographic, health‐related behaviors, health services, and health outcomes data were presented to community members at community/patient

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Appendix A Essentia Health West, Fargo, ND Implementation Strategy focus groups held at or near each hospital facility. Participants were asked to identify and prioritize three amenable community health needs based on the data. As the health needs identified and prioritized at these meetings were similar across the hospital facilities and similar to the health needs identified through the Collaborative’s process, they were aggregated into a collection of ten system‐ wide health needs. Each of the top three health needs for each hospital facility will be addressed through a 3‐year intervention. The first intervention will begin in 2013, the second in 2014, and the third in 2015.

Town Hall Meetings

The first step in addressing each prioritized health need is a Town Hall Meeting. Town Hall Meetings will be held annually with each focused on one of the three priority health needs. During the Town Hall Meetings, intervention options for meeting the relevant health need will be presented, and participants will select the option best suited to their community. Possible prospective participants include: the community/patient focus group participants, social service and service organization representatives, city and county government officials, tribal government/leadership/representatives and/or other minority population group members/representatives, primary care and other health care providers, lead county public health officials, industry/business leaders/representatives, educators/educational administrators, and other relevant entities. As described below, a Town Hall Meeting for Essentia Health West’s first priority will not be held. Town Hall Meetings for the second and third priorities will occur in late 2013/early 2014 and late 2014/early 2015, respectively.

Intervention Planning Meetings

Further details such as the research and evaluation protocol for the selected interventions will be delineated after the Town Hall Meetings. These details will be presented at Intervention Planning Meetings to potential collaborators and hospital facility employees with authority to commit resources to implement the interventions. Many of these individuals will have likely attended the previous Town Hall Meeting, or in the case of Essentia Health West’s first priority health need, will be members of the Collaborative or will have been identified as community leaders by the Collaborative. At the Intervention Planning Meetings, interventions will be further tailored to the particular hospital facility and community’s programs and resources.

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Appendix A Essentia Health West, Fargo, ND Implementation Strategy

Health Need 1

Description of Health Need

Physical health, encompassing obesity, poor nutrition/eating habits, and inactivity and/or lack of exercise, was voted as the highest priority health need. To merge this need with those of the other participating Essentia Health hospital facilities, this need will hereafter be defined as obesity, physical activity, and nutrition as risk factors for chronic diseases, such as type 2 diabetes.

Town Hall Meeting

The intervention options presented at the Town Hall Meetings for the other participating Essentia Health hospital facilities were adapted from the Community Preventive Services Task Force (CPSTF) (2). These options included: A) type 2 diabetes self‐management education (DSME) in community gathering places, B) type 2 diabetes care coordination, and C) creation of or enhanced access to places for physical activity combined with informational outreach activities. These interventions were selected because they were recommended by the CPSTF (2), feasible for a health system, and have measurable outcomes that can be tracked over time. By focusing on type 2 diabetics, the first two options target a specific group known to suffer from poor nutrition and physical inactivity. The idea of a hybrid of options A and C – type 2 DSME in community gathering places with enhanced access to places for physical activity and informational outreach activities – arose at the Essentia Health Holy Trinity Hospital Town Hall Meeting. This hybrid was subsequently presented as a fourth option at Town Hall Meetings for the other hospitals and is hereafter referred to as enhanced DSME.

Because Essentia Health West joined Essentia Health’s coordinated CHNA process later than the other hospitals, a Town Hall Meeting will not be held for the first need. Enhanced DSME will be the intervention implemented to meet the Essentia Health West community’s first health need. As participants at almost all Town Hall Meetings for the other participating Essentia Health hospitals selected enhanced DSME as their intervention, it was likely participants at a Town Hall Meeting for Essentia Health West would have done likewise. Furthermore, establishing similar, yet tailored interventions in several communities served by Essentia Health enables the health system to A) uphold its value of stewardship by maximizing resources used in planning, implementing, maintaining, and evaluating the interventions, B) enhance the likelihood of intervention success as a result, and C) maximize sample size for evaluating the interventions.

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Appendix A Essentia Health West, Fargo, ND Implementation Strategy

Description of Intervention

According to CPSTF, “DSME is the process of teaching people to manage their diabetes. The goals of DSME are to control the rate of metabolism (which affects diabetes‐related health), to prevent short‐ and long‐term health conditions that result from diabetes, and to achieve for clients the best possible quality of life, while keeping costs at an acceptable level” (3). In brief, the DSME intervention will involve a group of type 2 diabetes patients attending one to four group meetings per month related to type 2 diabetes self‐management over a one‐year period in a community gathering place. The primary meeting leader will be a Certified Diabetes Educator (CDE) or other qualified individual. With a three‐ year intervention, there will be three, one‐year series of DSME meetings.

Part of the enhanced aspect of enhanced DSME is including a wider group of individuals in the intervention. The wider group will involve individuals with prediabetes who will be identified through methods such as applying a risk score to data from electronic medical records or self‐reported at screening events. Blood glucose may also be measured at screening events. Screening events will occur during the first and second years of the intervention, so individuals identified at these events would begin DSME meetings in years two and three. The wider group of individuals will also involve families of patients attending the DSME meetings who will be invited to participate in all activities.

The other part of the enhanced aspect of enhanced DSME is greater focus on strategies for improved nutrition and physical activity. Nutrition‐related activities for the DSME meeting series may involve cooking classes, grocery store tours, or education on topics such as label reading and understanding a type 2 diabetes‐friendly diet. In addition to informing participants on physical activity strategies and options in the community, the intervention will attempt to reduce barriers to physical activity through, for example, reducing fees at local fitness facilities, providing transportation to facilities, or offering fitness classes live and/or on local television. While not currently diabetic, these aspects of the intervention will benefit adults identified as prediabetics and family members as well, given that poor nutrition and inadequate physical activity are risk factors for type 2 diabetes, as well as other chronic conditions such as cardiovascular disease.

The primary anticipated impacts of this intervention differ by the population group of interest. For individuals with type 2 diabetes, anticipated impacts include decreased body mass index, improved glycemic control, better lipid profiles, improved knowledge of type 2 diabetes self‐management, improved knowledge of the importance of blood pressure monitoring and control, improved nutrition knowledge, increased exercise frequency, and increased health care engagement. Through these same improvements, the anticipated impact of this intervention for prediabetics is reduced type 2 diabetes risk. The anticipated impact for family members without type 2 diabetes or prediabetes is improved

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Appendix A Essentia Health West, Fargo, ND Implementation Strategy knowledge of type 2 diabetes self‐management and consequently enhanced support for their diabetic or prediabetic family member. As described above, family members may also benefit personally from improved nutrition and physical activity.

Intervention Planning Meeting

The Intervention Planning Meeting is slated to occur in July 8, 2013. The current “Compendium of Resources” table accompanying this implementation strategy describes specific programs, resources, and potential collaborators for implementing the intervention. Selected representatives from this table will be invited to the Intervention Planning Meeting. While not all resources in the table will be utilized, they present a menu from which to tailor the intervention to the hospital facility and community’s needs and capabilities. For example, a current CDE could lead the DSME meetings. If a current CDE is unwilling or unable to participate, the first priority would be identifying and certifying an individual with those credentials or the equivalent. According to the National Certification Board for Diabetes Educators, eligibility requirements for sitting for the certification exam include a discipline/licensure requirement, DSME professional practice experience, continuing education hours, and an application (4). Individuals in the community who may meet these requirements include local registered nurses, pharmacists, physicians, or dieticians. If a new CDE or the equivalent must be obtained, DSME meetings may not start immediately, but identifying an individual for the role would be a first step. Other potentially‐ useful resources included in the current Compendium of Resources are the YMCA for both fitness opportunities and meeting space, a variety of ongoing community health initiatives for possible collaboration, and the Red River Valley Fair for a screening event. The base guideline for the hospital’s financial contribution is 0.1% of net patient revenue less bad debt [i.e. 0.1%*(NPR‐BD)] for each of the three interventions, each of which will last three years with the first beginning in Financial Year 2014. Additionally, all hospitals are strongly encouraged by Bert Norman, Essentia Health’s Chief Financial Officer, to reallocate current Community Benefit funding to supplement the base financial contribution guideline.

Health Need 2

Description of Health Need

Mental health, specifically availability of mental health services and hereafter referred to as access to mental health care, was voted as the second‐highest priority health need.

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Appendix A Essentia Health West, Fargo, ND Implementation Strategy

Town Hall and Intervention Planning Meetings

A Town Hall Meeting to select an intervention to meet this health need will be held late 2013 or early 2014. The Intervention Planning Meeting is slated to occur in May 2014. The current “Compendium of Resources” table accompanying this implementation strategy describes potentially‐useful programs, resources, and collaborators for implementing the intervention. Selected representatives from this table may be invited to the Intervention Planning Meeting. While not all resources in the table will be utilized, and new ones may develop or be discovered over time, they present a menu from which to tailor the intervention to the hospital facility and community’s needs and capabilities. The anticipated impact of an intervention addressing access to mental health care is improved patient outcomes related to the mental health issue targeted by the selected intervention.

Health Need 3

Description of Health Need

Health care, encompassing availability of prevention programs or services and coordination of care was voted as the third‐highest priority health need. To merge this need with those of the other participating Essentia Health hospital facilities, this need will hereafter be described as access to health care and defined as enhanced health care for the local population.

Town Hall and Intervention Planning Meetings

A Town Hall Meeting to select an intervention to meet this health need will be held late 2014 or early 2015. The Intervention Planning Meeting is slated to occur in May 2015. The current “Compendium of Resources” table accompanying this implementation strategy describes potentially‐useful programs, resources, and collaborators for implementing the intervention. Selected representatives from this table may be invited to the Intervention Planning Meeting. While not all resources in the table will be utilized, and new ones may develop or be discovered over time, they present a menu from which to tailor the intervention to the hospital facility and community’s needs and capabilities. The anticipated impact of an intervention addressing access to health care is improved patient outcomes related to the health issue targeted by the selected intervention.

Unprioritized Health Needs and Plans

The other Essentia Health system‐wide health needs identified among the hospital facilities participating in the coordinated CHNA process include:

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Appendix A Essentia Health West, Fargo, ND Implementation Strategy

1. Substance use and influence (Essentia Health West) 2. Violence and safety (Essentia Health West) 3. Reduction of excessive/binge drinking 4. Tobacco use primary prevention/cessation 5. Immunizations 6. Preventive care, encompassing primary prevention (e.g. health education, wellness plans, immunizations) and secondary prevention/screening 7. Secondary prevention/screening

The hospital facility does not intend to directly meet the health needs listed above due to resource constraints. Rather than inadequately addressing all health needs, the hospital facility will focus resources, financial and otherwise, on its community’s three prioritized health needs in order to foster success in meeting those needs. Despite not directly meeting the unprioritized health needs, interventions addressing the three prioritized needs may partially address the unprioritized needs that overlap with the prioritized needs. For example, enhanced DSME will involve health education, screening for prediabetes, and discouraging substance use as it relates to type 2 diabetes. DSME for individuals with prediabetes is itself secondary prevention in that the goal is to prevent disease progression. If the unprioritized health needs remain in the next CHNA cycle, they may be directly addressed at that time.

References

1. IRS. Notice 2011‐52 Notice and Request for Comments Regarding the Community Health Needs Assessment Requirements for Tax‐exempt Hospitals. [Online] [Cited: February 6, 2013.] http://www.irs.gov/pub/irs‐drop/n‐11‐52.pdf.

2. Community Preventive Services Task Force (a). The Guide to Community Preventive Services, The Community Guide, What Works to Promote Health. [Online] [Cited: February 6, 2013.] http://www.thecommunityguide.org/index.html.

3. Community Preventive Services Task Force (b). Diabetes Prevention and Control: Self‐Management Education. The Guide to Community Preventive Services, The Community Guide, What Works for Health. [Online] [Cited: February 6, 2013.] http://www.thecommunityguide.org/diabetes/selfmgmteducation.html.

4. National Certification Board for Diabetes Educators. Eligibility Requirements. National Certification Board for Diabetes Educators Web Site. [Online] [Cited: February 6, 2013.] http://www.ncbde.org/certification_info/eligibility‐requirements/.

\\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

Appendix B – Intervention Protocols for First Health Need

The following protocols will be implemented to address the hospital facility’s highest priority health need. They were refined to this form over the course of discussions with both community members and Essentia Health staff. The final implemented intervention may differ further to conform to the needs and resources of the hospital facility and community.

Part A: Type 2 Diabetes Prevention Intervention Protocol

This intervention is directed at adults assessed as being prediabetic. In some instances adults diagnosed with diabetes during the past six months who are currently on no antihyperglycemic medication or are on metformin only and, at a minimum, have previously been seen at a diabetes self‐management program for individual instruction on diabetes meal planning and self‐monitoring of blood glucose will be included as participants in this program (see Part B: Enhanced Type 2 Diabetes Education Intervention Protocol). Prediabetic participants will be identified through blood screening or the Centers for Disease Control and Prevention Prediabetes Screening Test (1) provided at community screening events. The intervention also includes family members and others who constitute an individual’s support system. With these inclusion criteria, primary, secondary, and tertiary prevention are addressed by this intervention as displayed in the diagram below. The intervention is community‐ based and entails elements of physical activity education and participation, nutrition education, and developing enhanced cooking and shopping skills. This intervention was informed by previous studies (2,3) and utilizes the National Diabetes Prevention Program and the Lifestyle Intervention curriculum (4). Additional measurements are included to track results.

The overall approach is culturally competent in terms of diet, social emphasis, family participation, and incorporation of cultural health beliefs.

Dietitians or other community workers will arrange and conduct group visits to local grocery stores to help individuals apply dietary information learned. Social support will be fostered through support from family members and friends, group participants, the intervention team, and community workers.

The weekly support group sessions will provide opportunities for participants and family members/friends to meet in an informal and safe atmosphere to discuss their problems in preventing diabetes, ask questions in a non‐threatening environment, review previously‐learned information and skills, and participate in cooking demonstrations. Also, group leaders will emphasize the importance of support from family members and encourage support persons to improve their health habits. Individual participants will be provided the opportunity to discuss their concerns and problems, and members of the group, facilitated by a CDE, dietitian, or other professional, will assist each other in solving problems.

\\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

Family Members and Support System for Adults with Diabetes and Adults Assessed with Pre-Diabetes

Adults Assessed with Pre-Diabetes

Adults with Diabetes

TERTIARY PREVENTION

SECONDARY PREVENTION

PRIMARY PREVENTION

Intervention Participants

Participants will receive the year‐long intervention in any number of community‐based facilities such as schools, churches, county agricultural extension offices, adult day care centers, and health clinics. Primary outcomes are:

 Nutrition knowledge  Glycosylated hemoglobin (HbA1c)  Fasting blood glucose (FBG)  Lipid panel  Body mass index (BMI)  Physical activity

Body weights will be measured with a balance beam scale with individuals in street clothing and without shoes. Heights will be obtained using a secured stadiometer. BMI will be calculated as [weight(kg)/height(meters)2]. HbA1c, FBG, and cholesterol testing will be arranged for the program participants and the results reviewed with the individuals.

\\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

The National Diabetes Prevention Program

In the National Diabetes Prevention Program, lifestyle change classes led by trained coaches meet for 16 core sessions as participants focus on losing 5% to 7% of their body weight and increasing physical activity to 150 minutes each week. After the initial 16 sessions, classes meet monthly for 6‐8 months.

Who: To be eligible, participants may be at risk for prediabetes and type 2 diabetes if they answer yes to a few of the following questions:

 I am 45 years of age or older.  I am overweight.  I have a parent with diabetes.  I have a sister or brother with diabetes.  My family background is African American, Hispanic/Latino, American Indian, Asian American, or Pacific Islander.  I had diabetes while I was pregnant (gestational diabetes), or I gave birth to a baby weighing 9 pounds or more.  I am physically active less than three times a week

Pre‐diabetic participants will meet eligibility criteria outlined in the Centers for Disease Control and Prevention Diabetes Prevention Recognition Program Standards and Operating Procedures. The intervention may also include some adults with a recent diagnosis of type 2 diabetes and, in some activities, family members and others who constitute an individual’s support system.

What: The National Diabetes Prevention Program is designed to bring to communities evidence‐based lifestyle change programs for preventing type 2 diabetes. It is based on the Diabetes Prevention Program research study led by the National Institutes of Health and supported by Centers for Disease Control and Prevention.

Why: The lifestyle program shows that making modest behavior changes, such as improving food choices and increasing physical activity to at least 150 minutes per week, results in participants losing 5% to 7% of their body weight. These lifestyle changes reduce the risk of developing type 2 diabetes by 58% in people at high risk for diabetes. People with prediabetes are more likely to develop heart disease and stroke.

Adapted from (5).

\\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

Type 2 Diabetes Prevention Intervention Flow Chart

Lifestyle Coach

Training

Participant Electronic medical records, community screening events (Form A) recruitment

Measures at baseline, 6 months, and 12 months: Weekly core sessions Demographics (Form B) for 16 weeks Family medical history

Medication history Physical Activity (Form C) Blood Pressure Knowledge (Form D) Nutrition Knowledge and Diet Assessment HbA1c and FBG Monthly post core Systolic and diastolic blood pressure sessions for 6‐8 Lipid panel BMI months

Participant objectives . Attend all 16 weekly core sessions in designated community setting . Change unhealthy lifestyle behaviors . Increase activity . 150 minutes/week . Improve food choices . Keep diary & follow fat gram goal . Lose weight, if overweight . 5‐7% of body weight . Attend post core sessions offered monthly for 6‐8 months

56 \\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

Table 1. Description of the Intervention Mid‐ and Post‐ Baseline Intervention1 Intervention 6‐8 Post Core 16 Core Sessions Measures Sessions Measures (one/week) (one/month) (6 and 12 months) Demographics2 (Form B) Introduction Use post core Demographics curriculum and: Family medical history Be a Fat and Calorie Detective Family medical history ‐review Medication history Three Ways to Eat Less Fat and Fewer Calories previously Medication history Physical Activity (Form C) Healthy Eating learned content Physical Activity Blood Pressure Knowledge Move Those Muscles ‐assess Blood Pressure (Form D) participants’ Knowledge knowledge and Nutrition Knowledge and Being Active – A Way of Life Nutrition Knowledge

Diet Assessment skills regarding and Diet Assessment topic being HbA1c and FBG Tip the Calorie Balance addressed HbA1c and FBG Blood pressure Take Charge of What’s Around You ‐discuss ongoing Blood pressure Lipid panel Problem Solving barriers to Lipid panel BMI Four Keys to Healthy Eating Out adopting BMI healthy lifestyle

Talk Back to Negative Thoughts changes‐‐‐ The Slippery Slope of Lifestyle Change engaging in Jump Start Your Activity Plan group problem‐ Make Social Cues Work For You solving ‐open You Can Manage Stress discussion of Ways to Stay Motivated any topic group chooses/ introduces 1Activities such as fitness classes, cooking classes, and grocery store tours should be incorporated when possible.

2Age, gender, age at diagnosis, race/ethnicity, education attainment, marital status, children, annual household income, health insurance status

•OVERALL CHARACTERISTICS OF THE INTERVENTION•

• 16 weekly core sessions plus 6‐8 monthly post core sessions • Longitudinal (follow‐up for one year) • Community‐based — schools, churches, adult day care centers, agricultural extension centers, and community health clinics sites • Designed to promote group problem‐solving to address individual's health questions and issues • Organized to obtain support from family, friends, group participants, nurses/dietitians/community workers • Incorporates activities to reduce barriers to physical activity and nutrition

\\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

FORM A: CDC Prediabetes Screening Test1

A score of nine or higher on this screening test indicates that the tested person is at high risk for having prediabetes. In a national sample of U.S. adults aged 18 years and older (2007–08 National Health and Nutrition Examination Survey), this screening test correctly identified 27%–50% of those with a score of 9 or higher as true cases of prediabetes based on the HbA1c, fasting blood glucose, or two‐hour oral glucose tolerance confirmatory diagnostic tests (Division of Diabetes Translation, Centers for Disease Control and Prevention, 2010).

An online widget of the screening test can be downloaded at http://www.cdc.gov/widgets. The screening test can be given on paper using the document below.

Prediabetes You Could Be at Risk

Prediabetes means your blood glucose (sugar) is higher than normal, but not yet diabetes. Diabetes is a serious disease, which can cause heart attack, stroke, blindness, kidney failure, or loss of toes, feet or legs. Type 2 diabetes can be delayed or prevented in people with prediabetes, however, through effective lifestyle programs. Take the first step. Find out your risk for prediabetes.2

Take the Test — Know Your Score!

Answer these seven simple questions. For each “Yes” answer, add the number of points listed. All “No” answers are 0 points.

Question Yes No Are you a woman who has had a baby weighing more than 9 pounds at birth? 1 0 Do you have a sister or brother with diabetes? 1 0 Do you have a parent with diabetes? 1 0 Find your height on the chart. Do you weigh as much as or more than the weight 5 0 listed for your height? (See chart below) Are you younger than 65 years of age and get little or no exercise in a typical day? 5 0 Are you between 45 and 64 years of age? 5 0 Are you 65 years of age or older? 9 0 Total points for all “yes” responses:

\\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

Know Your Score

9 or more points: High risk for having prediabetes now. Please bring this form to your health care provider soon.

3 to 8 points: Probably not at high risk for having prediabetes now. To keep your risk level below high risk:  If you’re overweight, lose weight  Be active most days  Don’t use tobacco  Eat low‐fat meals including fruits, vegetables, and whole‐grain foods  If you have high cholesterol or high blood pressure, talk to your health care provider about your risk for type 2 diabetes

At‐Risk Weight Chart Height Weight (in pounds) 4’10” 129 4’11” 133 5’0” 138 5’1” 143 5’2” 147 5’3” 152 5’4” 157 5’5” 162 5’6” 167 5’7” 172 5’8” 177 5’9” 182 5’10” 188 5’11” 193 6’0” 199 6’1” 204 6’2” 210 6’3” 216 6’4” 221

1 Appendix B: CDC Prediabetes Screening Test. Centers for Disease Control and Prevention Diabetes Prevention Recognition Program Standards and Operating Procedures. [Online][Cited: May 9, 2013] http://www.cdc.gov/diabetes/prevention/pdf/DPRP_Standards_09‐02‐2011.pdf 2 Based on Herman WH, Smith PJ, Thomason TJ, Engelgau MM, Aubert RE. A new and simple questionnaire to identify people at risk for undiagnosed diabetes. Diabetes Care 1995 Mar;18(3);382‐7.

\\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

FORM B. Demographics Survey

What is your date of birth?

What is your sex?

Present Marital Status:  Married  Divorced  Common law  Widowed  Separated  Single

Number of children under 18 living at home: ____ Total number of people living in your home: ____ How many years have you lived in this community? _____

Education and Employment Questions

What is the highest level of schooling you have completed?

 Some elementary school  Some community college or  Elementary school graduation university  Some high school  Community college or university  High school graduation diploma graduation diploma  Some trade, technical, or  Don’t know vocational school  I prefer not to respond

Are you currently working for pay (wages, salary, self-employment)?

 No  Yes ___ (If yes, answer the following question)

For the year ending December 31, please think of the total income, before deductions, from all sources, for all household members, including yourself. Please look at this list and choose which range it falls into.

 No income or income loss  $60,000 - $79,999  Under $19, 999  $80,000 and over  $20,000 - $39,999  Don’t know  $40,000 - $59,999  I prefer not to respond

\\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

FORM C:

1. Physical Activity Self-Assessment Points Total Frequency (How often you do physical Activity) (Select 1) Daily or almost daily 35 3 - 5 times per week 25 1-2 times per week 15 Less often 6 Intensity (How hard do you do physical activity.) (Select 1) Sustained heavy breathing & perspiring (ex. jogging) 35 Intermittent heavy breathing 25 Moderately heavy (ex. recreational sports, cycling) 15 Moderate (ex: volleyball, softball) 6 Light (ex. fishing, strolling) 1 Time (how long do you do physical activity each time) (Select 1) Over 30 minutes 30 21-30 minutes 20 10-20 minutes 10 Under 10 minutes 2 Total Physical Activity Score

\\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

FORM D:

3. Blood Pressure Knowledge Questions True* False* 1. A blood pressure of 120/80 is considered average. x 2. A blood pressure of 160/100 is high. x 3. Exercising every day may make blood pressure go down. x 4. A low sodium diet can lower blood pressure. x 5. Losing weight can make blood pressure go down. x 6. When someone’s blood pressure is too high, they usually have a x headache. 7. When someone’s blood pressure is too high, they usually feel fine x and do not know that it is high. 8. High blood pressure can cause heart attacks. x 9. High blood pressure can cause cancer. x 10. High blood pressure can cause kidney problems. x 11. People with high blood pressure should eat less salt. x 12. Orange juice is usually high in salt. x 13. Canned vegetables are usually high in salt. x 14. Bananas are high in salt. x 15. Canned soup is usually high in salt. x * The “x’s” will not be shown on the participant surveys Source: Adapted from Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med 1998;158:166-72.

\\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

Part B: Enhanced Type 2 Diabetes Education Intervention Protocol

This intervention is directed at adults with type 2 diabetes. These individuals will be identified through electronic medical records or through provider referral. The intervention also includes family members and others who constitute an individual’s support system. Additionally, the core of the intervention, the National Diabetes Prevention Program, will include individuals with prediabetes (see Part A: Type 2 Diabetes Prevention Intervention Protocol). With these inclusion criteria, primary, secondary, and tertiary prevention are addressed by this intervention as displayed in the diagram below. The intervention is community‐based and entails elements of physical activity education and participation, nutrition education and developing enhanced cooking and shopping skills, and self‐monitoring of glucose levels and blood pressure. This intervention was informed by previous studies (2,3) and utilizes the National Diabetes Prevention Program (NDPP) and the Lifestyle Intervention curriculum (4). It is supplemented by topics outlined in the National Standards for Diabetes Self‐Management Education and Support (6) and additional measurements to track results.

The overall approach is culturally competent in terms of diet, social emphasis, family participation, and incorporation of cultural health beliefs.

The weekly support group sessions will provide opportunities for participants and family members/friends to meet in an informal and safe atmosphere to discuss their problems in managing diabetes, ask questions in a non‐threatening environment, review previously‐learned information and skills, and participate in cooking demonstrations. Also, group leaders will emphasize the importance of support from family members and encourage support persons to improve their health habits. Individual participants will be provided the opportunity to discuss their concerns and problems, and members of the group, facilitated by a CDE, dietitian, or other professional, will assist each other in solving problems.

\\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

Family Members and Support System for Adults with Diabetes and Adults Assessed with Pre-Diabetes

Adults Assessed with Pre-Diabetes

Adults with Diabetes

TERTIARY PREVENTION

SECONDARY PREVENTION

PRIMARY PREVENTION

Intervention Participants Participants will receive the year‐long intervention in any number of community‐based facilities such as schools, churches, county agricultural extension offices, adult day care centers, and health clinics. Primary outcomes are:

 Nutrition knowledge  Diabetes related knowledge  Glycosylated hemoglobin (HbA1c)  Fasting blood glucose (FBG)  Lipid panel  Body mass index (BMI)  Physical activity

\\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

In the NDPP, lifestyle change classes led by trained coaches meet for 16 core sessions as participants focus on losing 5% to 7% of their body weight and increasing physical activity to 150 minutes each week. After the initial 16 sessions, classes meet monthly for six‐eight months. This content also forms the foundation of type 2 diabetes management and is, therefore, an essential piece of this intervention.

Who: To be eligible, participants must  Be diagnosed during the past six months with type 2 diabetes as defined by the American Diabetes Association (7): o Fasting plasma glucose > 126 mg/dL, OR o HB A1c ≥ 6.5%, OR o 2 hour plasma glucose ≥ 200 mg/dL during an oral glucose tolerance test, OR o A random plasma glucose ≥ 200 mg/dL in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis AND  Be on no antihyperglycemic medication or on metformin only, AND  Have previously been seen at a diabetes self‐management program for individual instruction on diabetes meal planning and self‐management of blood glucose

In some activities, the enhanced diabetes education intervention will also include family members and others who constitute an individual’s support system.

What: The NDPP is designed to bring to communities evidence‐based lifestyle change programs for preventing type 2 diabetes. It is based on the Diabetes Prevention Program research study led by the National Institutes of Health and supported by Centers for Disease Control and Prevention. The National Standards for Diabetes Self‐Management Education and Support are designed to define quality diabetes education and support and are reviewed and revised approximately every five years by key stakeholders and experts within the diabetes education community (4).

Why: The lifestyle program shows that making modest behavior changes, such as improving food choices and increasing physical activity to at least 150 minutes per week, results in participants losing 5% to 7% of their body weight. These lifestyle changes can slow the progression of type 2 diabetes and lower the risk of chronic complications associated with diabetes.

When: Participants work with a lifestyle coach in a group setting to receive a 1‐year lifestyle change program that includes 16 core sessions (1 per week) and 6‐8 post‐core sessions (1 per month). The diabetes education content will be delivered by a Certified Diabetes Educator (CDE) whenever possible, or by a designated healthcare professional.

Adapted from (5).

\\- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

Enhanced Type 2 Diabetes Education Intervention Flow Chart

Lifestyle Coach

Training

Participant Electronic medical records, provider

referral recruitment

Measures at baseline, 6 months, and 12 months:

Weekly core sessions Demographics (Form B) Family medical history for 16 weeks Medication history Physical Activity (Form C) Blood Pressure Knowledge (Form D) Diabetes Knowledge (Form E) Diabetes Self ‐Efficacy (Form F) Nutrition Knowledge and Diet Assessment Monthly post core HbA1c and FBG sessions for 6‐8 Systolic and diastolic blood pressure Lipids panel months BMI

Participant objectives

. Attend all 16 weekly core sessions in designated community setting . Change unhealthy lifestyle behaviors . Increase activity

. 150 minutes/week . Improve food choices . Keep diary & follow fat gram goal . Lose weight, if overweight . 5‐7% of body weight . Attend post core sessions offered monthly for 6‐8 months

\ ~ Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

Table 1. Description of the Intervention Mid‐ and Post‐ Baseline Intervention1 Intervention 6‐8 Post Core 16 Core Sessions Measures 3 Sessions Measures (one/week) (one/month)3 (6 and 12 months) Demographics2 (Form B) Introduction Use post core Demographics curriculum and: Family medical history Be a Fat and Calorie Detective Family medical history ‐review Medication history Three Ways to Eat Less Fat and Fewer Calories previously Medication history Physical Activity (Form C) Healthy Eating learned content Physical Activity Blood Pressure Knowledge Move Those Muscles ‐assess Blood Pressure (Form D) participants’ Knowledge

Diabetes Knowledge (Form E) Being Active – A Way of Life knowledge and Diabetes Knowledge skills regarding Diabetes Self‐Efficacy (Form Tip the Calorie Balance topic being Diabetes Self‐Efficacy F) addressed Nutrition Knowledge and Take Charge of What’s Around You ‐discuss ongoing Nutrition Knowledge Diet Assessment barriers to and Diet Assessment adopting HbA1c and FBG Problem Solving HbA1c and FBG healthy lifestyle Blood pressure Four Keys to Healthy Eating Out changes‐‐‐ Blood pressure Lipid panel Talk Back to Negative Thoughts engaging in Lipid panel BMI The Slippery Slope of Lifestyle Change group problem‐ BMI solving Jump Start Your Activity Plan ‐open Make Social Cues Work For You discussion of You Can Manage Stress any topic group Ways to Stay Motivated chooses/ introduces 1Activities such as fitness classes, cooking classes, and grocery store tours should be incorporated when possible. 2Age, gender, age at diagnosis, race/ethnicity, education attainment, marital status, children, annual household income, health insurance status 3Supplemental information will be provided on: Describing the diabetes disease process and treatment options; using medication(s) safely and for maximum therapeutic effectiveness; monitoring blood glucose and other parameters and interpreting and using the results for self‐management decision making; and preventing, detecting, and treating acute and chronic complications. •OVERALL CHARACTERISTICS OF THE INTERVENTION• • 16 weekly core sessions plus 6‐8 monthly post core sessions • Longitudinal (follow‐up for one year) • Community‐based — schools, churches, adult day care centers, agricultural extension centers, and community health clinics sites • Designed to promote group problem‐solving to address individual's health questions and issues • Organized to obtain support from family, friends, group participants, nurses/dietitians/community workers • Incorporates activities to reduce barriers to physical activity and nutrition

\\~ Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

FORM E:

2. Diabetes knowledge questions True* False* 1. Normal fasting blood sugar is between 70 mg/dl (3.9 mg/dl) and 100 x mg/dl (5.5 mmol/L) (for someone without diabetes) 2. Insulin and diabetes pills make your blood sugar go down. x 3. A person with diabetes should check their feet for sores every day. x 4. When you exercise, your blood sugar goes down. x 5. If you feel shaky, sweaty and hungry, it usually means your blood x sugar is low. 6. If diabetes is not well controlled, it can injure both kidneys and nerves. x

7. A person with diabetes should get their eyes checked every year. x 8. If you feel thirsty, you could have low blood sugar. x 9. If your hemoglobin A-1C blood test is < 10%, then your diabetes is in x good control. 10. For people with diabetes, the goal for the ‘bad cholesterol’ (LDL) is x >100. * The “x’s” will not be shown on the participant surveys Source: Adapted from Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med 1998;158:166-72. Notes: # 9 - hemoglobin A-1C blood test is measured in a percentage and the goal is; <7% in a person with diabetes <6% in a person without diabetes #10 – Bad cholesterol (LDL) the goal is <100

\\-- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced TyT pe 2 Diabetes Prevention and Education Intervention Protocols

FORM F:

Self-Efficacy for Diabetes

1. I I I to 4 8 9 10 cal

I I 8 9

3. I I I I t J 4 8 9

I I I I I I I to 1 J 4 8 9 10 cal

5. I I J 4 8 9

6. n I I I I I to co 4 8 9 10 C0'1

7. n I I I I co - 4 8 9

8. I I I I J 8 9

\\-- Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced TyT pe 2 Diabetes Prevention and Education Intervention Protocols

coring

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Comments

References UN'lUHic;.ru>d

\\~ Essentia Health Here with you Appendix B Essentia Health West, Fargo, ND Enhanced Type 2 Diabetes Prevention and Education Intervention Protocols

References 1. Appendix B: CDC Prediabetes Screening Test. Centers for Disease Control and Prevention Diabetes Prevention Recognition Program Standards and Operating Procedures. Accessible at: http://www.cdc.gov/diabetes/prevention/pdf/DPRP_Standards_09‐02‐2011.pdf.

2. Diabetes Educ. 1999;25(2):226‐236.

3. Diabetes Care. 2002;25(2):259‐68.

4. Centers for Disease Control and Prevention. National Diabetes Prevention Program. Accessible at: http://www.cdc.gov/diabetes/prevention/.

5. Michigan State University Extension. National Diabetes Prevention Program. Accessible at: http://events.anr.msu.edu/event.cfm?folder=NDPPGeneseeMay2013.

6. Diabetes Care. 2013;36(Supp 1):S100‐S108.

7. Diabetes Care. 2013;36(Supp 1):S13.

V Essentia Health Here with you

Appendix C Essentia Health West, Fargo, ND Compendium of Resources

Appendix C – Compendium of Resources Description Obesity, physical activity, and nutrition as risk factors Access to mental health care Access to health care Category and/or for chronic diseases, including diabetes, community community resources community resources examples resources  County public health departments o Fargo Cass Public Health, 401 3rd Avenue North Fargo, ND 58102, 701‐241‐1360 o Clay County Public Health, 715 11th Street North, Suite 303, Moorhead, MN 56560, 218‐299‐5220 o Adult Home and Pregnancy/post‐partum visits with health education and support, Women’s Way – free breast and cervical cancer screening for low income females, correctional health services and education, emergency preparedness education, Family Planning services and education with STD screening, tobacco use and cessation, physical activity, nutrition, safe communities and environmental topics; preventative health education and screening for infants up to 21 years of age and on Medicaid; school nursing program; TB management and education; WIC – food and nutrition with education for Health care pregnant/breastfeeding women and children Hospitals, facilities primary (Essentia and  Dentists care clinics other) Fargo, ND o Melinda Harr Dental, 1509 32nd Avenue South, Fargo, ND 58103, 701‐271‐1060 o Friendly Smiles Family Dentistry, 2701 9th Avenue South, Suite F, Fargo, ND 58103, 701‐364‐9990 o Southpointe Dental, 3210 18th Street South, Suite A, Fargo, ND 58104, 701‐280‐1941 o Lundstrom Family Dentistry, 4110 40th Street South, #102, Fargo, ND 58104, 701‐235‐3803 o Cornerstone Dental Group, LLC, 1815 S University Drive, Fargo, ND 58103, 701‐237‐3583 o Evergreen Dental Clinic, 1220 Main Avenue, #220, Fargo, ND 58103, 701‐237‐6307 o Smile Care, 3011 25th Street South, #1, Fargo, ND 58103, 701‐280‐0088 o Smile Solutions, PC, 1910 42nd Street South, Suite A, Fargo, ND 58103, 701‐365‐0507 o Designer Smiles, 3525 25th Street South, Fargo, ND 58104, 701‐298‐9400

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Appendix C Essentia Health West, Fargo, ND Compendium of Resources

o McDonald & Gruchalla D.D.S., P.C., 1231 27th Street South, Suite A, Fargo, ND 58103, 701‐235‐1261 o Northcreek Dental, 100 4th Street South, Suite 312, Fargo, ND 58103, 701‐232‐2409 o Peterson Dental Care, 3226 13th Avenue South, Fargo, ND 58103, 701‐232‐3379 o Tronsgard & Sullivan Dental, 1231 27th Street South, Suite C, Fargo, ND 58103, 701‐232‐6983 o Insight Dental Associates, 1383 21st Avenue North, Suite B, Fargo, ND 58102, 701‐237‐3517 o Peter T. Mathison, DDS Center for Dentistry, 1351 Page Drive South, Suite 102, Fargo, ND 58103, 701‐478‐ 4500 o Dakota Pediatric Dentistry, P.C., 4265 45th Street South, Suite 202, Fargo, ND 58104, 701‐478‐5439 o Fargo Family Dentistry, Hallmark Office Park 3210 18th Street South, Suite B, Fargo, ND 58104, 701‐237‐ 6008 o Serenity Valley Family Dentistry, 4141 31st Avenue South, #104, Fargo, ND 58104, 701‐373‐0681 o Dakota Smiles, 4357 13th Avenue South, #106, Fargo, ND 58103, 701‐235‐2860 o Family Dentistry: Mark Sheils, DDS, 1300 Gateway Drive South, #2, Fargo, ND 58103, 701‐232‐6683 o Cornforth – Gill Orthodontics, 2534 S University Drive, #6 Fargo, ND 58103, 701‐232‐1500 o Orthodontic Associates, 1017 Broadway Street North, Fargo, ND 58102, 701‐237‐3725 o Face & Jaw Surgery Center, 4344 20th Avenue South, #1, Fargo, ND 58103, 701‐239‐5969 o South University Dental Associates, 3115 S University Drive, Fargo, ND 58103, 701‐232‐8884 o Bruce K Hummel PC, 1324 23rd Street South, Fargo, ND 58103, 701‐237‐5616 o Valley Oral & Facial Surgery, 2701 9th Avenue South, Suite F, Fargo, ND 58103, 701‐235‐7379 o Anderson Dental Family & Cosmetic Dentistry, 4521 38th Avenue South, Fargo, ND 58104, 701‐232‐1368 o Brent L. Holman DDS PC, 2538 S University Drive, Fargo, ND 58103, 701‐232‐1148 o Taylor Endodontics, 2910 S University Drive, Fargo, ND 58103, 701‐212‐1206 o Valley Dental Center, 1338 Gateway Drive South, Fargo, ND 58103, 701‐232‐1664 o Coffey & Baker, 1790 32nd Avenue South, Fargo, ND 58103, 701‐232‐0774 o Prairie Oral Surgery, Ltd., 2585 23rd Avenue South, Fargo, ND 58103, 701‐478‐4404 o Cook Endodontics, 4710 Amber Valley Parkway South, Suite A, Fargo, ND 58104, 701‐232‐1956 o Pediatric Dentistry, Ltd., 3142 49th Street South, Fargo, ND 58104, 701‐293‐6999

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Appendix C Essentia Health West, Fargo, ND Compendium of Resources

o Kent A. Spriggs D.D.S., M.S., P.C., 2910 University Drive S Fargo, ND 58103, 701‐235‐1113 o Keim Orthodontics, 2585 23rd Avenue South, Fargo, ND 58103, 701‐293‐0006 o Mengedoth Dental, 2585 23rd Avenue South, Suite C, Fargo, ND 58103, 701‐356‐1280 o Dr. Brian C. Mathison, DDS, 4749 Amber Valley Parkway South, Fargo, ND 58104, 701‐356‐3999 o Sanford 1717 Medical Building, 1717 S University Drive, Fargo, ND 58103, 701‐280‐4640 or 701‐234‐2331 o James H. Lancaster, PC, 1211 Harwood Drive, Suite A, Fargo, ND 58104, 701‐232‐1781 o Dr. Daniel G. Lysne, DDS, 1322 23rd Street South, Fargo, ND 58103, 701‐232‐3323 o Jay P. Erickson, DDS, 1331 32nd Avenue South, #3, Fargo, ND 58103, 701‐235‐7322 o Advanced Dental Technology Center, 827 28th Street South, #A, Fargo, ND 58103, 701‐280‐1020 o David W Casagrande D.D.S., M.S., 1231 27th Street South, Fargo, ND 58103, 701‐484‐0687 o VA Medical Center – Fargo, 2101 Elm Street North, Fargo, ND 58102, 701‐232‐3241 o West Acres Office Park Dental, 1701 38th Street SW, Fargo, ND 58103, 701‐282‐4111 or 701‐282‐4905 or 701‐282‐4044 o Marvin L. Ugland, DDS, 825 28th Street South, #F, Fargo, ND 58103, 701‐237‐4297 o Hegge Dental Office, 1411 32nd Street South, Fargo, ND 58103, 701‐235‐8978 o West Orthodontics, 4710 Amber Valley Parkway, Suite B, Fargo, ND 58104, 701‐293‐5300 o Great Plains Periodontics, PC, 2838 S University Drive, Fargo, ND 58103, 701‐293‐0577 o Dr. Terry L. Moe, DDS, 118 Broadway North, Suite 708, Fargo, ND 58102, 701‐232‐8314 o Dr. Nicholas C. Dorsher, DDS, 118 Broadway North, Suite 711, Fargo, ND 58102, 701‐237‐4331 o R & L Dental Laboratory, 118 Broadway North, Suite 302, Fargo, ND 58102, 701‐235‐5132 o Essentia Health, 1702 S University Drive, Fargo, ND 58103, 701‐364‐3211 o Dr. James F. Johnson, DDS, 825 28th Street South, Suite F, Fargo, ND 58103, 701‐237‐4297 o Moeckel Family Dentistry, 2534 S University Drive, #3, Fargo, ND 58103, 701‐293‐0751 o John J. Pollard, DDS, PC, 1221 Harwood Drive, Fargo, ND 58104, 701‐235‐6622 o Dr. Robert A. Saunders, DDS, 2834 S University Drive, Fargo, ND 58103, 701‐293‐9886 o Dr. Mark Jung, DDS, 3533 25th Street South, Fargo, ND 58104, 701‐234‐0333 o Dr. Derek W. Harnish, DDS, 100 4th Street South, #304, Fargo, ND 58103, 701‐235‐6075

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on Dr. Ro McClure, DDS, 520 Main Avenue, #705, Fargo, ND 58103, 701‐237‐4341 o Robert A. Bond, DDS, 2851 S University Drive, Fargo, ND 58103, 701‐235‐3205 o Family Healthcare Dental, 306 4th Street North, Fargo, ND 58102, 701‐271‐3331 o OSM Associates, 300 Main Avenue, #201, Fargo, ND 58103, 701‐232‐9565 Moorhead, MN o Red River Valley Dental Access Project, 715 11th Street North, Suite 201, Moorhead, MN 56560, 701‐364‐ 5364 o Skatvold Family Dentistry, 1401 8th Street South, Moorhead, MN 56560, 218‐236‐5644 o Dr. Toutges Dental Clinic, 3505 8th Street South, #3, Moorhead, MN 56560, 218‐287‐2324 o Edeen Family Dentistry, 806 Center Avenue, West Dilworth, MN 56529, 218‐287‐2938 o Woodlawn Dental, 320 2nd Avenue South, #106, Moorhead, MN 56560, 218‐236‐1666 o Harvey Orthodontics, 1550 30th Avenue South, Moorhead, MN 56560, 218‐236‐1322 o Southview Dental Care, 2704 12th Street South, Moorhead, MN 56560, 218‐233‐0570 o Northland Dental, Ltd., 2121 Highway 10 East, Moorhead, MN 56560, 218‐236‐7076 o Steidl Family Dentistry, PC, 523 8th Street South, Moorhead, MN 56560, 218‐236‐9319 o Donabauer Family Dentistry, 211 5th Street South, Moorhead, MN 56560, 218‐233‐1754 o Family Dentistry of Moorhead, Ltd., 1616 30th Avenue South, Moorhead, MN 56560, 218‐233‐4267

 Pharmacies Fargo, ND o CVS Drug North, 1321 19th Avenue North, Fargo, ND 58102, 701‐232‐2720 o CVS Drug South, 2425 13th Avenue South, Fargo, ND 58103, 701‐232‐4872 o Dakota Clinic Pharmacy / Essentia Health Pharmacy, 1702 S University Drive, Fargo, ND 58103, 701‐364‐3450 o Family HealthCare, 306 4th Street North Fargo, ND 58102, 701‐239‐7135 o Linson Pharmacy, 3175 25th Street South #D, Fargo, ND 58103, 701‐293‐6022 o Medical Pharmacy, Inc., 100 4th Street South #104, Fargo, ND 58103, 701‐237‐0322 o Medicine Shoppe, 1605 S University Drive, Fargo, ND 58103, 701‐293‐3060

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o Medicine Shoppe, 2800 Broadway, Fargo, ND 58102, 701‐293‐0221 o Metro Drug, 123 N. Broadway, Fargo, ND 58102, 701‐232‐6150 o Northport Drug, 2522 Broadway, Fargo, ND 58102, 701‐235‐5543 o Prairie Pharmacy, 4731 13th Avenue South, Fargo, ND 58103, 701‐373‐0325 o Prescription Center Pharmacy, 2701 13th Avenue South, Fargo, ND 58103, 701‐234‐3630 o Sanford Health Broadway Pharmacy, 737 N Broadway, Fargo, ND 58102, 701‐234‐2416 o Sanford Health Mills Avenue Pharmacy, 801 N Broadway Drive, Fargo, ND 58103, 701‐234‐3330 o Sanford Health Southpointe, 2400 32nd Avenue South, Fargo, ND 58103, 701‐234‐2000 o Thrifty Drug, 1521 S University Drive, Fargo, ND 58103, 701‐232‐8690 o Thrifty Drug – Hornbacher’s, 1532 32nd Avenue South #4, Fargo, ND 58103, 701‐280‐1929 o Walgreens – Fargo, 4201 13th Avenue South, Fargo, ND 58103, 701‐282‐4198 o West Acres Pharmacy, 3902 13th Avenue South #3706, Fargo, ND 58103, 701‐282‐0285 o Thrifty White Drug, 1401 33rd Street SW, Fargo, ND 58103, 701‐235‐5511 o Thrifty White Drug, 4255 30th Avenue South, Fargo, ND 58104, 701‐478‐8953 o Thrifty White Drug, 1100 13th Avenue East West, Fargo, ND 58078, 701‐281‐5695 o Thrifty White Drug, 708 38th Street North #C, Fargo, ND 58102, 701‐893‐9050 o Medical Pharmacy – Hornbacher’s, 4151 45th Street South, Fargo, ND 58104, 701‐282‐8075 Moorhead, MN o CVS Drug, 822 30th Ave S., Moorhead, MN 56560, 218‐236‐0807 o Cash Wise, 3300 Highway 10 East, Moorhead, MN 56560, 218‐236‐0345 o Foss Drug, 420 Center Ave, Suite 33, Moorhead, MN 56560, 218‐236‐7400 o K‐Mart, 3000 Highway 10 East, Moorhead, MN 56560, 218‐236‐1556 o Medical Pharmacy – Hornbacher’s, 101 11th Street S, Moorhead, MN 56560, 218‐236‐6333 o Moorhead Drug, 510 Center Avenue, Moorhead, MN 56560, 218‐233‐1529 o Sanford Health Pharmacy, 1301 8th Street South, Moorhead MN 56560, 701‐234‐3250 o SunMart, 2605 8th Street South, Moorhead, MN 56560, 218‐291‐0242 o Target, 3301 Highway 10 East, Moorhead, MN 56560, 218‐233‐2953

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o Walgreens – Moorhead, 900 Main Avenue, Moorhead, MN 56560, 218‐236‐0252 o Walgreens – Moorhead, 700 30th Avenue South, Moorhead, MN 56560, 218‐331‐2668

 Hospitals, facilities/clinics where primary care physicians with hospital privileges work, and other health care facilities Fargo, ND o Red River Women’s Clinic, 512 1st Ave N, Fargo, ND 58102, 701‐298‐9999 o Catalyst Medical Center, 1800 21st Ave S, Fargo, ND 58103, 701‐365‐8700 o North Dakota Center for Sleep, 4152 30th Ave S, Suite 103, Fargo, ND 58104, 701‐356‐3000 o Family Healthcare, 301 Northern Pacific Ave N, Fargo, ND 58102, 701‐271‐3344 o Prairie St. John’s Clinic, 510 4th St S, Fargo, ND 58103, 701‐476‐7800 o Pediatric Arts Clinic, 2301 25th St S, Suite N, Fargo, ND 58103, 701‐478‐4722 o Red River Spine Associates, 2829 University Dr S, Suite 201, Fargo, ND 58103, 701‐280‐0057 o Internal Medicine Associates, 1707 Gold Dr S, Fargo, ND 58103, 701‐280‐2033 o Independent Family Doctors, 1711 Gold Dr S, Suite 160, Fargo, ND 58103, 701‐234‐9400 o 7‐ Day Clinic Walk‐in Express Care, 4622 40th Ave S, Fargo, ND 58104, 701‐364‐2909 o 7‐ Day Clinic Walk‐in Express Care, 1517 32nd Ave S, Fargo, ND 58103, 701‐232‐6211 o UrgentMed, 2301 25th St S, Suite N, Fargo, ND 58103, 701‐232‐9000 o Sanford West Fargo Clinic, 1220 Sheyenne Street West, Fargo, ND 58078, 701‐234‐4445 o Sanford Fargo North Clinic, 2601 Broadway N, Fargo, ND 58102, 701‐234‐2900 o Sanford South University, 1720 S University Drive, Fargo, ND 58103, 701‐234‐2000 o Sanford Children’s Southwest Clinic, 2701 13th Ave S, Fargo, ND 58103, 701‐234‐3620 o Sanford 1717 Medical Building, 1717 S University Drive, Fargo, ND 58103, 701‐234‐2000 o Sanford Medical Center Fargo, 801 Broadway N, Fargo, ND, 701‐234‐2000 o Sanford 2801 Medical Building, 2801 University Drive S, Fargo, ND 58103, 701‐234‐5673 o Sanford Southpointe Clinic, 2400 32nd Ave S, Fargo, ND 58103, 701‐234‐8800 o Essentia Health West Acres Clinic, 3902 13th Ave S, Suite 3706, Fargo, ND 58103, 701‐364‐8900

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o Essentia Health West Fargo Clinic, 1401 13th Ave E West, Fargo, ND 58078, 701‐364‐5751 o Essentia Health – Fargo / 32nd Avenue Clinic, 3000 32nd Ave S, Fargo, ND 58103, 701‐364‐8000 o Essentia Health South University Clinic, 1702 South University Drive, Fargo, ND 58103, 701‐364‐3300 Moorhead, MN o Prairie St. John’s Clinic, 2925 20th St S, Moorhead, MN 56560, 218‐284‐0300 o 7‐ Day Clinic Walk‐in Express Care, 720 Main Ave, Moorhead, MN 56560, 218‐359‐0399 o Sanford Moorhead Clinic, 1308 8th St S, Moorhead, MN 56560, 701‐234‐3200 o Essentia Health Moorhead Clinic, 801 Belsly Blvd, Moorhead, MN 56560, 701‐364‐6800

Prospective entities to invite Prospective entities to invite include: include:  Social service  Patient/community organization focus group representatives participants  Service organization  Social service representatives organization Entities  City and county representatives invited to government officials  Service organization the Town  Tribal government/ representatives Hall leadership/  City and county meeting representatives if government officials applicable and/or  Tribal government/ other minority leadership/ population group representatives if members/ applicable and/or representatives other minority  Primary care and population group

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other health care members/ providers representatives  Lead county public  Primary care and health officials other health care  Industry/business providers leaders/  Lead county public representatives health officials  Educators/educational  Industry/business administrators leaders/  Other relevant entities representatives  Educators/ educational administrators  Other relevant entities

Certified Diabetes Educators  Local Mental Health  Essentia Health, 1702 S. University Drive, providers Fargo, (701) 364‐8900  Case Management  North Dakota State University, (701) 231‐5200 providers nd Additional  Sanford Health – Southpointe, 2400 32 Ave S, Human Individuals Fargo, (701) 234‐2000  Apple A Day, Inc., 213 10th Ave W, West Fargo, (701) 282‐6826  Sanford Health, 801 Broadway N, Fargo, (701) 234‐5659

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 VA Medical Center, 2101 North Elm Street, Fargo, (701) 239‐3700 ext. 2708

Registered dietician(s)  Essentia Health, 3000 32nd Ave S, Fargo, (701) 364‐8900  Sanford Health, 736 Broadway, Fargo, (701) 234‐2000  Sanford Health‐ Southpointe, 2400 32nd Ave S, Fargo, (701) 234‐2000  Sanford Health, 801 Broadway, Fargo, (701) 234‐2000 or (701) 234‐2245  Sanford Eating Disorders & Weight Management Center, 1717 S. University Drive, Fargo, (701) 234‐4111  Sanford Roger Maris Cancer Ctr, 820 4th Street N, Fargo, (701) 234‐6161

Primary care providers who could participate in intervention  MD and NP‐C, Endocrinologist/Diabetic Care, Essentia Health, 1702 University Dr S. Fargo, ND, 701‐364‐8900  MDs, Internal Medicine (Diabetes), Essentia Health, 1702 University Dr S. Fargo, ND, 701‐ 364‐8900

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 MD, Pediatrician (Diabetes), Essentia Health, 1702 University Dr S. Fargo, ND, 701‐364‐8900  MD, Internist/Endocrinologist (Diabetes), Sanford Health, 737 Broadway N. Fargo, ND, 701‐234‐2000  MD, Endocrinologist/OBGYN, Sanford Health, 737 Broadway N. Fargo, ND, 701‐234‐2000  MD, Endocrinologist (Diabetes), Sanford Health, 737 Broadway N. Fargo, ND, 701‐234‐ 7980  MD, Internal Medicine/Endocrinology (Diabetic care), 737 Broadway N. Fargo, ND, 701‐234‐2245  MDs, FACP, Internal Medicine (Diabetes), Internal Medical Associates, 1707 Gold Dr. S Fargo, ND, 701‐280‐2033  PA‐C, Women’s health (Diabetes), Internal Medical Associates, 1707 Gold Dr. S Fargo, ND, 701‐280‐2033  MDs, PA‐C, and NP‐C, Family Medicine, Essentia Health – West Acres, 3902 13th Ave. S Fargo, ND, 701‐364‐6600  MDs and RNP, Family Medicine, Essentia Health, 1401 13th Ave. E West Fargo, ND, 701‐ 364‐8900  MDs and FNP‐C, Family Medicine, Essentia

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Health, 1702 S University Dr. S. Fargo, ND, 701‐ 364‐8900  MDs, DNPs, NP‐C, PA‐Cs, Family Medicine, Essentia Health, 901 Belsly Blvd. Moorhead, MN, 701‐364‐6800  MDs, NP, FNP, and PA‐Cs, Family Medicine, Sanford Health, 2400 32nd Ave. S Fargo, ND, 701‐234‐8830  PA‐C, Family Medicine, Sanford Health, 2601 Broadway North Fargo, ND, 701‐234‐2900  MDs, NP, Family Medicine , Sanford Health, 1220 Sheyenne St. West Fargo, ND, 701‐234‐ 4445  MDs, Family Medicine, Sanford Health, 1720 University Dr. Fargo, ND, 701‐280‐4140  MD, Family Medicine/Internal Medicine, Sanford Health, 2601 Broadway N Fargo, ND, 701‐234‐2900  NP, Family Medicine, Sanford Health, 737 N Broadway Dr. Fargo, ND, 701‐234‐2300  MD, Family Medicine, Sanford Health, 1717 University Dr. Fargo, ND, 701‐280‐4140  MD, Family Medicine , Sanford Health, 801 Broadway N. Fargo, ND, 701‐234‐4445  MDs, Family Medicine, Sanford Health, 1301 8th St. S Moorhead, MN, 701‐234‐3260

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Financial Grants and The base guideline for the hospital’s financial contribution is 0.1% of net patient revenue less bad debt [i.e. 0.1%*(NPR‐BD)] hospital for each of the three interventions, each of which will last three years with the first beginning in Financial Year 2014. contribution Additionally, all hospitals are strongly encouraged by Bert Norman, Essentia Health’s Chief Financial Officer, to reallocate current Community Benefit funding to supplement the base financial contribution guideline.

University Extension Cass & Clay County Social Home Health  NDSU Extension Service, NDSU Dept 7000, 315 Services  Access of Red River Morrill Hill, Fargo, ND 58108, (701) 231‐8944 Valley, 403 Center FirstLink  Cass County Extension Service, 1010 2nd Avenue Suite 512

Moorhead, MN Avenue South, Box 2806 Fargo, ND 58108, SENDCA 701‐241‐5700 56560, 218‐233‐3991  Clay County, 715 11th Street North, Suite 107B Mental Health Association  Care 2000 Moorhead, MN 56560, 218‐299‐5020 Homehealth Care Social Connection Services of

Community Community Education Moorhead, 725 The Village’s intensive home health Center Avenue Suite  NDSU Region V Parenting Resource Center, visitation program for prenatal Programmatic activities 3A Moorhead, MN NDSU Dept. 7000 315 Morrill Hall, P.O. Box already 6050 Fargo, ND, (701) 231‐8944. Provides Early intervention services 56560, 218‐233‐1000 occurring educational programs, newsletters, a lending  Creative Care for library, and educational literature to help ND KIDS program (used to be Reaching

families succeed. called Infant Development) Independence,

American Square ARC of West Central MN Building 725 Center Churches  First Baptist Church, 701‐235‐6361. Classes in CCRI Avenue Suite 7 retirement, legal issues. Moorhead, MN  First Lutheran Church, 619 Broadway Fargo, Clay County Chemical 56560, 218‐236‐6730 Dependency Services ND, 701‐235‐7389. Women’s’ Support Group,  Good Samaritan

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Grief Support Group, Fitness. Society, 4502 37th  First Presbyterian Church, 650 2nd Avenue Community Outreach Center at Avenue South Fargo, North, Fargo, North Dakota 58102, 701‐293‐ MSUM ND 58104, 701‐282‐

6311, Narcotics Anonymous, Parish Nurse 2651 Crisis Responders  Hope Lutheran Church,  Hospice of the Red o North Campus, 2900 Broadway North, Human Service Associates River Valley, 1701

Fargo, ND 58102 38th Street South o South Campus, 3636 25th St. South, Lost & Found #101 Fargo, ND Fargo, ND 58104, 701‐235‐6629 Ministry/Recovery Worship 58103, 701‐356‐1500

o Fitness, Grief & Disability Support  Prairieland Home Lutheran Social Services Group Health Agency, 1102

 Nativity Catholic Church, 1825 11th St S Fargo, Gamblers Choice Page Drive SW Fargo, ND, 701‐232‐2414. Support Groups & Parish ND 58103, 701‐232‐ Nurse Safe Harbour 1245  Olivet Lutheran Church, 1330 University Drive  Sanford Home Care, Solutions South; Fargo, ND, 701‐235‐6603. Classes in 1711 S University

CPR, AED, Living Wills, DPA for Healthcare, Drive Fargo, ND Tran$ Em (Transitional SAID, Disaster Preparedness, Women’s Supported Employment of MN) 58103, 701‐234‐4900 Support Group, Grief Support Group  Spectrum Home Care,  St. Joseph’s Catholic Church, 218 10th St. S, Alzheimer’s Program 2108 S University Moorhead, MN, 218‐236‐5066. Bereavement Catholic Family Services Drive Suite 106B Support Group; financial planning, fitness Fargo, ND 58103, Gambling Problem Helpline 701‐293‐8172

Clay County Collaborative, 715 11th St. N Sexaholics Anonymous Moorhead, MN 56560, 218‐498‐2389. For a complete Respite services or adult day

listing of classes and support groups offered, see Sister’s Path care for respite  Bethany Day Services,

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http://www.claycountycollaborative.org/resources/kids Bethany on activities090518.jpg Alzheimer’s Association, 701‐ University 201 277‐9757 University Drive

Head Start Program, 3233 S University Dr South Fargo, ND EAP in the workplace

Fargo, ND, 701‐235‐8931. To see a full listing of 58103, 701‐239‐3545 classes/services offered see,  Home Instead Senior http://www.sendcaa.org/programs.htm Care, 505 Broadway #204 Fargo, ND Sanford Health, 801 Broadway N., Fargo, ND, 701‐234‐ 58102, 701‐478‐1010 5570 or 1‐877‐234‐4240. For a complete list of  Johnson Eldercare educational classes & events, see Home, 3531 1st Street http://www.sanfordhealth.org/ClassesAndEvents/Searc North Fargo, ND h 58102, 701‐277‐7195  Rainbow Square YWCA, 3100 12th Ave. N., Fargo, ND, 701‐232‐2547. Courtyard, Rosewood Comprehensive employment and educational readiness on Broadway 1351 training to assist unemployed and under employed Broadway Fargo, ND women residing at the Emergency Shelter. Supportive 58102, 701‐277‐7999 services include: job counseling, advocacy, and referrals  HeartSprings, 2010 and a variety of on‐site curriculum including resume North Elm Street and interview classes. Additionally, Steps to Success, an Fargo, ND 58102, intensive hands‐on job readiness course, is offered 701‐261‐3142 monthly to YWCA housing participants. Skills learned  Club Connection, Villa prepare women to enter or re‐enter the job market Maria 3102 S while bolstering self‐confidence and self‐esteem. University Drive, Fargo, ND 58103,

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YMCA of Cass and Clay Counties 701‐293‐7750  4243 19th Ave S., Fargo, ND, 701‐281‐0126  Touchmark at  400 1st Ave. S. Fargo, ND, 701‐293‐9622 Harwood Groves,  Mission: The YMCA of Cass and Clay Counties 1200 Harwood Drive is a not‐for‐profit community service Fargo, ND 58104, organization dedicated to enhancing the spirit, 701‐476‐1200 mind and body of all persons through quality  LSS Caregiver Support leadership, programs, services, and facilities and Respite Services, Our Saviors Lutheran FM Ambulance, 2215 18th St S, Fargo, ND 58103, 701‐ Church 610 13th 364‐1750. For a complete list of educational classes Street North, see, http://www.fmambulance.com/education Moorhead, MN 56560, 218‐233‐7521 Essentia Health, 3000 32nd Ave S. Fargo, 701‐364‐8000. For a complete list of educational classes & events, see Health Care for Homeless http://essentiahealth.org/main/classesandgroups.aspx Vets, Fargo VA Health Care System 2101 North Elm Street

Fargo, ND 58102, 701‐239‐ Moorhead Community Education, Probstfield Center 3700 for Education, 2410 14th St. S. Moorhead MN, 56560, 218‐284‐3400. For a complete Homeless Health Services, 670 th list of educational classes, see 4 Avenue North St. Mark’s https://communityed.moorhead.k12.mn.us/ Lutheran Church Fargo, ND 58102, 701‐298‐9245

Fargo Adult Learning Center, Fargo Public Schools, 1305 RRV Dental Access Project, 9th Avenue South, Fargo, ND 58103, 701‐446‐2806. For 715 11th Street North Suite a complete list of educational classes and locations see, 201 Moorhead, MN 56560, 701‐364‐5364

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http://www.dpi.state.nd.us/adulted/learnctr.shtm Community Care Programs Cass Clay Healthy People Initiative: Partnership of (Essentia, Sanford)

health‐minded organizations that have come together Caring Program

to make Cass and Clay Counties the healthiest in America. Working community‐wide to decrease the Prescription Assistance incidence of obesity and chronic disease by Program transforming communities to promote active living and healthy eating. Provides experienced and passionate Care Coordinators fitness and nutrition expertise. Have resources for Sanford RN Health Coaches, communities, schools, child cares and others to build Ask‐A‐Nurse Program, and this new, healthy culture. Have a special focus on the Shelter Parish Nurses next generation ‐‐ on the young ‐ so that they have the health to achieve their full potential. Set a 10‐year goal Blue Cross Member Advocate to reduce childhood obesity rates in Cass and Clay Program counties by 20% by 2020: "20% by 2020" is the goal.

Includes the following programs: Streets Alive!, Schools Medical Home Program

Alive!, Join the Movement!, ChildCare Alive!, Faith Blue Cross Case Managers Community Alive!, Dakota Medical Foundation, 4141 28th Avenue South, Fargo, ND 58104, 701‐356‐3132

Active in Moorhead: AIM is a partnership between Clay County Public Health, the City of Moorhead and the Fargo‐Moorhead Metropolitan Council of Governments (Metro COG). AIM works to incorporate physical activity into everyday life through the community design. 715 11th Street North, Moorhead, MN 56560,

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218‐299‐5220

Food Systems Initiative: The goal of the Cass Clay Food System Initiative (CCFSI) is to increase access to safe, nutritious, and affordable food for our residents by strengthening all aspects of the local food system. The local food system includes producers, processors, distributors, sales, and consumers. Includes the “Let’s Eat Local!” Program. Fargo Cass Public Health, 401 3rd Ave. N, Fargo, ND 58102, 701‐241‐1360

Sanford Fit Kids Initiative: A Comprehensive Suite of Resources that will Empower Children and Parents to make Healthy Lifestyles Choices that Help Prevent Childhood Obesity – for more information go to: http://www.sanfordhealth.org/healthinformation/kids health/article/35919

Metrocog: The Fargo‐Moorhead Metropolitan Council of Governments (Metro COG) is the Metropolitan Planning Organization (MPO) for the Fargo‐Moorhead area. An MPO is a transportation policy‐making organization made up of representatives from local government and transportation authorities. Programs Include, but not limited to: Complete Streets ‐ process of planning, designing, building, and operating streets so they routinely and safely accommodate all modes of

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local and regional travel. FM Metro COG, Case Plaza Suite 232, One 2nd Street North, Fargo, ND 58102, 701‐ 232‐3242

Energize Program: This is like a “healthy” school carnival – will be in 11 schools this year. Provides education on how to improve food choices, increase physical activity and reduce screen time.

TNT Kids Fitness & Gymnastics Academy: Will be taking their mobile fitness lab into Head Start sites. TNT Kid’s Fitness & Gymnastics is organized for the purpose of providing all boys and girls, regardless of age, financial, mental or physical ability the opportunity to experience the benefits of gymnastics and fitness while becoming part of our family of athletes. The officers, directors, staff and volunteers are committed to helping children to reach full potential through utilization of exercise or the sport of gymnastics to encourage expanded opportunities, 2800 Main Ave, Fargo, ND 58103, 701‐ 365 ‐8868

Healthy Blues Program (through ND Blue Cross): Free robust wellness site with inspirational articles on healthy living, easy‐to‐use trackers for health and nutrition, ability to interact with a dietitian or fitness trainer, online wellness workshops, customized

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challenges, mobile app for smart phones. 4510 13th Avenue South, Fargo, ND, 1‐888‐225‐4381 Complete Streets (have a policy, bike & pedestrian plan, etc.)

ND Worksite Wellness Programs: Launched in 2009 as a collaborative effort between Dakota Medical Foundation, Blue Cross Blue Shield of North Dakota and the North Dakota Department of Health. The goal is to get more North Dakota businesses and organizations to offer and participate in worksite wellness programs. Healthy North Dakota Worksite Wellness Director, 701‐ 277‐2414.

Schools and colleges with meetings spaces and/or Mental Health Centers Assisted living facilities Buildings or fitness facilities  235‐SEEK, Phone answered  Arbor Park Village, other built th th o Concordia College, 901 8 Street South 24 hours/day, 701‐235‐ 520 28 Street North environmen Moorhead, MN 56562, 218‐299‐4000 7335 Moorhead, MN t features 56560, 218‐359‐9999 that may be o North Dakota State University, 1340  Alcoholics Anonymous rd useful for Administration Avenue Fargo, ND 58102, 701‐ Club House, 1112 3  Four Seasons at Infrastructure th intervention 231‐8011 Avenue South Fargo, ND Moorhead, 2921 6 s, e.g. gyms, o Minnesota State University – Moorhead, 1104 58103, 701‐232‐9930 Avenue North community 7th Avenue South Moorhead, MN 56563, 218‐  Alzheimer’s Program, 701‐ Moorhead, MN centers, 477‐4000 235‐7335 56560, 218‐359‐9000 walking Minnesota State Community and Technical   Carriage House paths, etc. o Catholic Charities of North College, 1900 28th Avenue South Moorhead, Dakota, 5201 Bishops Blvd. Senior Apartments,

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MN 56560, 218‐299‐6500 Suite B Fargo, ND 58104, 3412 Village Green o Rasmussen College – Moorhead, 1250 29th 701‐235‐4457 Blvd. Moorhead, MN Avenue South Moorhead, MN 56560, 218‐304‐  Centre, Inc. Detox, 1519 1st 56560, 218‐236‐6454 6200 Avenue South Suite B  Linden Tree Circle, o Rasmussen College – Fargo, 4012 19th Avenue Fargo, ND 58103, 701‐237‐ Eventide on Eighth Southwest Fargo, ND 58103, 701‐277‐3889 3341 1405 7th Street South, o North Dakota State College of Science – Fargo  Drake Counseling Services, Moorhead, MN Skills and Technology Training Center, 1305 1202 23rd Street South #5 56560, 218‐233‐7508 th 19 Avenue North Fargo, ND 58102, 701‐231‐ Fargo, ND 58103, 701‐293‐  Eventide at Fairmont, 6900 5429 801 2nd Avenue th o Minnesota School of Business, 2777 34 Street  Fargo VA, 701‐239‐3700 North, Moorhead, South Moorhead, MN 56560, 218‐422‐1000 ext. 9‐3436 MN 56560, 218‐233‐ th o Fargo Davies High School, 7150 25 St S Fargo,  FirstLink Hotline, 4357 13th 8022 ND 58104, 701‐446‐5600 Avenue South #107 Fargo,  Evergreens of th o Fargo South High School, 1840 15 Avenue ND 58103, 701‐293‐6462 Moorhead, 502 3rd South Fargo, ND 58103, 701‐446‐2000 or 701‐235‐7335 (hotline) Avenue South, th o Fargo North High School, 801 17 Avenue  First Step Recovery, 409 7th Moorhead, MN North Fargo, ND 58102, 701‐446‐2400 Street South Fargo, ND 56560, 218‐233‐1535 th o West Fargo High School, 801 9 Street East 58103, 701‐293‐3384  Moorhead Manor, th West Fargo, ND 58078, 701‐356‐2050  Gamblers Anonymous, Inc., 1710 13 o Woodrow Wilson Alternative High School, 701‐235‐7335 Avenue North, th 1305 9 Avenue South Fargo, ND 58103, 701‐  Gamblers Choice – Moorhead, MN 446‐2800 Lutheran Social Services of 56560, 218‐236‐6286 o Oak Grove Lutheran School, 124 North Terrace ND, 1325 11th Street South  Northside Retirement th Fargo, ND 58102, 701‐237‐0212 Fargo, ND 58103, 701‐235‐ Home, 2004 8 th o Shanley High School, 5600 25 Street South 7341 Avenue North Fargo, ND 58104, 701‐893‐3200

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o Moorhead High School, 2300 4th Avenue South  Gambling Problem Moorhead, MN Moorhead, MN 56560, 218‐284‐2300 Helpline, 1‐800‐472‐2911 56560, 218‐233‐1583 th o Park Christian School, 300 17 Street North  Lutheran Social Services of  Park View Terrace Moorhead, MN 56560, 218‐236‐0500 ND, 1325 11th Street South Apartments, 100 3rd Fargo, ND 58103, 701‐235‐ Street North Churches with meetings spaces and/or fitness facilities 7341 Moorhead, MN Fargo, ND  Mental Health Association, 56560, 218‐233‐8548 th o St. Mary’s Cathedral, 619 7 Street North 124 8th Street North #1  River Pointe of Fargo, ND 58102, 701‐235‐6354 Fargo, ND 58102, 701‐237‐ Moorhead, 2401 th o Shepherd of the Prairie, 6151 25 Street South 5871 South 11th Street Fargo, ND 58104, 701‐235‐5711  Prairie St. John’s, 510 4th Moorhead, MN th o Gethsemane Cathedral, 3600 25 Street South Street South Fargo, ND 56560, 218‐287‐6900 Fargo, ND 58104, 701‐232‐3394 58103, 701‐476‐7800 or  Bethany Gables, th o Crosspoint Lutheran Church, 4500 37 Avenue 701‐476‐7216 (Free Needs Bethany on 42nd 4255 South Fargo, ND 58104, 701‐232‐7677 Assessment) 30th Avenue South th o Faith United Methodist Church, 909 19  Rape & Abuse Crisis Fargo, ND 58104,701‐ Avenue North Fargo, ND 58102, 701‐232‐6844 Center, 317 8th Street 478‐8910 nd o Calvary Chapel, 2796 2 Avenue South Fargo, North Fargo, ND 58102,  Bethany Towers, ND 58103, 701‐232‐1010 701‐293‐7273 Bethany on o St. Paul’s Newman Center, 1141 N University  Recovery Worship – First University 201 Drive Fargo, ND 58102, 701‐235‐0142 United Methodist Church, University Drive o Emmanuel Lutheran Church, 107 Broadway 701‐232‐4416 South Fargo, ND Fargo, ND 58102, 701‐553‐8546  Sanford Health, Behavioral 58103, 701‐239‐3439 o Plymouth Congregational Church, 901 Health 701‐234‐6000,  Edgewood Vista in th Broadway Fargo, ND 58102, 701‐235‐9226 Child / Adolescent Mental Fargo, 4420 37 th o First Baptist Church, 1501 17 Avenue South Health Services 701‐234‐ Avenue South Fargo, Fargo, ND 58103, 701‐235‐6361

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o Grace Lutheran Church, 821 5th Avenue South 4141, Eating Disorders ND 58104, 701‐365‐ Fargo, ND 58103, 701‐232‐1516 Institute 701‐234‐4111, 8200 o Beautiful Savior Lutheran Church, 2601 23rd Psychiatry & Psychology  Ecumen Evergreens Avenue SW Fargo, ND 58103, 701‐293‐1047 701‐461‐5600 of Fargo, 1401 West o First Assembly of God, 3401 25th Street South  SENDCA (SE ND Gateway Circle Fargo, Fargo, ND 58104, 701‐232‐0003 Community Action ND 58103, 701‐239‐ o Living Waters Lutheran Church, 4451 40th Agency), 701‐232‐2452 4524 Avenue South Fargo, ND 58104, 701‐282‐0530  Sexaholics Anonymous,  Good Samaritan o Temple Baptist Church, 2801 Broadway Fargo, 701‐235‐5303 Society, 4502 37th ND 58102, 701‐232‐6568  Sharehouse Outpatient & Avenue South Fargo, o Knollbrook Covenant Church, 3030 Broadway Residential Addiction ND 58104, 701‐282‐ Fargo, ND 58102, 701‐235‐4622 Services, 701‐282‐6561 2651 o River City Church, 323 Main Avenue Fargo, ND  Sharehouse Genesis, 701‐  Pioneer House 58103, 701‐364‐0088 478‐8440 Assisted Living, Elim th o Peace Lutheran Church, 1011 12 Avenue  Sister’s Path, 701‐478‐ Care 3540 University North Fargo, ND 58102, 701‐232‐7166 6562 Drive South Fargo, o Diocese of Fargo, 5201 Bishops Blvd Fargo, ND  Sharon Henshel ND 58104, 701‐271‐ 58104, 701‐356‐7900 Counseling1120 28th 1862 th o Hope Lutheran Church – South, 3636 25 Avenue N Suite B2 Fargo,  Riverview Place, 5300 th Street South Fargo, ND 58104, 701‐235‐6629 ND 58102, 701‐793‐5234 12 Street South o Hope Lutheran Church – North, 2900  Southeast Human Service Fargo, ND 58104, Broadway North Fargo, ND 58102, 701‐235‐ Center, 701‐298‐4500 701‐237‐4700 6629  Village Family Service  Touchmark at o St. Anne & Joachim Catholic Church Center, 701‐451‐4900 Harwood Groves, th o 5202 25 Street South Fargo, ND 58104, 701‐  Vosburg Counseling for 1200 Harwood Drive

235‐5757 Seniors, 701‐235‐2092 Fargo, ND 58104, o Calvary United Methodist Church,

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o 4575 45th Street South Fargo, ND 58104, 701‐ 7016 ‐47 ‐1200 232‐5650 Alcoholics Anonymous Club o Free Methodist Church, 1501 10th Avenue House Nursing homes

South Fargo, ND 58103, 701‐235‐2885  Eventide on Eighth, Village Family Service Center th 1405 7 Street South o Lutheran Church Missouri Synod – Beautiful rd Moorhead, MN Savior, 2601 23 Avenue South Fargo, ND Vosburg Counseling for Seniors 58103, 701‐293‐1047 56560, 218‐233‐7508 o Episcopal Church Diocese, 3600 25th Street Rape & Abuse Crisis Center  Eventide at Fairmont, nd South Fargo, ND 58104, 701‐235‐6688 801 2 Avenue North o Lutheran Atonement Church of Christ the King, SE Mental Health Moorhead, MN

4601 S University Drive Fargo, ND 58104, 701‐ 56560, 218‐233‐8022 Prairie (Fargo & Moorhead  Eventide at Sheyenne 237‐9651 locations) th th o Cornerstone Baptist Church, 1130 11 Street Crossings, 225 13 South Fargo, ND 58103, 701‐478‐7787 Lakeland Mental Health Avenue W West o First United Methodist Church, 906 1st Avenue Fargo, ND 58078, South Fargo, ND 58103, 701‐232‐4416 Fargo VA 701‐478‐6100 th o Jehovah’s Witness, 2207 18 Street South  Golden Living Center, The Anchorage nd Fargo, ND 58103, 701‐293‐5327 2810 2 Avenue

North Moorhead, MN o First Lutheran Church, 619 Broadway Fargo, Sharehouse ‐ Wellness Center, ND 58102, 701‐235‐7389 OP & Residential Addiction 56560, 218‐233‐7578 o Messiah Lutheran Church, 2010 Elm Street Services, Genesis Program  Bethany on North Fargo, ND 58102, 701‐237‐6770 University, 201 o Olivet Lutheran Church, 1330 S University Centre Detox University Drive

Drive Fargo, ND 58103, 701‐235‐6603 South Fargo, ND Clay County Detox o Church of the Nativity, 1825 11th Street South 58103, 701‐239‐3000 nd Fargo, ND 58103, 701‐232‐2414 Drake Counseling Services  Bethany on 42 , th th o Bethel Evangelical Free Church, 2702 30 4255 30 Avenue

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Avenue South Fargo, ND 58103, 701‐232‐4476 First Step Recovery South Fargo, ND o Community of Christ, 1604 52nd Avenue South 58104, 701‐478‐8900 Fargo, ND 58104, 701‐232‐3753 Dementia/Alzheimer’s  Elim Nursing Home, nd  Arbor Park Village, 520 o First Presbyterian Church, 650 2 Avenue 3534 South 28th Street North North Fargo, ND 58102, 701‐293‐6311 University Drive th Moorhead, MN 56560, o Holy Spirit Church, 1420 7 Street North Fargo, Fargo, ND 58104, 218‐359‐9999 ND 58102, 701‐232‐5900 701‐271‐1810 th  Eventide at Fairmont, 801 o Cathedral of St. Mary, 619 7 Street North  ManorCare Health 2nd Avenue North Fargo, ND 58102, 701‐235‐6354 Services, 1315 South th Moorhead, MN 56560, o Bethlehem Lutheran Church, 613 16 Street University Drive 218‐233‐8022 South Fargo, ND 58103, 701‐235‐6522 Fargo, ND 58103, th  o St. John Lutheran Church, 1710 5 Street River Pointe, 2401 South 701‐237‐3030 11th Street Moorhead, MN South Fargo, ND 58103, 701‐232‐2189  Rosewood on th 56560, 218‐287‐6900 o First Congregational Church, 1101 17 Avenue Broadway, 1351  South Fargo, ND 58103, 701‐232‐8985 Ecumen Evergreens of Broadway Fargo, ND rd o Immanuel Lutheran Church, 1258 Broadway Moorhead, 502 3 Avenue 58102, 701‐277‐7999 South Moorhead, MN Fargo, ND 58102, 701‐293‐7979  Villa Maria, 3102 th 56560, 218‐233‐1535 o Salem Evangelical Free Church, 1002 10 South University  Street South Fargo, ND 58103, 701‐237‐6094 Bethany on University, 201 Drive, Fargo ND th o Elim Lutheran Church, 321 9 Street North University Drive South, 58103, 701‐293‐7750

Fargo, ND 58102, 701‐232‐2574 Fargo, ND 58103, 701‐239‐ o Pontoppidan Lutheran Church, 309 4th Street 3000 Family HealthCare Center, th North Fargo, ND 58102, 701‐232‐0998  Edgewood Vista, 4420 37 1701‐ 27 ‐3344 o St. Anthony of Padua, 710 10th Street South Avenue South Fargo, ND

Fargo, ND 58103, 701‐237‐6063 58104, 701‐365‐8200

St. Mark’s Lutheran Church, 670 4th Avenue  Elim, 3534 S University o North Fargo, ND 58102, 701‐235‐5591 Drive Fargo, ND 58104,

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West Fargo, ND 701‐271‐1800 o Red River Church, 607 9th Street E West Fargo,  Ecumen Evergreens of ND 58078, 701‐282‐7180 Fargo, 1401 West Gateway o Triumph Lutheran Brethren Church, 3745 Circle Fargo, ND 58103, Sheyenne Street West Fargo, ND 58078, 701‐ 701‐239‐4524 281‐3821 o New Beginnings Assembly of God, 123 Main Avenue W West Fargo, ND 58078, 701‐281‐ 8600 o Faith Lutheran Church, 127 2nd Avenue E West Fargo, ND 58078, 701‐282‐3309 o St. Andrew Lutheran Church, 1005 1st Street West Fargo, ND 58078, 701‐282‐4195 o Blessed Sacrament Church, 210 5th Avenue W West Fargo, ND 58078, 701‐282‐3321 o Community Presbyterian Church, 702 Sheyenne Street West Fargo, ND 58078, 701‐ 282‐4135 o Flame of Faith United Methodist Church, 1222 6th Street E West Fargo, ND 58078, 701‐282‐ 5765 o Shepherd of the Valley Lutheran Church, 121 Sheyenne Street West Fargo, ND 58078, 701‐ 277‐8481 o Shiloh Evangelical Free Church, 2200 Shiloh Street Platted West Fargo, ND 58078, 701‐282‐ 3247

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o Living Hope Baptist Church, 1245 8th Street W West Fargo, ND 58078, 701‐282‐5076 o Holy Cross Catholic Church, 1420 16th Street E West Fargo, ND 58078, 701‐282‐7217 o Lutheran Church of the Cross, 1402 16th Street E West Fargo, ND 58078, 701‐282‐0514 Moorhead, MN o Bridgepointe Community Church, 804 17th Street North Moorhead, MN 56560, 218‐233‐ 7485 o Evangelical Lutheran Church, 310 14th Avenue South Moorhead, MN 56560, 218‐299‐3019 o Crossroads Christian Fellowship, 123 21st Street South Moorhead, MN 56560, 218‐233‐ 7115 o Trinity Lutheran Church, 210 7th Street South Moorhead, MN 56560, 218‐236‐1333 o St. Francis De Sales, 601 15th Avenue North Moorhead, MN 56560, 218‐236‐1505 o Our Redeemer Lutheran Church, 1000 14th Street Moorhead, MN 56560, 218‐233‐7569 o Bethesda Lutheran Church, 401 40th Avenue South Moorhead, MN 56560, 218‐236‐1420 o Our Savior’s Lutheran Church, 610 13th Street North Moorhead, MN 56560, 218‐233‐2412 o Triumph Lutheran Brethren Church, 2901 20th Street South Moorhead, MN 56560, 218‐233‐

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4048 o First Congregational – United, 406 8th Street South Moorhead, MN 56560, 218‐236‐1756 o St. Joseph’s Catholic Church, 218 10th Street South Moorhead, MN 56560, 218‐236‐1979 o Apostolic Bible Church, 1910 5th Avenue North Moorhead, MN 56560, 218‐233‐0617 o Christ The King Lutheran Church, 1900 14th Street South Moorhead, MN 56560, 218‐236‐ 7576 o Brookdale Baptist Church, 1401 40th Avenue South Moorhead, MN 56560, 218‐233‐8758 o Faith Hope Love Church, 204 4th Street South Moorhead, MN 56560, 218‐236‐7276 o Grace United Methodist Church, 1120 17th Street South Moorhead, MN 56560, 218‐233‐ 1857 o Calvary Church – Village Green, 2801 Village Green Blvd Moorhead, MN 56560, 218‐233‐ 3921 o Lutheran Church of the Good Shepherd, 4000 28th Street South Moorhead, MN 56560, 218‐ 233‐4980

Gym/fitness centers: o Core Fitness, 2424 13th Avenue S Fargo, ND 58103, 701‐212‐1085

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o NDSU Wellness Center, 1707 Centennial Blvd Fargo, ND 58102, 701‐231‐5200 o Fitnessworks, 2220 Main Ave E, #D West Fargo, ND 58078, 701‐298‐3336 o Max Training, 1132 28th Ave S, Moorhead, MN 56560, 218‐359‐0220 o Planet Fitness, 4325 13th Ave S, Suite 9 Fargo, ND 58103, 701‐478‐3300 o Snap Fitness . 814 30th Ave S Moorhead 56560, 218‐233‐ 7627 . 1525 32nd Ave S Fargo, ND 58103, 701‐ 356‐1095 . 1375 21st Ave N Fargo, ND 58102, 701‐ 364‐5545 . 4265 45th Street S Fargo, ND 58104, 701‐ 356‐3651 o Edge Fitness, 3501 8th Street South Moorhead 56560, 218‐422‐3343 o Total Balance, 1461 Broadway Fargo, ND 58102, 701‐293‐6037 o Touchmark, 1200 Harwood Drive Fargo, ND 58104, 701‐476‐1200 o Courts Plus Fitness Center, 3491 S University Drive Fargo, ND 58104, 701‐237‐4805 o Anytime Fitness . 2614 Broadway Fargo, ND 58102, 701‐

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239‐1781 . 1801 45th Street South Fargo, ND 58103, 701‐277‐5040 o YMCA . 1721 S University Drive Fargo 58103, 701‐ 232‐9360 . 4243 19th Ave SW Fargo, ND 58103, 701‐ 281‐0126 . 400 1st Avenue S Fargo, ND 58103, 701‐ 293‐9622 . 4225 38th Street South Fargo, ND 58104, 701‐232‐9360 o West Fargo Fitness Center, 215 Main Ave E West Fargo, ND 58078, 701‐356‐6555 o Cormax Fitness, 1518 29th Ave Moorhead, MN 56560, 218‐236‐2673 o Family Wellness Center, 2960 Seter Parkway Fargo, ND 58104, 701‐234‐2400 o TNT Kids Gym, 2800 Main Ave Fargo, ND 58103, 701‐365‐8868 o Metro Rec Center, 3110 Main Ave Fargo, ND 58103, 701‐235‐9211 o Ladies Workout Express, 1420 9th Street East, Suite 405 Pioneer Center West Fargo, ND 58078, 701‐277‐5711 o Curves, 123 21st Street South Moorhead, MN 56560, 218‐287‐4295

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o MSUM Wellness Center, 805 14th Street South Moorhead, MN 56563, 218‐477‐4300 o Xtreme Measures, 1612 Tom Williams Drive, Suite #B Fargo, ND 58104, 701‐293‐0002 o Elements for Women, 3120 25th Street, South Fargo, ND 58103, 701‐356‐5200 o CrossFit 701, 3309 Fiechtner Drive South Fargo, ND 58103, 701‐430‐1987 o Dance‐Fit, 1800 21st Avenue S Fargo, ND 58103, 701‐446‐6891 o Bodyshop Training, 4207 12th Avenue North Fargo, ND 588102, 701‐367‐2823 o Sports Center, 3320 Westrac Drive Fargo, ND 58103, 701‐232‐6564 o Wild Knights CrossFit, 3343 S University Drive Fargo, ND 58103, 701‐212‐1239 o Health Pros, 2108 University Drive S, #105B Fargo, ND 58103, 701‐297‐7767 o Total Woman Fitness, 3332 4th Avenue S, #C Fargo, ND 58103, 701‐356‐5110 o Fargo Bully Proof Kids, 2119 13th Ave S Fargo, ND 58103, 701‐235‐5506 o Ultimate Kung Fu, 3301 S University Drive Fargo, ND 58103, 701‐541‐0121

Community centers o Fargo Youth Commission, 2500 18th Street

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South Fargo, ND 58103, 701‐235‐2147 o YMCA, 4243 19th Avenue SW Fargo, ND 58103, 701‐281‐0126 o YMCA, 400 1st Avenue South Fargo, ND 58103, 701‐293‐9622 o Horace Senior Center, 214 Thue Ct. Horace, ND 58047, 701‐281‐0792 o Pride Collective & Community Center, 810 4th Avenue South #220 Moorhead, MN 56560, 218‐287‐8034 o Centro Cultural De Fargo / Moorhead, 1014 19th Street South Moorhead, MN 56560, 218‐236‐7318 o Metro Rec Center, 3110 Main Avenue Fargo, ND 58103, 701‐235‐9211

Swimming pools o Island Park Pool, 616 1st Avenue South Fargo, ND 58102, 701‐235‐7685 o Madison Swimming Pool, 1040 29th Street North Fargo, ND 58102, 701‐232‐5726 o Northside Recreation Pool, 801 17th Avenue North Fargo, ND 58102, 701‐446‐ 2437 o Southwest Recreation Pool, 1840 15th Avenue South Fargo, ND 58103, 701‐235‐ 4093

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o Davies Recreational Pool, 7150 25th Street South Fargo, ND 58104, 701‐446‐5940 o Moorhead Municipal Swimming Pool, 800 19th Street South, Moorhead, MN 56560, 218‐299‐5364 o Hansmann Park, 1320 12th Avenue North Moorhead, MN 56560, 218‐299‐5190 o Northeast Park Wading Pool, 1817 8th Avenue North Moorhead, MN 56560, 218‐ 299‐5356 o Ridgewood Park Wading Pool, 1818 31st Street South Moorhead, MN 56560, 218‐ 299‐5196 o Riverview Estates Park Wading Pool, 3801 5th Street South Moorhead, MN 56560, 218‐299‐5345 o South Park Wading Pool, 2101 14th Street South Moorhead, MN 56560, 218‐299‐ 5359 o Village Green Park Wading Pool, 2600 Village Green Blvd Moorhead, MN 56560, 218‐299‐5197

Local TV station and other media (e.g. newspapers) Radio Stations o KFNW AM 1200‐FM 97.9, 5702 52nd Avenue South Fargo, ND 58104, 701‐282‐

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5910 o KRVI FM – The River 95.1, 1020 25th Street South Fargo, ND 58103, 701‐237‐5346 o Rock 102 KRWK‐FM, 1020 25th Street South Fargo, ND 58103, 701‐237‐5346 o Radio Fargo‐Moorhead, 1020 25th Street South Fargo, ND 58103, 701‐237‐5346 o KFGO AM, 1020 25th Street South Fargo, ND 58103, 701‐237‐5346 o KKBX FM The Box 101.9, 1020 25th Street South Fargo, ND 58103, 701‐237‐5346 o The Fan KVOX‐AM, 1020 25th Street South Fargo, ND 58103, 701‐237‐5346 o North Dakota Public Radio, 207 5th Street North Fargo, ND 58102, 701‐241‐6900 o KQWB‐Q 98 – FM, 2720 7th Avenue South Fargo, ND 58103, 701‐234‐9898 o KPFX‐FM‐The Fox 107.9, 2720 7th Avenue South Fargo, ND 58103, 701‐237‐4500 o KVOX FM Froggy 99.9, 2720 7th Avenue South Fargo, ND 58103, 701‐237‐4500 o Prairie Public Broadcasting Inc., 207 5th Street North Fargo, ND 58102, 701‐241‐ 6900 o KFAB FM B93 92.7, 1020 25th Street South Fargo, ND 58103, 701‐235‐4293 o KLTA‐FM‐Lite Rock 105, 2720 7th Avenue

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South Fargo, ND 58103, 701‐237‐4500 o Triad Broadcasting, 2720 7th Avenue South Fargo, ND 58103, 701‐237‐4500 o KVOX AM The Ticket, 1020 25th Street South Fargo, ND 58103, 701‐237‐5346 o Y‐94 WDAY‐FM, 1020 25th Street South Fargo, ND 58103, 701‐237‐5346 o Heaven 88.7 FM, P.O. Box 107 Fargo, ND 58107, 701‐298‐8877 o KQWB‐AM Star 1660, 2720 7th Avenue South Fargo, ND 58103, 701‐237‐4500 o KDAM FM, 1020 25th Street South Fargo, ND 58103, 701‐237‐5346 o WDAY AM‐970‐TV, 301 8th Street South Fargo, ND 58103, 701‐237‐6500 o Guderian Broadcasting, 2720 7th Avenue South Fargo, ND 58103, 701‐271‐8106 o KDAM FM The Dam 104.7, 1020 25th Street South Fargo, ND 58103, 701‐280‐ 1047 o KQLX Radio, 417 38th Street South Fargo, ND 58103, 701‐356‐9790 o KCCM/KCCD Minnesota Public Radio, 901 8th Street South Moorhead, MN 56562, 218‐299‐3666 Print Media o The Forum, 101 5th Street North Fargo, ND

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58102, 701‐235‐7311 o High Plains Reader, 109 Broadway Fargo, ND 58102, 701‐235‐1553 o Prairie Homes Magazine, 205 4th Avenue North Fargo, ND 58102, 701‐297‐9111 o Fargo Moorhead Sun, 603 11th Street North Fargo, ND 58102, 701‐232‐7110 o Prairie Business Magazine, 808 3rd Avenue South, Suite 400 Fargo, ND 58103, 701‐ 232‐8893 o Fargo‐Moorhead Magazine, 322 Sheyenne Street West Fargo, ND 58078, 701‐282‐ 3260 o West Fargo Pioneer Newspaper, 322 Sheyenne Street West Fargo, ND 58078, 701‐282‐2443 o Midweek Eagle, 322 Sheyenne Street West Fargo, ND 58078, 701‐282‐2443 Television Stations o Moorhead Community Access Television, 118 5th Street South Moorhead, MN 56560, 218‐233‐9493 o KXJB‐TV‐Channel 4, 1350 21st Avenue South Fargo, ND 58103, 701‐282‐0444 o KVRR‐TV‐Fox, 4015 9th Avenue South Fargo, ND 58103, 701‐277‐1515 o Prairie Public Broadcasting Inc., 207 5th

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Street North Fargo, ND 58102, 701‐241‐ 6900 o KVNJ‐TV‐Channel, 2Frgo Fargo, ND 58102, 701‐232‐7110 o KCPM, P.O. Box 9292 Fargo, ND 58106, 701‐364‐9900

Hiking and biking trails o Brandt Crossing, 5050 33rd Avenue South Fargo, ND 58103 o Dike East, 100 2nd Street South Fargo, ND 58103 o Jefferson West Park, 1904 4th Avenue South Fargo, ND 58103 o Lindenwood Park, 1905 Roger Maris Drive Fargo, ND 58103 o Oak Grove Park, 170 Maple Street North Fargo, ND 58102 o These parks have recreational hiking and biking trails and also may include the following: disc golf, grills, horseshoes, picnic tables, playgrounds, tennis, baseball / softball, concessions, cross country ski trails, fishing, and shelters

Grocery stores o Hornbacher’s – Southgate, 1532 32nd

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Avenue South Fargo, ND 58104, 701‐280‐ 1999 o Hornbacher’s – Osgood, 4151 45th Street South Fargo, ND 58104, 701‐281‐8111 o Hornbacher’s Express, 1433 S University Drive Fargo, ND 58103, 701‐237‐9481 o Hornbacher’s – Village West, 4101 S 13th Avenue South Fargo, ND 58103, 701‐282‐ 6363 o Hornbacher’s – Moorhead, 101 11th Street South Moorhead, MN 56560, 218‐236‐ 6333 o Hornbacher’s – Northport, 2510 Broadway Fargo, ND 58102, 701‐293‐5444 o SunMart, 2605 8th Street South Moorhead, MN 56560, 218‐291‐9340 o SunMart, 1100 13th Avenue East West Fargo, ND 58078, 701‐277‐5566 o SunMart, 3175 25th Street South Fargo, ND 58103, 701‐237‐3007 o SunMart, 724 N University Drive Fargo, ND 58102, 701‐235‐3001 o Cash Wise, 3300 Highway 10 East Moorhead, MN 56560, 218‐236‐4910 o Cash Wise, 1401 South 33rd Street Fargo, ND 58103, 701‐237‐4120 o SUPERVALU, 3501 12th Avenue North

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Fargo, ND 58102, 701‐293‐2100 o Sam’s Club, 4831 13th Avenue SW Fargo, ND 58103 o Wal‐Mart Supercenter, 3757 55th Avenue South Fargo, ND 58104, 701‐526‐1167 o Wal‐Mart Supercenter, 4731 13th Avenue South Fargo, ND 58103, 701‐2881‐3971 o Wal‐Mart Supercenter, 415 34th Street North Dilworth, MN 56529, 218‐233‐9822 o Costco, 750 23rd Avenue East West Fargo, ND 5807, 701‐281‐2220 Malls o West Acres Mall, 3902 13th Avenue South Fargo, ND 58103, 701‐282‐2222 o Moorhead Center Mall, 510 Center Avenue Moorhead, MN 56560, 218‐233‐ 6117

Ice skating and/or roller rinks o Southwest Youth Arena, 4404 23rd Avenue South Fargo, ND 58103, 701‐356‐9888 o Madison Park Rink, 1040 29th Street North Fargo, ND 58102, 701‐298‐6915 o Teamsters Arena, 831 17th Avenue North Fargo, ND 58102, 701‐235‐4300 o Skateland, 3302 Interstate Blvd South Fargo, ND 58103, 701‐235‐0555

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Ski trails and/or slopes o Edgewood Golf Course, 19 Golf Course Avenue Fargo, ND 58102, 701‐499‐6091 o Prairiewood Golf Course, 22 Prairiewood Drive Fargo, ND 58103, 701‐232‐1445 o Rosecreek Golf Course, 1500 Rose Creek Parkway Fargo, ND 58103, 701‐235‐5100 o Lindenwood Park, 1905 Roger Maris Drive Fargo, ND 58103 o Dike East, 100 2nd Street South Fargo, ND 58103

Public golf courses o Fargo Country Club, 509 26th Avenue South Fargo, ND 58103, 701‐237‐9122 o Edgewood Golf Course, 19 Golf Course Avenue Fargo, ND 58102, 701‐499‐6091 o Prairiewood Golf Course, 22 Prairiewood Drive Fargo, ND 58103, 701‐232‐1445 o Rosecreek Golf Course, 1500 Rose Creek Parkway Fargo, ND 58103, 701‐235‐5100 o El Zagal Golf Course, 1400 Elm Street North Fargo, ND 58103, 701‐232‐8156 o Osgood Golf Course, 4400 Clubhouse Drive Fargo, ND 58104, 701‐356‐3070 o Meadows Golf Course, 401 34th Street South Moorhead, MN 56560, 218‐299‐

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7888 o Moorhead Country Club, 2101 North River Drive Moorhead, MN 56560, 218‐236‐ 0100

Farmers Markets Fargo, ND o Downtown Festival Market, 2nd Avenue North and Broadway Fargo, ND 58102, 701‐241‐1570, June – September, 8:30 am – 12:00 pm o Great Plains Producer Association’s Community Farmers’ Market, Off of 2nd Street, South of Main Avenue Fargo, ND, Dike East Park, south of Fargo High Rise, 701‐793‐5532, June – October, Tuesday, Thursday, Saturday 10:00 am – 5:00 pm o Stonewest Village Farmers Market, 4955 17th Avenue South (parking lot) Fargo, ND, 701‐356‐6600, Tuesday, 3:00 pm – 7:00 pm o VA Farmers Market, VA Health Care Center, 2101 North Elm Street Fargo, ND, 701‐232‐3241 ex: 9‐3352 or 701‐261‐ 8569, June 22 – October, Friday 11:00 am – 1:00 pm o Bayer Vegetable Farm, 612 19th Avenue

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NW West Fargo, ND, 701‐282‐3822, August – October, Monday – Saturday 9:00 am – 6:00 pm o Breadsmith, 1617 32nd Avenue South Fargo, ND, 701‐478‐8000, June – September at Farmers Market o Dawson Creek Orchard and Nursery, 419 12th Avenue West, Unit E West Fargo, ND, 701‐532‐0336 / 701‐320‐3667, April – August o Down by the Dike, Off 2nd Street, South of Main Avenue Fargo, ND, Dike East Park, south of the Fargo High Rise, 701‐238‐ 9627, July – October, Monday, Wednesday, Friday 10:00 am – 7:00 pm o Hildebrant’s FM Farmers Market, 349 East Main Avenue (Corner of 4th Street East and Main) West Fargo, ND, 701‐281‐1539 / 701‐238‐4944, June – November, Sunday 12:00 pm – 6:00 pm, Monday – Friday 9:00 am – 8:00 pm, Saturday 9:00 am – 6:00 pm o Gramps Produce, 951 5th Avenue West West Fargo, ND, 701‐799‐5334, July – October, Monday – Friday 4:00 pm – 10:00 pm, Saturday & Sunday 7:00 am – 10:00 pm

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o It’s About Thyme, 724 10th Street North Fargo, ND, 701‐261‐8698, July – November o Juan’s Craft, 3530 2nd Street, #2 Fargo, ND, 701‐212‐5122, July – October, every day o Farmers’ Market & Beyond, 500 13th Avenue West (South Elmwood Park Parking Lot) West Fargo, ND, 701‐433‐ 5360, July 7 – October 6 Thursday 4:00 pm – 7:00 pm, July 30 – October 8 Saturday 9:00 am – 1:00 pm o Lady Bug Acres (Red Barn) Produce Stand, Kmart Parking Lot, 2301 S University Drive Fargo, ND, July – October, every day, 12:00 pm – 6:00 pm o Herzog’s County Fresh Produce Stands, Kmart Parking Lot, 2301 S University Drive Fargo, ND, Scheel’s Home & Hardware, 3202 13th Avenue South Fargo, ND, Gravel Pulloff on Sheyenne Street by I‐94 Exit West Fargo, ND, 218‐205‐7980, July – October, Monday – Saturday 10:00 am – 6:00 pm Moorhead, MN o Gardener’s / Flea Market, 324 South 24th Street Moorhead, MN (west end of Hjemkomst Center parking lot)

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o My Sister’s Farm, Moorhead Center Mall o Sydney’s Health Market, 810 3th Avenue South Moorhead, MN, 218‐233‐3310, July – October, Tuesday or Friday 3:00 pm – 7:00 pm o The Three Bears Honey Co, 908 63rd Avenue North Moorhead, MN, 218‐236‐ 5933, Year Round, Monday – Friday o Whistle Stop Farmers Market, Whistle Stop Park at 14th Street NE Dilworth, MN (Near intersection of 4th Street NE and U.S. 10 / SE), 701‐241‐1367, July 12 – October, Thursday 3:00 pm – 7:00 pm o Old Trail Market, Probstfield Farm & Living History Foundation Moorhead, MN (three miles up from Main Avenue when heading north on 11th Street), Tuesday & Thursday, 3:00 pm – 7:00 pm, Saturday 8:00 am – 2:00 pm

Transportation services o Anytime Transportation, 1403 13 ½ Street South Fargo, ND 58103, 701‐232‐3322 o CareAVan Mobility 4U Inc., 2626 S Bay Drive S Fargo, ND 58103, 701‐235‐6699 o Transit Alternatives, 218‐998‐3002 o Doyle’s Yellow Checker Cab, Inc., 1418

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Main Avenue Fargo, ND 58103, 701‐235‐ 5535 o Fargo Senior Commission, 2801 32nd Avenue South #A Fargo, ND 58103, 701‐ 293‐1440 o Handi‐Wheels, 2525 Broadway Fargo, ND 58102, 701‐232‐3231 o Lucky 7 Taxi, 3431 4th Avenue South Suite D Fargo, ND 58103, 701‐235‐1717 o MATBUS, 502 NP Avenue North Fargo, ND 58102, 701‐232‐7500 o MAT Paratransit, 701‐235‐4464 o Medi‐Van, 800‐422‐0976 o Metro Senior Ride Service, 701‐356‐7433 o Moorhead Transit System, 218‐232‐7500 o People’s Diversity Forum Transportation Service, 26 Roberts Street North Fargo, ND 58102, 701‐235‐5440 o Ready Wheels, 2215 18th Street South Fargo, ND 58103, 701‐364‐1700 o Richards Transportation Service, 2139 100 Avenue NW Moorhead, MN 56560, 218‐ 233‐3404 o RSVP, 701‐298‐4602 o Rural Cass Bus, 2801 32nd Avenue South P.O. Box 2217 Fargo, ND 58108, 701‐293‐ 1440

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o Faith In Action Community of Care Volunteers, 4 Langer Avenue North Cassleton, ND 58012, 701‐347‐0032

o Fargo Marathon . May 18th, 2013 Sporting . Fargo Dome, 1800 N University Drive Fargo, ND 58102 Local events events, o Red River Valley Fair festivals . July 9th – 14th, 2013 . West Fargo Fair Grounds, 1805 West Main Avenue West Fargo, ND 58078

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2012 Greater Fargo-Moorhead Community Health Needs Assessment of Residents Results of an April 2012 generalizable survey ofresidents in Cass County, North Dakota and Clay County, Minnesota

July 2012

Prepared by: Center for Social Research at North Dakota State University, Fargo

Prepared for: Fargo-Moorhead Community Health Needs Assessment Collaborative 2 This report, entitled 2012 Greater Fargo-Moorhead Community Health Needs Assessment ofResidents, presents the results of an April 2012 generalizable survey of residents in Cass County, North Dakota and Clay County, Minnesota.

The study was conducted by the Center for Social Research at North Dakota State University on behalf of the Fargo-Moorhead Community Health Needs Assessment Collaborative. Funding for the study was provided by Collaborative member organizations.

Fargo-Moorhead Community Health Needs Assessment Collaborative Members Sanford Health Essentia Health United Way of Cass-Clay Dakota Medical Foundation North Dakota State University Fargo Cass Public Health Clay County Public Health Family HealthCare Center Urban Indian Health and Wellness Center of Fargo-Moorhead Center for Rural Health at the University of North Dakota Southeast Human Services Center

The 2012 Greater Fargo-Moorhead Community Health Needs Assessment ofResidents is a companion report to the 2012 Greater Fargo-Moorhead Community Health Needs Assessment ofCommunity Leaders.

3 PREFACE ...... 3

TABLE OF CONTENTS...... 4

EXECUTIVE SUMMARY ...... 6 Introduction...... 6 Study Design and Methodology ...... 6 Key Findings ...... 6 Summary of Survey Results ...... 7 Companion Report Comparisons ...... 9

SURVEY RESULTS ...... 11

Community Assets/Best Things About Their Community ...... 11 Figure 1. Respondents' level of agreement with statements about their community regarding PEOPLE ...... 11 Figure 2. Respondents' level of agreement with statements about their community regarding SERVICES AND RESOURCES ...... 12 Figure 3. Respondents' level of agreement with statements about their community regarding QUALITY OF LI FE ...... 13

General Concerns About Their Community ...... 13 Figure 4. Respondents' level of concern with statements about their community regarding ECONOM IC ISSUES ...... 14 Figure 5. Respondents' level of concern with statements about their community regarding TRANSPORTATION ...... 14 Figure 6. Respondents' level of concern with statements about their community regarding ENVIRONMENT ...... 15 Figure 7. Respondents' level of concern with statements about their community regarding CH ILDREN AND YOUTH ...... 15 Figure 8. Respondents' level of concern with statements about their community regarding THE AGING POPULATION...... 16 Figure 9. Respondents' level of concern with statements about their community regarding SAFETY ...... 16

Health and Wellness Concerns About Their Community ...... 17 Figure 10. Respondents' level of concern with statements about their community regarding ACCESS TO HEALTH CARE...... 18 Figure 11. Respondents' level of concern with statements about their community regarding PHYSICAL AND MENTAL HEALTH ...... 19 Figure 12. Respondents' level of concern with statements about t heir community regarding SUBSTANCE USE AND ABUSE ...... 20

Personal Health Care Information ...... 21 Figure 13. Respondents' primary health care provider ...... 21 Figure 14. Respondents' reasons for choosing primary health care provider ...... 21 Figure 15. Whether respondents had a cancer screening or cancer ca re in the past year ...... 22

4 Figure 16. Among respondents who have not had a cancer screening or cancer care in the past year, reasons for not having done so ...... 22 Figure 17. Methods respondents have used to pay for health care costs over the last 12 months ...... 23

Demographic Information ...... 23 Figure 18. Respondents' age ...... 23 Figure 19. Respondents' highest level of education ...... 24 Figure 20. Respondents' gender ...... 24 Figure 21. Whether respondents work/volunteer outside the home ...... 25 Figure 22. Respondents' annual household income before taxes ...... 25 Figure 23. Whether respondents own or rent their home ...... 26 Figure 24. Respondents' race or ethnicity ...... 26 Figure 25. Whether respondents are the parent or primary caregiver of a child or children 18 years of age or younger ...... 27 Table 1. Additional concerns and suggestions ...... 28

APPENDICES ...... 29 Appendix Tables ...... 29 Survey Cover Letter ...... 40 Survey lnstrument ...... 41

5 Introduction

The purpose of this generalizable survey of residents in the greater Fargo-Moorhead (F-M) area (i.e., Cass County, North Dakota and Clay County, Minnesota) was to learn about the perceptions of area residents regarding the prevalence of disease and health issues in their community.

Study Design and Methodology

A generalizab le survey was conducted of residents in the greater F-M area. The survey instrument was developed in collaboration with the F-M Community Health Needs Assessment Collaborative and contained 27 questions.

The survey was designed as a scannable mail survey and was sent to 1,500 randomly selected households in Cass and Clay counties. The sampling frame was obtained from a qualified vendor. A total of 236 completed surveys were returned which provides a generalizable sample with a confidence level of 95 percent and an error rate of plus or minus 6 percent. Approval from the Institutional Review Board (IRB) at North Dakota State University was obtained to ensure proper protocol was used and the rights of human subjects maintained. The survey consisted of questions that focused on community assets, general concerns about communities, a variety of community health and wellness concerns, some personal health care information, and demographic information.

Key Findings

Respondents had high levels of agreement that their community has quality educational opportunities and programs, the community is a good place to ra ise kids and is a healthy place to live, and there is quality health care. However, respondents agreed the least that there is tolerance, inclusion, and open mindedness in their community.

Respondents were most concerned about t he aging population (i.e., ava ilability/cost of long-term ca re, availability of resources to help elderly stay in their homes, and availability of resources for family and friends caring for elders). Respondents had similar levels of concern with safety issues (i.e., presence and influence of drug dealers, domestic violence, property crimes, and child abuse and neglect) as they did with economic issues (i.e., employment opportunities, economic disparities between higher and lower classes, and cost of living). Respondents were also concerned with issues relating to children (i.e., bullying and availability/cost of quality child care). Respondents were least concern ed about the availability and cost of public transportation as well as traffic congestion. Environmental issues regarding garbage and litter, water quality, air quality, and noise levels were also not a large concern.

With respect to health and wellness concerns, respondents were most concerned with issues relating to cost and access (i.e., cost of health insurance, cost of health ca re, cost of prescription drugs, and adequacy of hea lth insurance ). Respondents were also concerned about access to health insurance coverage and the availability and cost of dental or vision insu rance and dental or vision care. Physical and mental health issues (i.e., cancer, chronic disease, and obesity) were also a concern. Respondents were least concerned about distance to health ca re services, availability of bilingual providers or translators, patient confidentiality, and availability or access to transportation.

6 Summary of Survey Results

Community Assets/Best Things About Their Community

Using a 1 to 5 scale, with 1 being "not at all" and 5 being "a great deal," respondents were asked to rate their level of agreement with various statements about their community regarding people, services and resources, and quality of life.

Respondents indicated the top five community assets or best things about the community were: there are quality higher education opportunities and institutions, the community is a good place to raise kids, there are quality school systems and programs for youth, there is quality health care, and the community is a healthy place to live.

Services and resources Respondents had high levels of agreement that there are quality higher education opportunities and institutions, as well as quality school systems and programs for youth in their community (mean=4.51 and mean=4.26, respectively). Respondents generally agreed there is effective transportation in their community (mean=3.69).

Quality of life Respondents had high levels of agreement that their community is a good place to raise kids and that it is a healthy place to live (mean=4.35 and mean=4.23, respectively). Although still well above average, among quality of life issues, respondents agreed the least that their community is a safe place to live and has little or no crime (mean=3.86).

People Respondents had fairly high levels of agreement that people are friendly, helpful, and supportive in their community and that there is a sense of community or feeling connected to people who live here (mean=4.06 and mean=3.87, respectively). Respondents were moderate in their agreement regarding tolerance, inclusion, and open-mindedness in their community (mean=3.29).

General Concerns About Their Community

Using a 1 to 5 scale, with 1 being "not at all" and 5 being "a great deal," respondents were asked to rate their level of concern with various statements about their community regarding economic issues, transportation, environment, children and youth, the aging population, and safety.

Respondents indicated the top six general concerns about the community were: the availability and/or cost of long-term care, the availability of resources to help the elderly stay in their homes, the availability of resources for family and friends caring for elders, the presence and influence of drug dealers in the community, the availability of employment opportunities, and domestic violence.

The aging population With respect to the aging population in their community, respondents had above average concerns with the availability and cost of long-term care (mean=3.66). Respondents were least concerned about the availability or cost of activities for seniors and the availability of resources for grandparents caring for grandchildren (mean=3.16 and mean=3.15, respectively).

Safety Regarding safety issues in their community, respondents were most concerned with the presence and influence of drug dealers (mean=3.51). Respondents were least concerned with elder abuse and violent crimes (mean=3.08 and mean=3.06, respectively).

7 Economic issues Respondents had moderate levels of concern with respect to the availability of employment opportunities (mean=3.49), economic disparities between higher and lower classes (mean=3.44), and the cost of living in their community (mean=3.43). Respondents were least concerned with homelessness and hunger in their community (mean=3.01 and mean=3.00, respectively).

Children and youth Regarding children and youth, respondents were most concerned with bullying and the availability and/or cost of quality child care in their community (mean=3.44 and mean=3.42, respectively). Respondents were least concerned with school dropout rates and truancy (mean=2.82).

Transportation Respondents were moderately concerned with issues of transportation in their community. The cost of automobile ownership was the largest concern (mean=3.42) followed by the availability of good walking or biking options (mean=3.25). Among transportation issues, respondents were least concerned with traffic congestion (mean=2.85).

Environment There was little concern among respondents with environmental issues in their community. Garbage and litter issues (mean=2.70) were more of a concern than water (mean=2.63), noise (mean=2.56), and air quality concerns (mean=2.37).

Health and Wellness Concerns About Their Community

Using a 1 to 5 scale, with 1 being "not at all" and 5 being "a great deal," respondents were asked to rate their level of concern with various health and wellness issues with respect to access to health care, physical and mental health, and substance use and abuse.

The top five health and wellness concerns among respondents were: the cost of health insurance, the cost of health care, the cost of prescription drugs, the adequacy of health insurance coverage, and access to health insurance coverage.

Access to health care Respondents had high levels of concern with respect to costs associated with health and wellness in their community. Among all the health care issues, cost of health insurance (mean=4.32), cost of health care (mean=4.25), and cost of prescription drugs (mean=4.06) were the top three concerns.

Respondents also had concerns with respect to access and the availability of health and wellness services and providers in their community. Access to health insurance coverage (mean=3.79), availability and cost of dental and/or vision coverage (mean=3.76), and availability of and cost of dental and vision care (mean=3.76) were all above average in level of concern.

Respondents had below average levels of concern with availability of or access to transportation (mean=2.63), patient confidentiality (mean=2.57), availability of bilingual providers and translators (mean=2.40), and distance to health care services (mean=2.33).

Physical and mental health Respondents had moderately high levels of concern with respect to physical and mental health issues in their community. Respondents were most concerned about cancer (mean=3.76), followed by chronic disease (mean=3.70), obesity (mean=3.69), and stress (mean=3.66). Respondents were least concerned about suicide and communicable disease (mean=3.04 and mean=2.83, respectively).

8 Substance use and abuse The levels of concern among respondents regarding substance use and abuse issues in their community were slightly higher than average. Respondents were most concerned about drug use and abuse and alcohol use and abuse (mean=3.55 and mean=3.52, respectively). Respondents were least concerned about exposure to second-hand smoke (mean=3.35).

Personal Health Care Information

The top three reasons respondents gave for their choice of a primary health care provider were quality of services (38.6 percent), location (35.6 percent), and availability of services (34.7 percent).

When asked whether they had a cancer screening or cancer care in the past year, 35.4 percent of respondents said they had not. The most common reasons for not having a cancer screening or cancer care in the past year was that it was not necessary (35.4 percent) and their doctor hadn't suggested it (29.1 percent).

Most respondents paid for their health care costs over the last 12 months by health insurance through an employer (60.2 percent). Other methods of payment include Medicare (26.3 percent), private health insurance (21.6 percent), and personal income (21.6 percent).

Demographic Information

Most respondents are 45 to 64 years of age (47.9 percent); 29.1 percent are 65 years or older and 6.0 percent are younger than age 30.

A majority of respondents have a Bachelor's degree or higher (53.0 percent), including 25.0 percent who have a graduate or professional degree.

The gender distribution among respondents is evenly split among males and females.

Three in four respondents said they work or volunteer outside the home (76.6 percent).

Half of respondents said their annual household income is $40,000 to $69,999 (25.2 percent) and $70,000 to $119,999 (24.8 percent). Five percent earned less than $20,000 annually (5.3 percent).

A majority of respondents own their home (83.3 percent).

The vast majority of respondents are white (95.3 percent).

One-fourth of respondents said they are the parent or primary caregiver of children 18 years of age or younger (25.9 percent).

Companion Report Comparisons

The 2012 Greater Fargo-Moorhead Community Health Needs Assessment of Residents is a companion report to the 2012 Greater Fargo-Moorhead Community Health Needs Assessment ofCommunity Leaders. Caution should be used when interpreting the comparisons as findings from the community leaders' survey are not generalizable to the community.

Overall, community leaders had higher levels of agreement and higher levels of concern than did the residents.

9 Among community assets, both residents and community leaders agreed the most that there are quality higher education opportunities, institutions, school systems, and programs for youth; there is quality health care, and that it is a good place to raise kids. Compared to community leaders, residents agreed less that there is an engaged government and a sense that you can make a difference. Residents agreed the least that there is tolerance, inclusion, and open-mindedness, whereas community leaders agreed the least that there is effective transportation.

Among general concerns, both residents' and community leaders' top concerns were directed at the aging population (i.e., availability and cost of long-term care, availability of resources to help the elderly stay in their homes, availability of resources for family and friends caring for elders). However, community leaders were most concerned about domestic violence. Availability of quality child care and bullying were also among the top concerns among community leaders, whereas availability of employment opportunities and the presence and influence of drug dealers in the community were top concerns among residents. Both residents and community leaders were least concerned about environmental issues (i.e., garbage and litter, water quality, air quality, and noise levels).

Among health and wellness concerns, both residents' and community leaders' top concerns were access-related issues (i.e., the cost of health insurance, the cost of health care, and the cost of prescription drugs). With respect to physical and mental health, residents were more concerned about cancer, chronic disease, and obesity. Community leaders, on the other hand, were most concerned about obesity, poor nutrition and eating habits, and inactivity or lack of exercise. Both residents and community leaders were least concerned about communicable disease and suicide.

With respect to demographic characteristics, community leaders tended to be more highly educated and have higher incomes than residents overall. While the gender distribution among residents was evenly split, a larger proportion of community leaders who completed the survey were female.

10 Community Assets/Best Things About Their Community

Using a 1 to 5 scale, with 1 being "not at all" and 5 being "a great deal," respondents were asked to rate their level of agreement with various statements regarding PEOPLE, SERVICES AND RESOURCES, and QUALITY OF LIFE in their community.

Overall, respondents had moderately high levels of agreement regarding positive statements that reflect the people in their community (Figure 1, Appendix Table 1). • On average, respondents agreed the most that people in their community are friendly, helpful, and supportive {mean=4.06); 26.4 percent agreed a great deal. • Respondents also had a fairly high level of agreement that there is a sense of community or feeling connected to people who live here {mean=3.87). • Although still a moderate level of agreement, respondents agreed the least that there is tolerance, inclusion, and open-mindedness in their community {mean=3.29); 8.4 percent of respondents agreed a great deal.

Figure 1. Respondents' level of agreement with statements about their community regarding PEOPLE

People are friendly, helpful, and supportive (N=231)

There is a sense of community/feeling connected t o people who live here (N=227) Th e community is socially and culturally diverse (N=225) People who live here are aware of/engaged in social, civic, or political issues (N=227)

There is an engaged government (N=225)

There is a sense that you can make a difference (N=226) There is tolerance, inclusion, and open-mindedness (N=225)

1 2 3 4 5 Mean (l=not at all, S=a great deal)

11 Overall, respondents had a high level of agreement with positive statements regarding services and resources issues in their community (Figure 2, Appendix Table 2). • On average, respondents agreed the most that there are quality higher education opportunities and institutions in their community (mean=4.51); 61.6 percent agreed a great deal. Respondents also had a high level of agreement that there are quality school systems and programs for youth (mean=4.26) and that there is quality health care (mean=4.25). • Although still above average in their level of agreement, respondents agreed the least that there is effective transportation in their community (mean=3.69).

Figure 2. Respondents' level of agreement with statements about their community regarding SERVICES AND RESOURCES

There are quality higher education opportunities and institutions (N=229) There are quality school systems and programs for youth (N=227)

There is quality health care (N=228)

There is access to healthy food (N=230)

There is access to family services (N=231)

There is effective transportation (N=228)

1 2 3 4 5 Mean (l=not at all, S=a great deal)

12 Overall, respondents had a high level of agreement with positive statements regarding quality of life issues in their community (Figure 3, Appendix Table 3). • On average, respondents agreed the most that their community is a good place to raise kids and that it is a healthy place to live {mean=4.35 and mean=4.23, respectively). • Although still well above average in their level of agreement, respondents agreed the least that their community is a safe place to live and has little or no crime {mean=3.86).

Figure 3. Respondents' level of agreement with statements about their community regarding QUALITY OF LIFE

The community is a good place to raise kids (N=230)

The community is a healthy place to live (N=230)

There are many recreational, exercise, and sports activities/opportunities (N=229) The community has a peaceful, calm, and quiet environment (N=230) There are quality arts, cultural activities, events, and festivals (N=229) The community is a safe place to live and has little or no crime (N=231)

1 2 3 4 5

Mean {l=not at all, S=a great deal)

Respondents were asked to describe other best things about their community {see Appendix Table 4 for a list ofthemes). • Respondents mentioned the faith and religious organizations and their wonderful contributions to the community. • Respondents also mentioned their satisfaction with city services {i.e., quick response, great recycling and garbage program, and snow removal).

General Concerns About Their Community

Using a 1 to 5 scale, with 1 being "not at all" and 5 being "a great deal," respondents were asked to rate their level of concern with various statements regarding ECONOMIC ISSUES, TRANSPORTATION, ENVIRONMENT, CHILDREN AND YOUTH, THE AGING POPULATION, and SAFETY in their community.

Overall, respondents had a moderate level of concern with economic issues in their community (Figure 4, Appendix Table 5). • On average, respondents were most concerned with the availability of employment opportunities {mean=3.49), economic disparities between higher and lower classes {mean=3.44), and the cost of living {mean=3.43). • Although still moderately concerned, on average, respondents were least concerned with homelessness and hunger in their community {mean=3.01 and mean=3.00, respectively).

13 Figure 4. Respondents' level of concern with statements about their community regarding ECONOMIC ISSUES

Availability of employment opportunities (N=226)

Economic disparities between higher and lower classes (N=219)

Cost of living (N=224)

Wage levels (N=225)

Availability of affordable housing (N=227)

Poverty (N=224)

Homelessness (N=224)

Hunger (N=221)

1 2 3 4 5 Mean (l=not at all, S=a great deal)

Overall, respondents had a moderate level of concern with transportation issues in their community {Figure 5, Appendix Table 6). • On average, respondents were most concerned with the cost of automobile ownership followed by the availability of good walking or biking options {mean=3.42 and mean=3.25, respectively). • Although still moderately concerned, on average, respondents were least concerned with traffic congestion {mean=2.85).

Figure 5. Respondents' level of concern with statements about their community regarding TRANSPORTATION

Cost of automobile ownership (e.g., gas, maintenance, insurance) (N=225) Availability of good walking or biking options (as alternatives to driving) (N=224)

Driving habits (e.g., speeding, road rage) (N= 226)

Road conditions (N=224)

Availability and/or cost of public transportation (N=225)

Traffic congestion (N=230)

1 2 3 4 5

Mean (l=not at all, S=a great deal)

14 Overall, respondents were not that concerned with environmental issues in their community (Figure 6, Appendix Table 7). • On average, respondents had a higher level of concern with garbage and litter (mean=2.70) than with water quality (mean=2.63), noise level (mean=2.56) and air quality (mean=2.37).

Figure 6. Respondents' level of concern with statements about their community regarding ENVIRONMENT

Garbage and litter concerns {N=232)

Water quality concerns {N=227)

Noise level concerns {N=229)

Air quality concerns {N=223)

1 2 3 4 5

Mean (l=not at all, S=a great deal)

Overall, respondents had a moderate level of concern with issues relating to children and youth in their community (Figure 7, Appendix Table 8). • On average, respondents were most concerned about bullying and the availability or cost of quality child care (mean=3.44 and mean=3.42, respectively). • Although still moderately concerned, on average, respondents were least concerned with school dropout rates and truancy (mean=2.82).

Figure 7. Respondents' level of concern with statements about their community regarding CHILDREN AND YOUTH

Bullying (N=209)

Availability and/or cost of quality child care {N=209)

Avai lability and/or cost of activities for children and youth {N=216) Ava ilability and/or cost of services for at-risk youth {N=208)

Youth crime (N=218)

Teen pregnancy (N=209)

School dropout rates/truancy (N=214)

1 2 3 4 5 M ean {l=not at all, S=a great deal)

15 Overall, respondents had moderately high average levels of concern with issues relating to the aging population in their community (Figure 8, Appendix Table 9). • On average, respondents were most concerned about the availability and cost of long-term care (mean=3.66); 30.0 percent said they had a great deal of concern. • Although still moderately concerned, on average, respondents were least concerned about the availability or cost of activities for seniors and the availability of resources for grandparents caring for grandchildren (mean=3.16 and mean=3.15, respectively).

Figure 8. Respondents' level of concern with statements about their community regarding THE AGING POPULATION

Availability and/or cost of long-term care (N=227)

Availability of resources to help the elderly stay in their homes {N=221) Availability of resources for family and friends ca ring for elders (N=224) Availability and/or cost of activities for seniors (N=226) Availability of resources for grandparents caring for grandchildren (N=220)

1 2 3 4 5

Mean (l=not at all, S=a great deal)

Overall, respondents had a slightly higher than average level of concern with safety issues in their community (Figure 9, Appendix Table 10). • On average, respondents were most concerned with the presence and influence of drug dealers in the community (mean=3.51), domestic violence (mean=3.46), property crimes (mean=3.41), and child abuse and neglect (mean=3.39). • Although still moderately concerned, on average, respondents were least concerned with elder abuse and violent crimes (mean=3.08 and mean=3.06, respectively).

Figure 9. Respondents' level of concern with statements about their community regarding SAFETY

Presence and influence of drug dealers in the community {N=226)

Domestic violence (N =214)

Property crimes (N =222)

Ch ild abuse and neglect (N =217)

Elder abuse (N=215)

Violent crimes {N=223)

1 2 3 4 5

Mean (l=not at all, S=a great deal)

16 Respondents were asked their opinion of other community concerns (see Appendix Table 11 for a list of themes). • Some respondents had concerns regarding vandalism of cars (e.g., broken windows, flat tires) and nuisance issues relating to loud cars and stereos, and people not picking up after their dogs. • Some respondents also wrote about how it was not easy to get socially connected to people if you were not from the area.

Health and Wellness Concerns About Their Community

Using a 1 to 5 scale, with 1 being "not at all" and 5 being "a great deal," respondents were asked to rate their level of concern about health and wellness issues in their community regarding ACCESS TO HEALTH CARE, PHYSICAL AND MENTAL HEALTH, and SUBSTANCE USE AND ABUSE.

Overall, respondents had high levels of concern regarding several issues associated with access to health care in their community (Figure 10, Appendix Table 12). • Respondents were most concerned about cost issues: o Cost of health insurance (mean=4.32); 55.8 percent were concerned a great deal. o Cost of health care (mean=4.25); 50.2 percent were concerned a great deal. o Cost of prescription drugs (mean=4.06); 40.6 percent were concerned a great deal. o Adequacy of health insurance (e.g., amount of copays, deductibles) (mean=3.97); 39.5 percent were concerned a great deal. • Respondents also had moderately high levels of concern regarding access and availability of health and wellness, coverage, providers, costs, and services: o Access to health insurance coverage (e.g., preexisting conditions) (mean=3.79); 33.3 percent were concerned a great deal. o Availability and/or cost of dental and/or vision insurance coverage (mean=3.76); 30.8 percent were concerned a great deal. o Availability and/or cost of dental and/or vision care (mean=3.76); 29.7 percent were concerned a great deal. • Among health care access issues, respondents had the least concern for transportation and distance issues, patient confidentiality, and availability of bilingual providers/translators: o Availability of/access to transportation (mean=2.63). o Patient confidentiality (mean=2.57). o Availability of bilingual providers and/or translators (mean=2.40). o Distance to health care services (mean=2.33).

17 Figure 10. Respondents' level of concern with statements about their community regarding ACCESS TO HEALTH CARE

Cost of health insurance (N=226)

Cost of health care (N=231)

Cost of prescription drugs (N=229)

Adequacy of health insurance (e.g., amount of co pays, deductibles) (N=220) Access to health insurance coverage (e.g., preexisting conditions) (N=225) Availability and/or cost of dental and/or vision insurance coverage (N=221) Availability and/or cost of dental and/or vision care (N=222) Availability of prevention programs or services (N=216) Use of emergency room services for primary health care (N=221) Availability of doctors, nurses, and/or specialists (N=218)

Time it takes to get an appointment (N=223)

Coordination of care (N=218)

Availability of non-traditional hours (e.g., evenings, weekends) (N=221) Availability of mental health services and providers (N=216)

Providers not taking new patients (N=223)

Avai lability of/access to transportation (N=221)

Patient confidentiality (N=220)

Availability of bilingual providers and/or translators (N=215)

Distance to health care services (N =226)

1 2 3 4 5

Mean (l=not at all, S=a great deal)

18 Overall, respondents had moderately high levels of concern regard ing physical and mental health issues in their community (Figure 11, Appendix Table 13). • On average, respondents indicated the physical and mental health issues they were most concerned about in their community were cancer, chronic disease, obesity, and stress (mean=3.76, mean=3.70, mean=3.69, and mean=3.66, respectively). • Although still a moderate level of concern, on average, respondents were least concerned about suicide and communicable disease (mean=3.04 and mean=2.83, respectively).

Figure 11. Respondents' level of concern with statements about their community regarding PHYSICAL AND MENTAL HEALTH

Cancer {N=218)

Chronic disease {e.g., diabetes, heart disease, multiple sclerosis) {N=217)

Obesity {N=219)

Stress {N=216)

Poor nutrition/eating habits {N=222)

Inactivity and/or lack of exercise {N=219)

Dementia/Alzheimer's disease {N=219)

Depression (N=218)

Suicide (N=218)

Communicable disease {e.g., sexually transmitted diseases, AIDS) {N=219)

1 2 3 4 5 Mean {l=not at all, S=a great deal)

19 Overall, respondents' levels of concern regarding substance use and abuse in their community were very similar and moderately higher (Figure 12, Appendix Table 14). • On average, respondents were most concerned about drug use and abuse and alcohol use and abuse (mean=3.55 and mean=3.52, respectively). • On average, respondents were least concerned with exposure to second-hand smoke (mean=3.35).

Figure 12. Respondents' level of concern with statements about their community regarding SUBSTANCE USE AND ABUSE

Drug use and abuse (N=221)

Alcohol use and abuse (N=220)

Smoking and tobacco use (N=220)

Exposure to second-hand smoke (N=221)

1 2 3 4 5 Mean (l=not at al l, S=a great deal)

Respondents were asked to describe other health and wellness concerns in their community (see Appendix Table 15 for a list of themes). • Most of the respondents' comments were about the costs associated with health care, insurance, medical devices, and medications. • Some respondents said there was a lack of mental health and dental services.

20 Personal Health Care Information

Respondents were asked which provider they used for their primary health care and why they chose that provider. • Three in five respondents said they use Sanford Health as their primary health care provider (62.7 percent); one in five said they use Essentia Health (21.2 percent) (Figure 13, Appendix Table 16).

Figure 13. Respondents' primary health care provider

Sanford Hea lth 62.7

Essentia Health 21.2

Independent Family Doctors

Did not access health care in the last 12 months

Family Hea lthCare Center 1.3

Use emergency room/urgent care for primary care 0.4 services

Other** 5.1

0 10 20 30 40 so 60 70 80 90 100 Percent*

N=236 *Percentages do not equal 100.0 due to multiple responses. **See Appendix Table 16 for a list of other responses.

• The top three reasons respondents gave for their choice of primary health care provider were quality of services, location, and availability of services (38.6 percent, 35.6 percent, and 34.7 percent, respectively) (Figure 14, Appendix Table 17). • One in four respondents said choosing their primary health care provider was influenced by their hea lth insurance as well as being valued as a patient (24.6 percent and 23.3 percent, respectively. Cost was not an issue in choosing a provider for most respondents (5.1 percent).

Figure 14. Respondents' reasons for choosing primary hea lth care provider

Quality of services 38.6 Location •!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 35.6 Ava ilability of services I!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 34.7 Influenced by health insurance I!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 24.6 Sense of being valued as a patient •!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 23.3 Cost I!!!!! 5.1 Other** 12.7

0 10 20 30 40 so 60 70 80 90 100

Percent* N=236 *Percentages do not equal 100.0 due to multiple responses. * *See Appendix Table 17 for a list of other responses.

21 Respondents were asked whether they had a cancer screening or cancer care in the past year, and if they had not, reasons for not having done so. • One in three respondents said they had not had a cancer screening or cancer care in the past year (35.4 percent) (Figure 15, Appendix Table 18).

Figure 15. Whether respondents had a cancer screening or cancer care in the past year

Yes 64.6

0 10 20 30 40 so 60 70 80 90 100

Percent

N=223

• Among respondents who had not had a cancer screening or cancer care in the past year, one in three said they had not done so because it was not necessary (35.4 percent); 29.1 percent said their doctor had not suggested it. Cost and fear were also reasons for some respondents (15.2 percent and 10.1 percent, respectively) (Figure 16, Appendix Table 19). • One in five respondents gave "other" reasons for not having a cancer screening or cancer care. The most common reason was that they were not due to have a screening. Some respondents had chosen not to screen and others said that time was a barrier (see Appendix Table 19for a list of themes).

Figure 16. Among respondents who have not had a cancer screening or cancer care in the past year, reasons for not having done so

Not necessary 35.4 Doctor hasn't suggested .!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 29.1 Cost l!!I!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 15.2 Fear II!!!!!!!!!!!!!!!!!!!!!!!!!!• 10.1 I don't know who to see 5.1 Unfamiliar with recommendations l!!I!!!!!!!!!!!!! 5.1 Unable to access care 0.0

Other* * l!!I!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 21.s

0 10 20 30 40 so

Percent*

N=79 *Percentages do not equal 100.0 due to multiple responses. **See Appendix Table 19 for a list of other responses.

22 Respondents were asked how they had paid for health care costs, for themselves or family members, over the last 12 months. • A majority of respondents said they had paid for health care costs over the last 12 months by health insurance through an employer (60.2 percent); 26.3 percent of respondents used Medicare to pay for health care costs. Personal income and private health insurance were also used (21.6 percent each) (Figure 17, Appendix Table 20).

Figure 17. Methods respondents have used to pay for health care costs over the last 12 months

Health insurance through an employer 60.2

Medicare

Personal income (e.g., cash, check, credit)

Private health insurance

Medicaid

Did not access health care in last 12 months

Other**

0 10 20 30 40 50 60 70 80 90 100

Percent*

N=236 *Percentages do not equal 100.0 percent due to multiple responses. **See Appendix Table 20 for a list of other responses.

Demographic Information

Most respondents indicated they were 45 to 64 years of age (47.9 percent); 29.1 percent of respondents were 65 years or older (Figure 18, Appendix Table 21).

Figure 18. Respondents' age

18 to 29 years

30 to 44 years

45 to 64 years 47.9

65 to 74 years

75 years or older

Prefer not to answer

0 10 20 30 40 50 Percent

N=234

23 • A majority of respondents said they had a Bachelor's degree or higher (53.0 percent), including 25.0 percent who had a Graduate or Professional degree (Figure 19, Appendix Table 22). • Approximately one in 10 respondents had, at most, a high school diploma or GED (13.8 percent).

Figure 19. Respondents' highest level of education

Some high school

High school diploma or GED

Some college/no degree

Associate's degree

Bachelor's degree

Graduate or Professional degree

Prefer not to answer

0 10 20 30 40 so Percent

N=232

• The gender distribution among respondents was evenly split between males and females (49.4 percent and 46.8 percent, respectively) (Figure 20, Appendix Table 23).

Figure 20. Respondents' gender Prefer not

Male 49.4

Female 46.8

N=233

24 • Three in four respondents said they work or volunteer outside their home (76.6 percent) (Figure 21, Appendix Table 24).

Figure 21. Whether respondents work/volunteer outside the home Prefer not

Yes 76.6

N=231

• Half of respondents said their annual household income was $40,000 to $69,999 (25.2 percent) and $70,000 to $119,999 (24.8 percent). Five percent ea rned less than $20,000 annually {5.3 percent) (Figure 22, Appendix Table 25).

Figure 22. Respondents' annual household income before taxes

Less than $20,000

$20,000 to $39,999

$40,000 to $69,999 25.2

$70,000 to $119,999 24.8

$120,000 or more

Do not know/prefer not to answer

0 10 20 30 40 50 Pe rcent

N=226

25 • The vast majority of respondents said they own their home {83.3 percent) (Figure 23, Appendix Table 26).

Figure 23. Whether respondents own or rent their home

Prefer not ----- to answer 1.7

N=234

• The vast majority of respondents were white {95.3 percent) (Figure 24, Appendix Table 27)

Figure 24. Respondents' race or ethnicity

Black/Africa n American 0.8

Native American/Alaska Native 0.8

Asian/Pacific Islander 0.4

Hispanic 0.8

Other* * 0.8

0 10 20 30 40 so 60 70 80 90 100 Percent*

N=236 * Percentages do not equal 100.0 due to multiple responses. **See Appendix Table 27 for a complet e list of other responses .

26 • One in four respondents said they are the parent or primary caregiver of a child or children 18 years of age or younger (25.9 percent) (Figure 25, Appendix Table 28)

Figure 25. Whether respondents are the parent or primary caregiver of a child or children 18 years of age or younger

Prefer not to answer ---- 0.9

No 73.2

N=228

27 Respondents were asked to share any additional concerns or suggestions they had. Table 1 displays respondents' comments.

Table 1. Additional concerns and suggestions Comments More services/assistance and better options for residents who have worked their whole life and get displaced from their job. When you support the system, it would be nice to receive the same support when you really need it. We need more women primary care providers and internal medicine physicians. Despite its alleged "friendliness," Fargo has been the least welcoming community I have ever moved to. Need national court reform to reduce health care costs. Cap on malpractice lawsuits per type of case is overdue. (Too [many] bad lawyers run this country). My health care is good. Some people have problems. Don't wreck my health care with "Obama-care" which will lead to complete government control - I ought to know as I worked for the Feds. Insurance is "far" too high! I feel health care these days is somewhat like Russian roulette. Too many mistakes! Hospital, workers (nurses, aides, etc.) not sought for advice and treated primarily like slaves! Experience can't be denied! I know a lot of people who have been at [organizational name] and have not had very good care. Four people I know have died and I will not go there. All they do is give you pills and send you home. This needs to change. I am upset over high cost of health insurance of [insurer]. It is now $490.00 a month. Considering I need gas for my job, my 2nd job doesn't rely on ra ises but how many customers. It [wage] never raises. I am worried about insurance costs for our community as a whole, as well as medical/dental/vision costs for the larger community. Adequate health insurance must be made available to all people. I work in a ca ll center and have read a good deal about the health impacts of such work. No physical activity, high stress, and the associated health care costs. I think employers should be under more pressure to allow physical activity during the work day - we are simply not allowed to. The costs are significant. The cost of COBRA is outrageous. I have kids that are grown who are too old to be on my insurance but don't have their own and pray every day they stay healthy because of medica l costs. There are big differences between North Fargo and South Fargo, i.e., availability of senior citizen housing (rental), library facilities (North Fargo library has limited holdings), t raffic congestion on North side is much less than South side, threat of loss of housing due to flooding is a huge problem on South side. Taking into account only the F-M community (and no others), the crime rate in this community has risen to an alarming rate within t he past decade, or so. This community is not the safe-haven it was prior. Its quality of life has been slowly (and steadily) eroding. The only rea son t hat I decided to live here after college is t hat my family (parents, grandparents) live here. I don't feel like the job positions available in this city reflect the level of pay t hat may be available elsewhere. I feel opportunities are limited here. More workshops on exercise and hea lthy living. Free personal trainer - someone to help hold you accountable. Thank you for doing this survey! Looking forward to seeing the results! Would be great to have a Whole Foods grocery store or Trader Joes. More options for organic/healthy food. I appreciate your survey, but you need to do all you ca n and make sure the elderlies receive good assist ance or treatment.

28 Community Assets/Best Things About Their Community

Appendix Table 1. Respondents' level of agreement with statements about their community regarding PEOPLE Percent of respondents Level of agreement Statements regarding (l=not at all, S=a great deal) people Mean 1 2 3 4 s Total People are friendly, helpful, and supportive {N=231) 4.06 0.0 2.2 15.6 55.8 26.4 100.0 There is a sense of community/feeling connected to people who live here {N=227) 3.87 0.9 4.8 22.9 48.9 22.5 100.0 People who live here are aware of/engaged in social, civic, or political issues {N=227) 3.59 0.9 7.0 38.3 40.1 13.7 100.0 The community is socially and culturally diverse {N=225) 3.62 3.6 10.2 27.6 37.8 20.9 100.1 There is an engaged government (N=225) 3.56 2.2 7.6 33.8 44.9 11.6 100.1 There is tolerance, inclusion, and open-mindedness {N=225) 3.29 3.1 16.4 36.9 35.1 8.4 99.9 There is a sense that you can make a difference {N=226) 3.34 4.4 11.9 40.3 31.9 11.5 100.0

Appendix Table 2. Respondents' level of agreement with statements about their community regarding SERVICES AND RESOURCES Percent of respondents Level of agreement Statements regarding (l=not at all, S=a great deal) services and resources Mean 1 2 3 4 5 Total There are quality school systems and programs for youth {N=227) 4.26 0.0 2.2 9.7 47.6 40.5 100.0 There are quality higher education opportunities and institutions {N=229) 4.51 1.7 0.9 3.5 32.3 61.6 100.0 There is quality health care {N=228) 4.25 1.3 1.8 10.5 43.0 43.4 100.0 There is effective transportation {N=228) 3.69 3.1 11.8 22.4 38.2 24.6 100.1 There is access to healthy food {N=230) 4.21 0.4 4.3 11.3 41.3 42.6 99.9 There is access to family services {N=23 1) 4.00 1.3 3.5 22.1 39.8 33.3 100.0

29 Appendix Table 3. Respondents' level of agreement with statements about their community regarding QUALITY OF LIFE Percent of respondents Level of agreement Statements regarding (l=not at all, S=a great deal) quality of life Mean 1 2 3 4 5 Total The community is a safe place to live and has little or no crime (N=231) 3.86 0.4 4.8 23.4 51.1 20.3 100.0 The community is a good place to raise kids (N=230) 4.35 0.4 0.4 10.0 41.7 47.4 99.9 The community has a peaceful, calm, and quiet environment (N=230) 4.09 0.0 1.3 17.0 53.0 28.7 100.0 The community is a healthy place to live (N=230) 4.23 0.0 0.9 10.4 53.5 35.2 100.0 There are quality arts, cultural activities, events, and festivals (N=229) 3.98 0.9 6.6 17.9 43.2 31.4 100.0 There are many recreational, exercise, and sports activities/opportunities (N=229) 4.17 0.4 3.9 16.2 37.6 41.9 100.0

Appendix Table 4. Responses to other best things about their community Best things about the community Responses Faith/religious community: their contributions and outreach 4 City services: quick response, great recycling and garbage program, snow removal 4 Parks and recreation: good programs and activities for kids and adu lts, well-maintained parks 3 Volunteer outreach unites community: emergencies and day-to-day 3 Economically sound, low unemployment, employment opportunities 3 Safe place to live, sense of well-being, little traffic congestion 3 Becoming a more walkable, pedestrian friendly community 2 Proximity to lakes 2 Fairly good media 1 Lived all over - likes it here best . 1 None/NA 3 N=27

30 Appendix Table 5. Respondents' level of concern with statements about their community regarding ECONOM IC ISSUES Percent of respondents Level of concern Statements regarding (1=not at all, S=a great deal) economic issues Mean 1 2 3 4 s Total Avai lability of affordable housing {N=227) 3.31 5.3 17.6 32.6 29.5 15.0 100.0 Availability of employment opportunities {N=226) 3.49 3.1 14.2 31.0 34.1 17.7 100.1 Wage levels {N=225) 3.35 3.1 16.9 37.8 26.2 16.0 100.0 Poverty {N=224) 3.20 4.5 17.0 41.5 28.6 8.5 100.1 Homelessness {N=224) 3.01 7.1 25.9 36.2 20.5 10.3 100.0 Cost of living (N=224) 3.43 3.1 8.5 41.5 36.2 10.7 100.0 Economic disparities between higher and lower classes {N=219) 3.44 4.1 9.6 41.1 28.3 16.9 100.0 Hunger {N=221) 3.00 5.0 27.6 37.6 21.7 8.1 100.0

Appendix Table 6. Respondents' level of concern with statements about their community regarding TRANSPORTATION Percent of respondents Level of concern Statements regarding (1=not at all, S=a great deal) transportation Mean 1 2 3 4 s Total Traffic congestion {N=230) 2.85 10.0 28.7 34.8 19.1 7.4 100.0 Availability and/or cost of public transportation {N=225) 2.97 9.3 24.9 36.0 19.1 10.7 100.0 Road conditions {N=224) 3.14 5.8 19.2 39.7 25.9 9.4 100.0 Driving habits {e.g., speeding, road rage) {N=226) 3.15 4.9 22.6 37.6 22.6 12.4 100.1 Availability of good walking or biking options {as alternatives to driving) {N=224) 3.25 8.5 16.1 35.7 21.9 17.9 100.1 Cost of automobile ownership {e.g., gas, maintenance, insurance) {N=225) 3.42 3.6 13.3 36.0 31.6 15.6 100.1

Appendix Table 7. Respondents' level of concern with statements about their commun ity regarding ENVIRONMENT Percent of respondents Level of concern Statements regarding (1=not at all, S=a great deal) environment Mean 1 2 3 4 s Total Water quality concerns {N=227) 2.63 26.9 23.8 19.8 18.1 11.5 100.1 Noise level conce rns {N=229) 2.56 21.4 28.8 28.4 14.8 6.6 100.0 Air quality concerns {N=223) 2.37 30.9 26.5 23.3 13.5 5.8 100.0 Garbage and litter concerns {N=232) 2.70 16.4 33.6 21.1 21.1 7.8 100.0 31 Appendix Table 8. Respondents' level of concern with statements about their community regarding CHILDREN AND YOUTH Percent of respondents Level of concern Statements regarding (l=not at all, S=a great deal) children and youth Mean 1 2 3 4 5 Total Availability and/or cost of services for at-risk youth (N=208) 3.05 8.7 19.7 37.0 27.4 7.2 100.0 Youth crime (N=218) 3.04 6.4 21.1 41.7 23.9 6.9 100.0 School dropout rates/truancy (N=214) 2.82 7.5 33.2 36.0 16.8 6.5 100.0 Teen pregnancy (N=209) 2.93 7.2 30.6 32.1 22.5 7.7 100.1 Bullying (N=209) 3.44 3.3 18.7 26.8 33.0 18.2 100.0 Availability and/or cost of activities for children and youth (N=216) 3.27 3.7 19.9 33.3 31.9 11.1 99.9 Availability and/or cost of quality child care (N=209) 3.42 3.8 18.2 27.3 34.0 16.7 100.0

Appendix Table 9. Respondents' level of concern with statements about their community regarding THE AGING POPULATION Percent of respondents Level of concern Statements regarding (l=not at all, S=a great deal) the aging population Mean 1 2 3 4 5 Total Avai lability and/or cost of activities for seniors {N=226) 3.16 5.8 21.7 32.3 31.4 8.8 100.0 Availability and/or cost of long- term care {N=227) 3.66 4.0 12.8 26.4 26.9 30.0 100.1 Availability of resources to help the elderly stay in their homes (N=221) 3.56 2.3 14.5 30.8 30.3 22.2 100.1 Availability of resources for family and friends caring for elders (N=224) 3.53 2.7 12.9 31.3 34.8 18.3 100.0 Availability of resources for grandparents caring for grandchildren {N=220) 3.15 6.8 15.9 43.6 22.7 10.9 99.9

32 Appendix Table 10. Respondents' level of concern with statements about their community rega rding SAFETY Percent of respondents Level of concern Statements regarding (l=not at all, S=a great deal) safety Mean 1 2 3 4 5 Total Child abuse and neglect (N=217) 3.39 3.2 21.2 27.6 29.0 18.9 99.9 Elder abuse (N=215) 3.08 8.4 23.3 33.5 21.4 13.5 100.1 Domestic violence (N=214) 3.46 3.3 16.4 30.8 30.4 19.2 100.1 Presence and influence of drug dealers in the community (N=226) 3.51 4.4 15.5 24.8 35.4 19.9 100.0 Property crimes (N=222) 3.41 1.8 19.4 33.3 27.5 18.0 100.0 Violent crimes (N=223) 3.06 9.4 25.1 30.0 21.1 14.3 99.9

Appendix Table 11. Responses to other community concerns Other community concerns Responses Vandalism/nuisance issues (broken windows, flat tires/people not picking up after their dogs/loud cars and stereos) 6 Foreigners brought here without the ability to function in society/"new" people coming here and bringing crime 3 Classism/strong sense that privilege impacts the individual experience/not easy to get socially connected if not from the area 3 Need better public transportation/longer hours, to rural areas 3 High property taxes/programs and activities are cost prohibitive/too much welfare 3 Natural disasters, flooding, water quality/contamination 2 Lack of access to affordable mental health services 2 Slow response to multiple reports of child abuse 1 Prescription drug abuse 1 Need more medical translators 1 Corrupt politics in public schools 1 Lack of diversity 1 Lack of tolerance of LGBTQ 1 Slow snow removal 1 Need community action goals 1 None 2 N=30

33 Health and Wellness Concerns About Their Community

Appendix Table 12. Respondents' level of concern with statements about their community regarding ACCESS TO HEALTH CARE Percent of respondents Level of concern Statements regarding (l=not at all, S=a great deal) access to health care Mean 1 2 3 4 5 Total Cost of health care (N=231) 4.25 1.3 3.0 15.2 30.3 50.2 100.0 Cost of prescription drugs (N=229) 4.06 1.7 4.8 19.7 33.2 40.6 100.0 Cost of health insurance (N=226) 4.32 1.3 3.1 13.3 26.5 55.8 100.0 Adequacy of health insurance (e.g., amount of co-pays, deductibles) (N=220) 3.97 1.8 9.1 19.1 30.5 39.5 100.0 Access to health insurance coverage (e.g., preexisting condit ions) (N=225) 3.79 4.4 8.9 23.6 29.8 33.3 100.0 Availability and/or cost of dental and/or vision insurance coverage (N=221) 3.76 5.4 6.3 26.2 31.2 30.8 99.9 Availability and/or cost of dental and/or vision care (N=222) 3.76 4.5 7.2 26.1 32.4 29.7 99.9 Availability of prevention programs or services (N=216) 3.37 6.0 13.9 32.9 31.5 15.7 100.0 Availability of doctors, nurses, and/or specialists (N=218) 3.24 9.6 17.4 28.4 28.4 16.1 99.9 Availability of bilingual providers and/or translators (N=215) 2.40 28.8 28.4 22.8 14.0 6.0 100.0 Distance to health care services (N=226) 2.33 28.8 32.7 21.2 11.5 5.8 100.0 Availability of/access to transportation (N=221) 2.63 24.4 23.1 25.3 19.0 8.1 99.9 Providers not taking new patients (N=223) 2.92 17.0 22.9 24.7 22.0 13.5 100.1 Time it takes to get an appointment (N=223) 3.06 12.6 21.1 27.8 25.1 13.5 100.1 Availability of non-tradit ional hours (e.g., evenings, weekends) (N=221) 3.00 10.9 20.4 37.6 20.8 10.4 100.1 Patient confidentiality (N=220) 2.57 30.5 23.6 18.2 13.6 14.1 100.0 Use of emergency room services for primary health care (N =221) 3.28 10.4 16.3 27.1 27.6 18.6 100.0 Availability of mental health services and providers (N=216) 2.96 11.6 22.7 34.7 20.4 10.6 100.0 Coordination of care (N=218) 3.05 10.1 19.3 39.0 19.3 12.4 100.1

34 Appendix Table 13. Respondents' level of concern with statements about their community regarding PHYSICAL AND MENTAL HEALTH Percent of respondents Level of concern Statements regarding (l=not at all, S=a great deal) physical and mental health Mean 1 2 3 4 5 Total Obesity (N=219) 3.69 5.5 8.2 23.3 37.4 25.6 100.0 Poor nutrition/eating habits (N=222) 3.59 3.6 11.3 26.1 40.1 18.9 100.0 In activity and/or lack of exercise (N=219) 3.58 4.6 9.6 28.3 37.9 19.6 100.0 Cancer (N=218) 3.76 2.8 9.2 23.9 37.6 26.6 100.1 Chronic disease (e.g., diabetes, heart disease, multiple sclerosis) (N=217) 3.70 3.7 9.2 24.9 38.2 24.0 100.0 Communicable disease (e.g., sexually transmitted diseases, AIDS) (N=219) 2.83 13.7 23.7 36.5 17.8 8.2 99.9 Dementia/Alzheimer's disease (N=219) 3.55 4.6 8.7 33.3 34.2 19.2 100.0 Depression {N=218) 3.54 4.1 9.6 34.4 31.7 20.2 100.0 Stress (N=216) 3.66 3.7 7.9 29.2 37.0 22.2 100.0 Suicide (N=218) 3.04 14.7 17.9 31.7 20.2 15.6 100.1

Appendix Table 14. Respondents' level of concern with statements about their community regarding SUBSTANCE USE AND ABUSE Percent of respondents Level of concern Statements regarding (l=not at all, S=a great deal) substance use and abuse Mean 1 2 3 4 5 Total Alcohol use and abuse (N=220) 3.52 8.6 11.4 23.2 33.2 23.6 100.0 Drug use and abuse (N=221) 3.55 8.1 11.8 20.8 35.7 23.5 99.9 Smoking and tobacco use (N=220) 3.46 9.5 12.7 26.4 24.5 26.8 99.9 Exposure to second-hand smoke (N=221) 3.35 11.8 18.6 19.9 22.6 27.1 100.0

Appendix Tab le 15. Responses to other health and wellness concerns Other health and wellness concerns Responses Costs: health care/insurance/medical devices/medications 5 Lack of mental health services/dental services 2 Problems accessing female doctors 2 Lack of coordination/multi-disciplinary approach to providing health care to patients 2 More aggressive approach to obesity, school lunches criticized for too much salt/sugar 2 Concerns regarding the Affordable Care Act 2 More health care provider choices/wish Family Health [Care] in Moorhead was still open 2 Ecological systems: air quality, water quality in lakes and rivers 1 Fragrance-free policies for people with asthma/chemical sensitivities 1 The city should do more Streets Alive events and lower the bike/pedestrian bridges sooner 1 Smoking is still allowed in the bar/restaurant of small community 1 How religion and music influence a person's life and health issues 1 Proper screening of foreigners for disease, parasites/instruction for proper hygiene 1 None/NA 7 N=28 35 Personal Health Care Information

Appendix Table 16. Respondents' primary health care provider Primary health care provider Percent of respondents* Essentia Health 21.2 Family HealthCare Center 1.3 Independent Family Doctors 11.0 Sanford Health 62.7 Use emergency room/urgent care for primary care services 0.4 Did not access health care in last 12 months 1.7 Other: 5.1 VA/Military (4) Internal Medicine Associates (2) Mayo (1) Prairie Medical (1) Tri-Care (1) None-not by choice (1) N=236 *Percentages do not equal 100.0 due to multiple responses.

Appendix Table 17. Respondents' reasons for choosing their primary health care provider Reasons for choice of primary health care provider Percent of respondents* Location 35.6 Cost 5.1 Quality of services 38.6 Availability of services 34.7 Sense of being valued as a patient 23.3 Influenced by health insurance 24.6 Other: 12.7 Have been there many years (8) Employer/former employer (7) Choice ofdoctors (5) Recommended/referred (4) Veteran (2) Respect f or patient confidentiality (1) Smaller in size (1) Switched provider due to inappropriate behavior by physician (1) Also houses cancer center (1) It's county- can't turn you away (1) Insurance (1) Used predecessor.org website (1) N=236 * Percentages do not equal 100.0 due to multiple responses.

36 Appendix Table 18. Whether respondents had a cancer screening or cancer care in the past year Percent of respondents Cancer screening/cancer care (N=223) Yes 64.6 No 35.4 Total 100.0

Appendix Table 19. Among respondents who have not had a cancer screening or cancer care in the past year, reasons for not having done so Reason for not screening Percent of respondents* Not necessary 35.4 Fear 10.1 Cost 15.2 Unfamiliar with recommendations 5.1 Doctor hasn't suggested 29.1 Unable to access care 0.0 I don't know who to see 5.1 Other: 21.5 Not due to have screening (5) Have chosen not to screen (3) Time is a barrier (3) No access to female physician/can'tfind a doctor {2) Had cancer surgery {2) Cancer treatment in the USA kills people (1) Inconvenience {1) So far, no symptoms (1) N=79 * Percentages do not equal 100.0 due t o mult iple responses.

Appendix Table 20. Methods used by respondents to pay for health care costs for themselves or family members over the past 12 months Methods of payment Percent of respondents* Health insurance through an employer 60. 2 Medicare 26.3 Private health insurance 21.6 Personal income (e.g., cash, check, credit) 21.6 Medicaid 5.1 Did not access health care in last 12 months 1.3 Other 5.1 Military/TriCare (5) Medical Assistance/MN Care {4} Employer and out ofpocket (2) Medicare supplements {2) Blue Cross and Blue Shield (1) Help from parents (1) N=236 *Percentages do not equal 100.0 due to multiple res ponses .

37 Demographic Information

Appendix Table 21. Respondents' age Percent of respondents Age (N=234) 18 to 29 years 6.0 30 to 44 years 15.4 45 to 64 years 47.9 65 to 74 years 15.4 75 years or older 13.7 Prefer not to answer 1.7 Total 100.1

Appendix Tab le 22. Respondents' highest level of education Percent of respondents Highest level of education (N=232) Some high school 2.2 High school diploma or GED 11.6 Some college/no degree 20.7 Associate's degree 11.2 Bachelor's degree 28.0 Graduate or professiona l degree 25.0 Prefer not to answer 1.3 Total 100.0

Appendix Table 23. Respondents' gender Percent of respondents Gender (N=233) Male 49.4 Female 46.8 Prefer not to answer 3.9 Total 100.1

Appendix Table 24. Whether respondents work/volunteer outside the home Percent of respondents Response (N=231) Yes 76.6 No 19.0 Prefer not to answer 4.3 Total 99.9

38 Appendix Table 25. Respondents' annual household income before taxes Percent of respondents Annual household income before taxes (N=226) Less than $20,000 5.3 $20,000 to $39,999 17.7 $40,000 to $69,999 25.2 $70,000 to $119,999 24.8 $120,000 or more 12.4 Do not know/prefer not to answer 14.6 Total 100.0

Appendix Table 26. Whether respondents own or rent their home Percent of respondents Tenure (N=234) Own 83.3 Rent 13.7 Prefer not to answer 1.7 Other: 1.3 Parsonage (1) Provided by employer (1) Rent apartment {1} Total 100.0

Appendix Table 27. Respondents' race or ethnicity Race/ethnicity Percent of respondents* White 95.3 Black/African American 0.8 Native American/Alaska Native 0.8 Asian/Pacific Islander 0.4 Hispanic 0.8 Other: 0.8 Euro-American (1) Native-born American ofGerman royalty (1) N=236 *Percentages do not equal 100.0 due to multiple responses.

Appendix Table 28. Whether respondents are the parent or primary caregiver of a child or children 18 years of age or younger Percent of respondents Response (N=228) Yes 25.9 No 73.2 Prefer not to answer 0.9 Total 100.0

39 NDSU NORTH DAKOTA STATE UNIVERSITY Phone: 701 -231-8621 Fax: 701-231-9730 Centerfor Social Research NDSU Dept. 8000 POBOX 6050 Fargo, ND 58108-6050

Dear Resident,

The F-M Community Health Needs Assessment Collaborative is partnering with the Center for Social Research at North Dakota State University to conduct a survey. The survey is about community assets and health and wellness concerns ofresidents in Cass County, North Dakota and Clay County, Minnesota. Information gathered from the survey will help us identify unmet needs in the community. Survey results will also assist in the development ofplans to address the gaps in services.

We invite you to participate in this research study. Your household was chosen at random for the study from a list ofall residential addresses in Cass and Clay counties. The survey is voluntary. You may skip any question you do not want to answer or quit the survey at any time.

The survey should take about 15 minutes to complete. Your responses are anonymous. Please do not leave any marks on the survey that would identify you. For your convenience, we have enclosed a postage-paid return envelope. In order to be included in the results, it is important that you return your survey by Friday, April 20, 2012.

If you have any questions about the survey, contact Dr. Richard Rathge at (701) 231-8621 or [email protected]. Ifyou have questions about your rights as a research participant, or to report a complaint, contact NDSU's Human Protection Program at (701) 231-8908.

Thank you for your participation.

Sincerely,

Richard Rathge, Director Center for Social Research North Dakota State University PO Box 6050, Dept. 8000 Fargo, North Dakota 58108-6050

SANF~~Ro· Essentia Health NO RTH DAKOTA 0 NDsl._ JSTATE UNIVERSITY United Way of Cass-Clay ~ FOUNDI\TION

4:i.it\ Center for Rural H eal th PublicHealth ~~ Univcuity o(No nh D~kou f Prt\'<'nt Promote. P rotec t o( Holch -Schoo! Mrdicint & Scitncu Farco CaN PubUc Health

NDSU is an equal opportunily inslitution. 2012 Community Health Needs Assessment

The Fargo-Moorhead Community Health Needs Assessment Collaborative invites you to participate in the 2012 Community Health Needs Assessment. The information that we gather from you will be important for the development of an action plan to address the identified unmet needs in the community. Your participation in this work is important to improving the health of our community. Please take a moment to complete the survey. You may skip any questions that you do not wish to answer. Your answers will be combined with other responses and reported in aggregate form. If you have any questions about the survey, you may contact Dr. Richard Rathge at 701-231-8621 or by email at [email protected].

• Use a pencil or blue or black pen. Correct Mark: • • Fill bubbles completely. • Do not mark answers with Xs or vs. Incorrect Marks: ~ @ C.

Community Assets/Best Things about Your Community

Level of agreement I Considering your community, what is your level of agreement with... (1=not at all; 5= a great deal) I

Not A Great Q1. PEOPLE at All Deal a. People are friendly, helpful, and supportive. 1 2 3 4 5 b. There is a sense of community/feeling connected to people who live here. 1 2 3 4 5 - c. People who live here are aware of/engaged in social, civic, or political issues. 1 2 3 4 5 - d. The community is socially and culturally diverse. 1 2 3 4 5 - e. There is an engaged government. 1 2 3 4 5 - f. There is tolerance, inclusion, and open-mindedness. 1 2 3 4 5 - g. There is a sense that you can make a difference. 1 2 3 4 5 - Q2. SERVICES AND RESOURCES a. There are quality school systems and programs for youth. 1 2 3 4 5 lllml b. There are quality higher education opportunities and institutions. 1 2 3 4 5 c. There is quality health care. 1 2 3 4 5 - d. There is effective transportation. 1 2 3 4 5 - e. There is access to healthy food. 1 2 3 4 5 - f. There is access to family services. 1 2 3 4 5 - Q3. QUALITY OF LIFE a. The community is a safe place to live and has little or no crime. 1 2 3 4 5 b. The community is a good place to raise kids. 1 2 3 4 5 - c. The community has a peaceful, calm, and quiet environment. 1 2 3 4 5 - d. The community is a healthy place to live. 1 2 3 4 5 - e. There are quality arts, cultural activities, events, and festivals. 1 2 3 4 5 - f. There are many recreational, exercise, and sports activities/opportunities. 1 2 3 4 5 -

Q4. What are other "best things" about your community that are not reflected in the questions above? General Concerns about Your Community Using a 1 to 5 scale, with one being "not at all" and 5 being "a great deal," please tell us the level of concern you have about you~ community in each of the following areas: ECONOMIC ISSUES, TRANSPORTATION, ENVIRONMENT, CHILDREN AND YOUTH, THE AGING POPULATION, and SAFETY.

Level of concern I Considering your community, what is your level of concern with ... 11 (1=not at all; 5= a great deal) I

Not ► A Great QS. ECONOMIC ISSUES at All ◄ Deal a. Availability of affordable housing (D (I) G) (D ® - b. Availability of employment opportunities (D (I) G) (D ® - c. Wage levels (D (I) G) (D ® - d. Poverty (D (I) G) (D ® - e. Homelessness (D (I) G) (D ® - f. Cost of living (D (I) G) (D ® - g. Economic disparities between higher and lower classes (D (I) G) (D ® - h. Hunger (D (I) G) (D ® Q6. TRANSPORTATION - a. Traffic congestion (D (I) G) (D ® - b. Availability and/or cost of public transportation (D (I) G) (D ® - c. Road conditions (D (I) G) (D ® - d. Driving habits (e.g., speeding, road rage) (D (I) G) (D ® - e. Availability of good walking or biking options (as alternatives to driving) (D (I) G) (D ® - f. Cost of automobile ownership (e.g., gas, maintenance, insurance) (D (I) G) (D ® Q7. ENVIRONMENT a. Water quality concerns (D (I) G) (D ® - b. Noise level concerns (D (I) G) (D ® - c. Air quality concerns (D (I) G) (D ® - d. Garbage and litter concerns (D (I) G) (D ® Q8. CHILDREN AND YOUTH a. Availability and/or cost of services for at-risl< youth (D (I) G) (D ® - b. Youth crime (D (I) G) (D ® - c. School dropout rates/truancy (D (I) G) (D ® - d. Teen pregnancy (D (I) G) (D ® - e. Bullying (D (I) G) (D ® - f. Availability and/or cost of activities for children and youth (D (I) G) (D ® - g. Availability and/or cost of quality child care (D (I) G) (D ® Q9. THE AGING POPULATION a. Availability and/or cost of activities for seniors (D (I) G) (D ® - b. Availability and/or cost of long-term care (D (I) G) (D ® - c. Availability of resources to help the elderly stay in their homes (D (I) G) (D ® - d. Availability of resources for family and friends caring for elders (D (I) G) (D ® - e. Availability of resources for grandparents caring for grandchildren (D (I) G) (D ® Q10. SAFETY a. Child abuse and neglect (D (I) G) (D ® - b. Elder abuse (D (I) G) (D ® - C. Domestic violence (D (I) G) (D ® - d. Presence and influence of drug dealers in the community (D (I) G) (D ® - e. Property crimes (D (I) G) (D ® - f. Violent crimes (D (I) G) (D ® Q11 . What other COMMUNITY CONCERNS do you have that are not reflected in the previous questions? Health and Wellness Concerns about Your Community Using a 1 to 5 scale, with 1 being "not at all" and 5 being "a great deal," please tell us your level of concern about health and wellness issues in your community within each of the following categories: ACCESS TO HEAL TH CARE, PHYSICAL AND MENTAL HEALTH, and SUBSTANCE USE AND ABUSE.

Level of concern I Considering your community, how concerned are you about... 11 (1=not at all; 5= a great deal) I

Not ► A Great 0 12. ACCESS TO HEALTH CARE at All ◄ Deal a. Cost of health care

015. What other HEALTH AND WELLNESS CONCERNS do you have about your community that are not reflected in the previous questions? Demographic Information - Please tell us about yourself.

Q16. What is your age? Q23. Are you the parent or primary caregiver of a - 0 18 to 29 years O 65 to 74 years child/children 18 years of age or younger? - 0 30 to 44 years O 75 years or older 0 Yes O No O Prefer not to answer - O 45 to 64 years O Prefer not to answer

Q24. What provider do you use for your primary health Q17. What is your highest level of education? care? - 0 Some high school O Bachelor's degree · 0 Essentia Health - O High school diploma or GED O Graduate or O Family HealthCare Center - 0 Some college/no degree Professional degree 0 Independent Family Doctors - O Associate's degree O Prefer not to answer O Sanford Health 0 Use emergency room/urgent care for primary care - services - Q18. What is your gender? 0 Did not access health care in last 12 months (skip to Q25) - 0 Male O Female O Prefer not to answer O Other (please specify) ______

Q24a. Why did you choose this provider? Q19. Do you work/volunteer outside the home? (choose all that apply) 0 Yes O No O Prefer not to answer O Location - O Cost - O Quality of services - Q20. What is your approximate annual household O Availability of services - income before taxes? O Sense of being valued as a patient - 0 Less than $20,000 O $70,000 to $119,999 O Influenced by health insurance - O $20,000 to $39,999 0 $120,000 or more o Other (please specify)______- O $40,000 to $69,999 0 Do not know/prefer not to answer Q25. Have you personally had a cancer screening Q21. Do you own or rent your home? (mammogram, Pap smear, breast exam, testicular 0 Own O Other (please specify)______exam, rectal exam, prostate blood test, colonoscopy, - O Rent O Prefer not to answer etc.) or cancer care in the past year? - 0 Yes (skip to Q26) - O No - Q22. What best describes your race/ethnicity? (choose all that apply) 4 Q25a. Why not? (choose all that apply) 0 White 0 Not necessary O Doctor hasn't suggested - 0 Black/African American 0 Fear O Unable to access care - O Native American/Alaska Native 0 Cost O I don't know who to see - O Asian/Pacific Islander O Unfamiliar with recommendations - o Hispanic 0 Other (please specify)______- O Other (please specify)______Q26. Over the past 12 months, how have you paid for health care costs (for you or family members)? - 0 Health insurance through an employer O Medicare - 0 Private health insurance O Did not access health care in last 12 months - 0 Personal income (e.g., cash, check, credit) 0 Other (please specify)______- 0 Medicaid

Q27. Please share any additional concerns and suggestions you may have.

Thank you for assisting us with this important survey!

2012 Greater Fargo-Moorhead Community Health Needs Assessment of Community Leaders Results ofa May 2012 survey ofcommunity leaders in Cass County, North Dakota and Clay County, Minnesota

July 2012

Prepared by: Center for Social Research at North Dakota State University, Fargo

Prepared for: Fargo-Moorhead Community Health Needs Assessment Collaborative 2 PREFACE

This report, entitled 2012 Greater Fargo-Moorhead Community Health Needs Assessment ofCommunity Leaders, presents the results of a May 2012 survey of community leaders in Cass County, North Dakota and Clay County, Minnesota.

The study was conducted by t he Center for Social Research at North Dakota St ate University on behalf of the Fargo-Moorhead Community Health Needs Assessment Coll aborative. Funding for the study was provided by Collaborative member organizations.

Fargo-Moorhead Community Health Needs Assessment Collaborative Members Sa nford Health Essentia Health United Way of Cass-Clay Dakota Medical Foundation North Dakota State University Fa rgo Cass Public Health Clay County Public Health Family HealthCare Center Urban Indian Health and Wellness Center of Fargo-Moorhead Center for Rural Health at the University of North Dakota Southeast Human Services Center

The 2012 Greater Fargo-Moorhead Community Health Needs Assessment ofCommunity Leaders is a companion report to the 2012 Greater Fargo-Moorhead Community Health Needs Assessment of Residents.

The Fargo-Moorhead Community Health Needs Assessment Collaborative wishes to thank the community leaders for their participation in this study. The Collaborative extends special thanks to the two mayors and five City Council/Commission members for their attendance and participation. Thanks are also extended to area physicians and nurses, school superintendents and board members, as well as representatives for the mentally and physically disabled, social services, non-profit organizations, financial services, legal services, and faith-based organizations for their participation.

3 TABLE OF CONTENTS

PREFACE ...... 3

TABLE OF CONTENTS...... 4

EXECUTIVE SUMMARY ...... 5 Introduction ...... 5 Study Design and Methodology ...... 5 Key Findings ...... 5 Summary of Survey Results ...... 6 Companion Report Comparisons ...... 9

SURVEY RESULTS ...... 10 Community Assets/Best Things About Their Community ...... 10 Figure 1. Respondents' level of agreement with statements about their community regarding PEOPLE ...... 10 Figure 2. Respondents' level of agreement with statements about their community regarding SERVICES AND RESOURCES ...... 11 Figure 3. Respondents' level of agreement w ith statements about t heir communit y regarding QUALITY OF LI FE ...... 12 General Concerns About Their Community ...... 12 Figure 4. Respondents' level of concern with statements about their community regarding ECONOM IC ISSUES ...... 13 Figure 5. Respondents' level of concern with stat ements about their community regarding TRANSPORTATI ON ...... 13 Figure 6. Respondents' level of concern with statements about their community regarding ENVIRONMENT ...... 14 Figure 7. Respondents' level of concern with statements about their community regarding CHI LDREN AND YOUTH...... 14 Figure 8. Respondents' level of concern with statements about their community regarding THE AGING POPULATION ...... 15 Figure 9. Respondents' level of concern with statements about their community regarding SAFETY ...... 15 Healt h and Wellness Concerns About Their Community ...... 16 Figure 10. Respondents' level of concern w ith statements about their community regarding ACCESS TO HEALTH CARE ...... 17 Figure 11. Respondents' level of concern with statements about their community regarding PHYSICAL AND MENTAL HEALTH ...... 18 Figure 12. Respondents' level of concern with statements about their community regarding SUBSTANCE USE AND ABUSE ...... 19 Personal Healt h Care Information ...... 19 Demographic Information ...... 20

APPENDICES ...... 21

Appendix Tables ...... 21 Survey Cover Letter ...... 33 Survey Instrument ...... 34

4 EXECUTIVE SUMMARY

Introduction

The purpose of the community leader survey was to explore the views of key leaders in the greater Fargo-Moorhead area (e.g., health professionals, social workers, educators, elected leadership, and nonprofit leaders) regarding the resident population's health and the prevalence of disease and health issues within the community.

Study Design and Methodology

The Fargo-Moorhead Community Health Needs Assessment Collaboration {FMCHNAC) convened a breakfast meeting of community leaders in early May 2012. The breakfast meeting served as an opportunity for discussion as well as having stakeholders in attendance complete the community health needs assessment survey. Center for Social Research (CSR) staff attended the breakfast meeting and documented discussion notes during the meeting. A representative of the Collaborative entered the completed survey data into an Internet-based su rvey tool (i.e., Survey Monkey) designed by the CSR staff.

The survey instrument was t he same instrument developed in collaboration with the FMCHNAC and used in the generalizable survey of residents of the Fargo-Moorhead metro area of Cass and Clay count ies (detailed in a separate report), w it h 30 questions focusing on community assets, general concerns about communities, community health and wellness concerns, and demographic information. The community leaders' version of the survey also included a set of questions at the end relating to the respondents' name, title, affiliation, area of expertise, city/town, and state. These questions were included to fulfill the current interpretation of IRS requirements for non-profit hospitals conducting community health needs assessments as part of t he new compliance requirements imposed by the Patient Protection and Affordable Care Act signed into law on March 23, 2010.

The list of community leaders invited to the breakfast meeting was generated by mem bers of the Collaborative. In addition, Collaborative members emailed additional community leaders that were not able to attend the breakfast meeting with instructions for them to fill out the survey via the Internet based survey tool. The data collection effort was organized by Collaborative members. Data were collected through mid-June. A total of 58 surveys were completed, including 44 at the breakfast meeting and 14 via the Internet survey link.

The findings from the community leaders' survey are not generalizable to the community. The findings offer important insight and should be interpreted as anecdotal narrative.

Key Findings

Respondents had very high levels of agreement that their community has educational opportunities and programs, the community is a good place to raise kids, and there is quality health care. However, respondents agreed the least that there is tolerance, inclusion, and open-mindedness in t heir community.

Respondents were most concerned about domestic violence and issues regarding the aging population (i.e., ava ilability and cost of long-term care; ava ilability of resources to help elderly stay in their homes; and availability of resources for fa mily and friends caring for elders). Respondents were also concerned with issues regarding children and youth (i.e., availability and cost of quality child care, bullying,

5 availability and cost of services for at-risk youth, and child abuse and neglect). Environmental issues regarding garbage and litter, water quality, air quality, and noise levels were not a large concern.

Among health and wellness concerns, respondents were most concerned about the costs associated with health insurance, health care, and prescription drugs. Respondents were also concerned about physical health issues, particularly obesity, poor nutrition and eating habits, and inactivity or lack of exercise. The adequacy of health insurance (i.e., amount of co-pays and deductibles) and access to health insurance coverage (i.e., preexisting conditions), as well as chronic disease (e.g., diabetes, health disease, multiple sclerosis) and depression were also among the top health and wellness concerns among respondents. Respondents were least concerned about patient confidentiality and distance to health care services.

Summary of Survey Results

Community Assets/Best Things About Their Community

Services and resources Respondents had high levels of agreement that there are quality higher education opportunities and institutions as well as quality school systems and programs for youth in their community (mean=4.74 and mean=4.43, respectively). Although still a moderate level of agreement, respondents agreed the least that there is effective transportation in their community (mean=3.39).

Quality of life Respondents had a very high level of agreement that their community is a good place to raise kids (mean=4.62). Respondents had high levels of agreement with the remaining components of quality of life issues in their community. Means ranged from 4.19 to 4.07 with respect to the community being a healthy place to live; the presence of quality arts, cultural activities, events, and festivals; the community being a safe place to live with little or no crime; the community having a peaceful, calm, and quiet environment; and the community having many recreational, exercise, and sports activities/oppo rtu n iti es.

People Respondents had fairly high levels of agreement that people in their community are friendly, helpful, and supportive and that there is a sense of community or feeling connected to people who live here (mean=4.22 and mean=4.21, respectively). Among issues regarding people in the community, respondents agreed the least that there is tolerance, inclusion, and open-mindedness in their community (mean=3.45).

General Concerns About Their Community

6 Respondents indicated the top five general concerns about the community were: domestic violence, the availability and cost of long-term care, the availability and cost of quality child care, the availability of resources to help the elderly stay in their homes, the availability of resources for family and friends caring for elders.

Safety Regarding safety issues in their community, respondents were most concerned with domestic violence (mean=3.97) and child abuse and neglect (mean= 3.76). Respondents were least concerned with violent crimes (mean=3.09).

The aging population With respect to the aging population in their community, respondents had moderately high concerns with the availability and cost of long-term care (mean=3.91), the availability of resources to help the elderly stay in their homes (mean=3.89), and the availability of resources for family and friends caring for elders (mean=3.86). Respondents were least concerned about the availability or cost of activities for seniors (mean=3.38).

Children and youth Regarding children and youth, respondents were most concerned with the availability and cost of quality child care in their community (mean=3.91), bullying (mean=3.82), and the availability and cost of services for at-risk youth (mean=3.81). Respondents were least concerned with youth crime (mean=3.09).

Economic issues Respondents had moderate levels of concern with respect to the availability of employment opportunities (mean=3.69), economic disparities between higher and lower classes (mean=3.64), homelessness (mean=3.64), and poverty (mean=3.62). Respondents were least concerned with the cost of living (mean=3.16).

Transportation Respondents were most concerned with availability of good walking or biking options (mean=3. 79). Respondents were least concerned with traffic congestion (mean=2.55).

Environment Respondents were not very concerned with environmental issues in their community. Garbage and litter concerns (mean=2.55) were more of a concern than water (mean=2.34), noise (mean=2.28), and air quality (mean=2.17).

Health and Wellness Concerns About Their Community

The top six health and wellness concerns among community leaders were: the cost of health insurance, the cost of health care, obesity, the cost of prescription drugs, poor nutrition and eating habits, and inactivity or lack of exercise.

7 Access to health care Respondents had high levels of concern with respect to costs associated with health and wellness in their community. Cost of health insurance, cost of health care, and cost of prescription drugs were the top three concerns (mean=4.57, mean=4.48, and mean=4.34, respectively).

Respondents also had concerns with respect to access and the availability of health and wellness service providers in their community. Access to health insurance coverage, availability of prevention programs, availability and cost of dental and vision care, availability of and cost of dental and vision insurance coverage, coordination of care, and availability of mental health services and providers were all well above average in level of concern (means ranged from 4.16 to 3.98).

Respondents had below average levels of concern with distance to health care services (mean=2.60) and patient confidentiality (mean=2.52).

Physical and mental health Regarding physical and mental health issues, respondents had the highest levels of concern with respect to obesity (mean=4.36), poor nutrition and eating habits (mean=4.28), inactivity and lack of exercise (mean=4.28), and chronic disease (mean=4.24). Respondents were least concerned with communicable disease (mean=3.31).

Substance use and abuse The levels of concern among respondents regarding substance use and abuse issues in their community were fairly high. Respondents were most concerned about alcohol use and abuse (mean=4.12). Although still moderately high, respondents were least concerned about exposure to second-hand smoke (mean=3. 72).

Personal Health Core Information

The top three reasons respondents gave for their choice of primary health care provider were quality of services, being influenced by their health insurance, and location (39.7 percent, 29.3 percent, and 27.6 percent, respectively).

Less than one in five respondents said they had not had a cancer screening or cancer care in the past year (17.2 percent). The most common reason for not having done so was because it was not necessary (60.0 percent). Fear, unfamiliarity with recommendations, and not knowing who to see were also reasons respondents gave (10.0 percent each).

The vast majority of respondents said they paid for health care costs by health insurance through an employer (91.4 percent); 43.1 percent of respondents paid using personal income.

Demographic Information

Most respondents are 45 to 64 years old (67.2 percent); one-fourth are 30 to 44 years old (25.9 percent).

Most respondents have a Bachelor's degree or higher (89.6 percent), including 58.6 percent who have a Graduate or Professional degree.

Two-thirds of respondents are female (65.5 percent).

Two in five respondents said their annual household income is $70,000 to $119,999 (38.6 percent); one in three respondents said their income is $120,000 or more (35.1 percent).

8 The vast majority of respondents are white (96.6 percent).

One-third of respondents are the parent or primary caregiver of a child or children 18 years of age or younger {34.5 percent).

Most respondents are employed in health care {37.9 percent), followed by government (29.3 percent), and educational services (25.9 percent).

Among respondents who are employed in health care, 40.9 percent are an administrator and 27.3 percent work in public health.

Companion Report Comparisons

The 2012 Fargo-Moorhead Community Health Needs Assessment ofCommunity Leaders is a companion report to the 2012 Fargo-Moorhead Community Health Needs Assessment of Residents. Caution should be used when interpreting the comparisons as findings from the community leaders' survey are not generalizable to the community.

Overall, community leaders had higher levels of agreement and higher levels of concern than did the residents.

Among community assets, both community leaders and residents agreed the most that there are quality higher education opportunities, institutions, school systems, and programs for youth, there is quality health care, and that it is a good place to raise kids. Compared to community leaders, residents agreed less that there is an engaged government and a sense that you can make a difference. Residents agreed the least that there is tolerance, inclusion, and open-mindedness, whereas community leaders agreed the least that there is effective transportation.

Among general concerns, both community leaders' and residents' top concerns were directed at the aging population (i.e., availability and cost of long-term care, availability of resources to help the elderly stay in their homes, availability of resources for family and friends caring for elders). However, community leaders were most concerned about domestic violence. Availability of quality child care and bullying were also among the top concerns among community leaders, whereas availability of employment opportunities and the presence and influence of drug dealers in the community were top concerns among residents. Both community leaders and residents were least concerned about environmental issues (i.e., garbage and litter, water quality, air quality, and noise levels).

Among health and wellness concerns, both community leaders' and residents' top concerns were access-related issues (i.e., the cost of health insurance, the cost of health care, and the cost of prescription drugs). With respect to physical and mental health, community leaders were most concerned about obesity, poor nutrition and eating habits, and inactivity or lack of exercise. Residents, on the other hand, were more concerned about cancer, chronic disease, and obesity. Both community leaders and residents were least concerned about communicable disease and suicide.

9 SURVEY RESULTS

Community Assets/Best Things About Their Community

Overall, respondents had moderately high levels of agreement regarding positive statements that reflect the people in their community {Figure 1, Appendix Table 1). • On average, respondents agreed the most that people in their community are friendly, helpful, and supportive (mean=4.22); 31.0 percent agreed a great deal. • Respondents also had a fairly high level of agreement that there is a sense of community or feeling connected to people who live here (mean=4.21); 32.8 percent agreed a great deal. • Although still a moderate level of agreement, respondents agreed the least that there is tolerance, inclusion, and open-mindedness in their community (mean=3.45); only 3.4 percent of respondents agreed a great deal.

Figure 1. Respondents' level of agreement with statements about their community regarding PEOPLE

People are friendly, helpful, and supportive (N=58)

There is a sense of community/feeling connected to people who live here (N=58)

There is an engaged government (N=58)

There is a sense that you can make a difference (N=57) People who live here are aware of/engaged in social, civic, or political issues (N=58) The community is socially and culturally diverse (N=58) There is tolerance, inclusion, and open-mindedness (N=58)

1 2 3 4 5 Mean (l=not at all, S=a great deal)

10 Overall, respondents had a high level of agreement with positive statements regarding services and resources issues in their community (Figure 2, Appendix Table 2). • On average, respondents agreed the most that there are quality higher education opportunities and institutions in their community {mean=4.74); 77.6 percent agreed a great deal. Respondents also had a high level of agreement that there are quality school systems and programs for youth (mean=4.43) and that there is quality health care {mean=4.42). • Although still moderate in their level of agreement, respondents agreed the least that there is effective transportation in their community {mean=3.39).

Figure 2. Respondents' level of agreement with statements about their community regarding SERVICES AND RESOURCES

There are quality higher education opportunities and 4.74 institutions (N=S8) There are quality school systems and programs for 4.43 youth (N=S8)

There is quality health care (N=57) 4.42

There is access to family services (N =58)

There is access to healthy food (N =S8)

There is effective transportation (N =57)

1 2 3 4 5 Mean (l=not at all, S=a great deal)

11 Overall, respondents had a high level of agreement with positive statements regarding quality of life in their community {Figure 3, Appendix Table 3}. • On average, respondents agreed the most that their community is a good place to raise kids and that it is a healthy place to live (mean=4.62 and mean=4.19, respectively).

Figure 3. Respondents' level of agreement with statements about their community regarding QUALITY OF LIFE

The community is a good place to raise kids (N=S8) 4.62

The community is a healthy place to live (N=S8)

There are quality arts, cultural activities, events, and festivals {N=58) The community is a safe place to live and has little or no crime {N =58) The community has a peaceful, calm, and quiet environment {N=56) There are many recreational, exercise, and sports activities/opportunities {N=S8)

1 2 3 4 5

Mean {l=not at all, S=a great deal)

Respondents were asked to describe other best things about their community (see Appendix Table 4 for a list ofthemes). • Respondents mentioned the strong partnerships and collaborations that are working to create healthier communities. Faith and religious organizations that are addressing social concerns and supporting the community were also mentioned. Respondents also said that affordable housing was another asset within the community.

General Concerns About Their Community

Overall, respondents had a moderate level of concern with economic issues in their community (Figure 4, Appendix Table 5). • On average, respondents were most concerned with the availability of employment opportunities (mean=3.69), economic disparities between higher and lower classes (mean=3.64), homelessness (mean=3.64), and poverty (mean=3.62). • Although still moderately concerned, on average, respondents were least concerned with the cost of living in their community (mean=3.16).

12 Figure 4. Respondents' level of concern with statements about their community regarding ECONOMIC ISSUES

Availability of employment opportunities (N=58)

Economic disparities between higher and lower classes (N=58)

Homelessness (N=58)

Poverty (N=58)

Availability of affordable housing (N=58)

Hunger (N=57)

Wage levels (N =58)

Cost of living (N=58)

1 2 3 4 5 Mean (l=not at all, S=a great deal)

Overall, respondents had a moderate level of concern with transportation issues in their community (Figure 5, Appendix Table 6). • On average, respondents were most concerned with the availability of good walking or biking options (mean=3.79), the ava ilability and cost of public transportation (mean=3.33), and road conditions (mean=3.25). • On average, respondents were least concerned with traffic congestion (mean=2.55).

Figure 5. Respondents' level of concern with statements about their community regarding TRANSPORTATION

Availability of good walking or biking options (as 3.79 alternatives to driving) (N =58) Ava ilability and/or cost of public transportation (N=58)

Road conditions (N =57)

Driving habits (e.g., speedi ng, road rage) (N =57)

Cost of automobile ownership (e.g., gas, maintenance, insurance) (N=57)

Traffic congestion (N=58)

1 2 3 4 5

Mean (l=not at all, S=a great deal)

13 Overall, respondents were not that concerned with environmental issues in their community (Figure 6, Appendix Table 7). • On average, respondents had a higher level of concern with garbage and litter (mean=2.55).

Figure 6. Respondents' level of concern with statements about their community regarding ENVIRONMENT

Garbage and litte r concerns (N=58)

Water quality concerns (N=58)

Noise level concerns (N=58)

Air quality concerns (N=58)

1 2 3 4 5

Mean {l=not at all, S=a great deal)

Overall, respondents had a moderate level of concern w ith issues relating to children and youth in their community (Figure 7, Appendix Table 8). • On average, respondents were most concerned about the ava ilability or cost of quality child care (mean=3.91), bullying (mean=3.82), and the availability and cost of services for at-risk youth (mean=3.81). • Although still moderately concerned, on average, respondents were least concerned with youth crime (mean=3.09).

Figure 7. Respondents' level ofconcern with statements about their community regarding CHILDREN AND YOUTH

Availability and/or cost of quality child care (N=57)

Bullying {N=57)

Availability and/or cost of services for at-risk youth (N=57) Availability and/or cost of activ ities for children and youth {N=58)

School dropout rates/truancy (N=57)

Teen pregnancy {N =58)

Youth crime {N =57)

1 2 3 4 5 M ean {l=not at all, S=a great deal)

14 Overall, respondents had moderately high levels of concern with issues relating to the aging population in their community (Figure 8, Appendix Table 9). • On average, respondents were most concerned about the avai lability and cost of long-term care (mean=3.91), the availability of resources to help the elderly stay in their homes (mean=3.89), and the availability of resources for family and friends caring for elders (mean=3.86). • Although still moderately concerned, on average, respondents were least concerned about the availability and cost of activities for seniors (mean=3.38).

Figure 8. Respondents' level of concern with statements about their community regarding THE AG ING POPULATION

Availability and/or cost of long-term care {N=57) 3.91

Availability of resources to help the elderly stay in their homes {N=57) Availability of resources for family and friends caring for elders {N=57) Availability of resources for grandparents caring for grandchildren {N=56)

Availability and/or cost of activities for seniors {N =58)

1 2 3 4 5

Mean {l=not at all, S=a great deal)

Overall, respondents had a moderately high level of concern with safety issues in their community (Figure 9, Appendix Table 10). • On average, respondents were most concerned with domestic violence (mean=3.97), child abuse and neglect (mean=3.76), and the presence and influence of drug dealers in the community (mean=3.52). • Although still moderately concerned, on average, respondents were least concerned about violent crimes (mean=3.09).

Figure 9. Respondents' level of concern with statements about their community regarding SAFETY

Domestic violence {N=58)

Child abuse and neglect {N=S8)

Presence and influence of drug dealers in the community {N=S8)

Elder abuse (N=57)

Property crimes {N=58)

Violent crimes {N =58)

1 2 3 4 5 Mea n {l=not at all, S=a great deal)

15 Respondents were asked to describe other community concerns (see Appendix Table 11 for a list of themes). • Some respondents said the community should support policies that promote health, such as land use policies, Safe Routes to School, and the inclusion of parks, trails, and gardening in new developments. More recycling was also mentioned. • Access to quality education and funding for K-12, and sufficient support programs for teen and single parents and for physically or mentally disabled persons were also concerns.

Health and Wellness Concerns About Their Community

Overall, respondents had high levels of concern regarding several issues associated with access to health care in their community (Figure 10, Appendix Table 12). • Respondents were most concerned about cost issues: o Cost of health insurance (mean=4.57); 63.8 percent were concerned a great deal. o Cost of health care (mean=4.48); 53.4 percent were concerned a great deal. o Cost of prescription drugs (mean=4.34); 51.7 percent were concerned a great deal. o Adequacy of health insurance (e.g., amount of copays, deductibles) (mean=4.24); 46.6 percent were concerned a great deal. • Respondents also had moderately high levels of concern regarding access and availability of health and wellness coverage, providers, and services: 0 Access to health insurance coverage (e.g., preexisting conditions) (mean=4.16); 44.8 percent were concerned a great deal. 0 Availability of prevention programs or services (mean=4.07); 43.1 percent were concerned a great deal. 0 Availability and/or cost of dental and/or vision care (mean=4.02); 34.5 percent were concerned a great deal. 0 Coordination of care (mean=4.00); 41.4 percent were concerned a great deal. 0 Availability and/or cost of dental and/or vision insurance coverage (mean=4.00); 36.2 percent were concerned a great deal. 0 Availability of mental health services and providers (mean=3.98); 39.7 percent were concerned a great deal. • Among health care access issues, respondents had the least concern for distance to health care services and patient confidentiality: o Distance to health care services (mean=2.60). o Patient confidentiality (mean=2.52).

16 Figure 10. Respondents' level of concern with statements about their community regarding ACCESS TO HEALTH CARE

Cost of health insurance {N=58)

Cost of hea lth care {N=58)

Cost of prescription drugs {N=58)

Adequacy of health insurance {e .g., amount of co pays, deductibles) {N=58) Access to health insu rance coverage {e.g., preexisting conditions) {N=58)

Availability of prevention programs or services {N=58)

Availability and/or cost of dental and/or vision care (N=58)

Coordination of care {N =58)

Ava ilability and/or cost of dental and/or vision insurance coverage {N=58) Availability of mental health services and providers {N=58) Use of emergency room services for primary health care {N=57)

Time it takes to get an appointment {N=58)

Ava ilability of doctors, nurses, and/or specialists {N=58) Availability of non-traditional hours {e.g., evenings, weekends) {N=58)

Providers not taking new patients {N=58)

Availability of/access to t ransportation {N =58)

Availability of bilingual providers and/or t ranslators {N =58)

Distance to health ca re services (N=58)

Patient confidentiality (N=58)

1 2 3 4 5 Mean (l=not at all, S=a great deal)

17 Overall, respondents had high levels of concern rega rding physical and mental health issues in their community (Figure 11, Appendix Table 13). • On average, respondents indicated the physical and mental health issues they were most concerned about in their community were obesity, poor nutrition and eating habits, inactivity and/or lack of exercise, and chronic disease (mean=4.36, mean=4.28, mean=4.28, and mean=4.24, respectively). • Although still a moderate level of concern, on average, respondents were least concerned about communicable disease (mean=3.31).

Figure 11. Respondents' level of concern with statements about their community regarding PHYSICAL AND MENTAL HEALTH

Obesity {N=58)

Poor nutrition/eating habits {N=58)

Inactivity and/or lack of exercise {N=58)

Chronic disease {e.g., diabetes, heart disease, multiple sclerosis) {N=58)

Depression {N=58)

Stress {N=57)

Dementia/Alzheimer's disease {N=57)

Cancer {N=58)

Suicide (N=58)

Communicable disease (e.g., sexually transmitted diseases, AIDS) (N=58)

1 2 3 4 5 Mean (l=not at all, S=a great deal)

18 Overall, respondents' levels of concern regarding substance use and abuse in their community were very similar and fairly high (Figure 12, Appendix Table 14). • On average, respondents were most concerned about alcohol use and abuse and drug use and abuse (mean=4.12 and mean=4.03, respectively). • Although still a moderately high level of concern, on average, respondents were least concerned with exposure to second-hand smoke (mean=3.72).

Figure 12. Respondents' level of concern with statements about their community regarding SUBSTANCE USE AND ABUSE

Alcohol use and abuse (N=58)

Drug use and abuse (N=58)

Smoking and tobacco use (N=57)

Exposure to second-hand smoke (N =58)

1 2 3 4 5 Mean (l=not at all, S=a great deal)

Respondents were asked to describe other health and wellness concerns in their community (see Appendix Table 15 for a list of themes). • Access to services, such as health care, dental care, urgent and preventive, and primary ca re for children was a concern listed by respondents. • Some respondents would like to see better quality foods made ava ilable to schools, and local, wholesale, unprocessed foods made more readily available in order to make healthier choices.

Personal Health Care Information (Appendix Tables 16-20}

• Three in five respondents said they use Sanford Health as their primary health care provider (62.1 percent); one in four said they use Essentia Health (27.6 percent). • The top t hree reasons respondents gave for their choice of primary hea lth ca re provider were quality of services, being influenced by thei r healt h insurance, and location (39.7 percent, 29.3 percent, and 27.6 percent, respectively). • Less than one in five respondents said they had not had a cancer screening or cancer ca re in the past year (17.2 percent). • Among those who had not had a screening or ca ncer ca re in the past year, 60.0 percent said the reason they had not done so was because it was not necessary. Fear, unfamiliarity with recommendations, and not knowing who to see were also reasons respondents gave (10.0 percent each). • The vast majority of respondents said they paid for health ca re costs for themselves or family members over the past 12 months by health insurance t hrough an employer (91.4 percent); 43.1 percent of respondents paid using personal income. 19 Demographic Information (Appendix Tables 21-30)

• Two-thirds of respondents are 45 to 64 years old (67.2 percent); one-fourth are 30 to 44 years old (25.9 percent). • Nine in 10 respondents have a Bachelor's degree or higher (89.6 percent), including 58.6 percent who have a graduate or professional degree. • Two-thirds of respondents are female (65.5 percent). • Nearly all respondents work or volunteer outside the home (98.3 percent). • Two in five respondents said their annual household income is $70,000 to $119,999 {38.6 percent); one in three respondents said their income is $120,000 or more (35.1 percent). • The vast majority of respondents own their home (94.8 percent). • The vast majority of respondents are white (96.6 percent). • One-third of respondents are the parent or primary caregiver of a child or children 18 years of age or younger (34.5 percent). • Most respondents are employed in health care (37.9 percent), followed by government (29.3 percent), and educational services (25.9 percent). • Among respondents who are employed in health care, 40.9 percent are an administrator; 27.3 percent work in public health.

20 APPENDICES

Community Assets/Best Things About Their Community

Appendix Table 1. Respondents' level of agreement with statements about their community regarding PEOPLE Percent of respondents Level of agreement Statements regarding (1=not at all,5=a great deal ) people Mean 1 2 3 4 5 Total People are friendly, helpful, and supportive (N=58) 4.22 0.0 0.0 8.6 60.3 31.0 99.9 There is a sense of community/feeling connected to people who live here (N=58) 4.21 0.0 0.0 12.1 55.2 32.8 100.1 People who live here are aware of/engaged in socia l, civic, or political issues (N=58) 3.59 0.0 5.2 44.8 36.2 13.8 100.0 The community is socially and culturally diverse (N=58) 3.52 1.7 10.3 34.5 41.4 12.1 100.0 There is an engaged government (N=58) 4.02 0.0 5.2 13.8 55.2 25.9 100.1 There is tolerance, inclusion, and open-mindedness (N=58) 3.45 0.0 8.6 41.4 46.6 3.4 100.0 There is a sense that you can make a difference (N=57) 3.86 0.0 3.5 24.6 54.4 17.5 100.0

Appendix Table 2. Respondents' level of agreement with statements about their community regarding SERVICES AND RESOURCES Percent of respondents Level of agreement Statements regarding (1=not at all,5=a great deal) Services and resources Mean 1 2 3 4 5 Total There are quality school systems and programs for youth (N=58) 4.43 0.0 1.7 6.9 37.9 53.4 99.9 There are quality higher education opportunities and institutions (N=58) 4.74 0.0 0.0 3.4 19.0 77.6 100.0 There is quality health care (N=57) 4.42 0.0 1.8 3.5 45.6 49.1 100.0 There is effective transportation (N=57) 3.39 3.5 17.5 24.6 45.6 8.8 100.0 There is access to hea lthy food (N=58) 3.71 0.0 8.6 25 .9 51.7 13.8 100.0 There is access to family services (N=58) 3.88 0.0 6.9 19.0 53.4 20.7 100.0

21 Appendix Table 3. Respondents' level of agreement with statements about their community regarding QUALITY OF LI FE Percent of respondents Level of agreement Statements regarding (1=not at all, 5=a great deal) quality of life Mean 1 2 3 4 5 Total The community is a safe place to live and has little or no crime (N=58) 4.14 0.0 1.7 10.3 60.3 27.6 99.9 The community is a good place to raise kids (N=58) 4.62 0.0 0.0 1.7 34.5 63.8 100.0 The community has a peaceful, calm, and quiet environment (N=56) 4.09 1.8 0.0 12.5 58.9 26.8 100.0 The community is a healthy place to live (N=58) 4.19 0.0 0.0 13.8 53.4 32.8 100.0 There are quality arts, cultural activities, events, and festivals (N=58) 4.16 0.0 3.4 13.8 46.6 36.2 100.0 There are many recreational, exercise, and sports activit ies/opportunities (N=58) 4.07 0.0 3.4 15.5 51.7 29.3 99.9

Appendix Table 4. Responses to other best things about their community ,, ' "' ...... , ' I ! , , Best thingsI about theirI community1,\} ,, ResponsesI ' ' ' ' '' ' Strong partnerships and collaborations working to create healthier communities/community sense of optimism/ pride of ownership/nice place to live 5 Faith/religious organizations address social concerns, support community 3 Affordable housing 3 Many opportunit ies are expensive - out of reach for low income 1 Close to family 1 Forward looking government 1 Low unemployment rate 1 Environmentally friendly: clean air, green spaces, low pollution 1 N=12

22 General Concerns About Their Community

Appendix Table 5. Respondents' level of concern with statements about their community regarding ECONOMIC ISSUES Percent of respondents Level of concern Statements regarding (1=not at all,5=a great deal) economic issues Mean 1 2 3 4 5 Total Availability of affordable housing (N=58) 3.47 1.7 12.1 34.5 41.4 10.3 100.0 Availability of employment opportunities (N=58) 3.69 0.0 19.0 13.8 46.6 20.7 100.1 Wage levels (N=58) 3.43 0.0 19.0 32.8 34.5 13.8 100.1 Poverty (N=58) 3.62 0.0 10.3 34.5 37.9 17.2 99.9 Homelessness (N=58) 3.64 1.7 6.9 36.2 36.2 19.0 100.0 Cost of living (N=58) 3.16 1.7 17.2 48.3 29.3 3.4 99.9 Economic disparities between higher and lower cla sses (N=58) 3.64 0.0 10.3 31.0 43.1 15.5 99.9 Hunger (N=57) 3.46 0.0 14.0 35.1 42.1 8.8 100.0

Appendix Table 6. Respondents' level of concern with statements about their community regarding TRANSPORTATION Percent of respondents Level of concern Statements regarding (1=not at all,5=a great deal) transportation Mean 1 2 3 4 5 Total Traffic congestion (N=58) 2.55 6.9 50.0 29.3 8.6 5.2 100.0 Avail ability and/or cost of public transportation (N=58) 3.33 3.4 19.0 27.6 41.4 8.6 100.0 Road conditions (N=57) 3.25 1.8 21.1 33.3 38.6 5.3 100.1 Driving habits (e.g., speeding, road rage) (N=57) 3.04 3.5 24.6 43.9 21.1 7.0 100.1 Avail ability of good walking or biking options (as alternatives to driving) (N=58) 3.79 0.0 6.9 31.0 37.9 24.1 99.9 Cost of automobile ownership (e.g., gas, maintenance, insurance) (N=57) 2.95 1.8 26.3 49.1 21.1 1.8 100.1

23 Appendix Table 8. Respondents' level of concern with statements about their community regarding CHILDREN AND YOUTH Percent of respondents Level of concern Statements regarding (1=not at all, 5=a great deal) children and youth Mean 1 2 3 4 5 Total Ava ilability and/or cost of services for at-risk youth {N=57) 3.81 0.0 8.8 21.1 50.9 19.3 100.1 Youth crime (N=57) 3.09 3.5 24.6 38.6 26.3 7.0 100.0 School dropout rates/truancy (N=57) 3.56 0.0 17.5 26.3 38.6 17.5 99.9 Teen pregnancy (N=58) 3.34 0.0 19.0 37.9 32.8 10.3 100.0 Bullying {N=57) 3.82 0.0 14.0 17.5 40.4 28.1 100.0 Ava ilability and/or cost of activities for children and youth (N=58) 3.67 1.7 10.3 22.4 50.0 15.5 99.9 Availability and/or cost of quality child care (N=57) 3.91 3.5 7.0 17.5 38.6 33.3 99.9

Appendix Table 9. Respondents' level of concern with statements about their community regarding THE AG ING POPULATION Percent of respondents Level of concern Statements regarding (1=not at all, 5=a great deal) the aging population Mean 1 2 3 4 5 Total Ava ilability and/or cost of activities for seniors (N=58) 3.38 3.4 13.8 34.5 37.9 10.3 99.9 Ava ilability and/or cost of long- term care {N=57) 3.91 1.8 5.3 21.1 43.9 28.1 100.2 Ava ilability of resources to help the elderly stay in their homes (N=57) 3.89 0.0 15.8 15.8 31.6 36.8 100.0 Ava ilability of resources for family and friends caring for elders {N=57) 3.86 1.8 14.0 14.0 36.8 33.3 99.9 Avai lability of resources for grandparents caring for grandchildren (N=56) 3.57 1.8 17.9 26.8 28.6 25.0 100.1

24 Appendix Table 10. Respondents' level of concern with statements about their community regarding SAFETY Percent of respondents Level of concern Statements regarding (1=not at all, 5=a great deal) safety Mean 1 2 3 4 5 Total Child abuse and neglect (N=S8) 3.76 1.7 12.1 19.0 43.1 24.1 100.0 Elder abuse (N=S7) 3.25 0.0 28.1 26.3 38.6 7.0 100.0 Domestic violence (N=S8) 3.97 0.0 5.2 24.1 39.7 31.0 100.0 Presence and influence of drug dealers in the community (N=S8) 3.52 1.7 12.1 37.9 29.3 19.0 100.0 Property crimes (N=S8) 3.14 1.7 22.4 44.8 22.4 8.6 99.9 Violent crimes (N=S8) 3.09 3.4 24.1 41.4 22.4 8.6 99.9

Appendix Table 11. Responses to other community concerns . ' ~ . y,. ( (' j ' j ... lJ r,' , ~ • :1 l .,· Other' community concerns 'Responses Support policies that promote health: land use policies/Safe Routes to School/include parks, trails, gardening in new developments 3 More recycling 2 Education: access to quality education Pre K-12/funding 2 Access to local healthy foods/food co-op 2 Sufficient support programs for: teen parents/single parents/physically or mentally disabled 2 Concern for elderly, especially in rural areas 1 N=13

25 Health and Wellness Concerns About Their Community

Appendix Table 12. Respondents' level of concern with statements about their community regarding ACCESS TO HEALTH CARE Percent of respondents Level of concern Statements regarding (1=not at all, 5=a great deal) access to health care Mean 1 2 3 4 5 Total Cost of health care (N=58) 4.48 0.0 1.7 1.7 43.1 53.4 99.9 Cost of prescription drugs (N=58) 4.34 0.0 3.4 10.3 34.5 51.7 99.9 Cost of health insurance (N=58) 4.57 0.0 0.0 6.9 29.3 63.8 100.0 Adequacy of health insurance (e.g., amount of co-pays, deductibles) (N=58) 4.24 0.0 5.2 12.1 36.2 46.6 100.1 Access to hea lth insurance coverage (e.g., preexisting conditions) (N=58) 4.16 0.0 5.2 19.0 31.0 44.8 100.0 Availability and/or cost of dental and/or vision insurance coverage (N=58) 4.00 1.7 6.9 17.2 37.9 36.2 99.9 Availability and/or cost of dental and/or vision care (N=58) 4.02 1.7 6.9 13.8 43.1 34.5 100.0 Availability of prevention programs or services (N=58) 4.07 0.0 6.9 22.4 27.6 43.1 100.0 Availability of doctors, nurses, and/or specialists (N=58) 3.47 3.4 19.0 29.3 24.1 24.1 99.9 Availability of bilingual providers and/or translators (N=58) 3.09 10.3 13.8 39.7 29.3 6.9 100.0 Distance to health care services (N=58) 2.60 25.9 31.0 12.1 19.0 12.1 100.1 Availability of/access to transportation (N=58) 3.22 8.6 24.1 24.1 22.4 20.7 99.9 Providers not taking new patients (N=58) 3.41 6.9 17.2 22.4 34.5 19.0 100.0 Time it takes to get an appointment (N=58) 3.52 5.2 13.8 25 .9 34.5 20.7 100.1 Availability of non-traditional hours (e.g., evenings, weekends) (N=58) 3.45 5.2 10.3 34.5 34.5 15.5 100.0 Patient confidentiality (N=58) 2.52 29.3 22.4 27.6 8.6 12.1 100.0 Use of emergency room services for primary health care (N=57) 3.86 3.5 8.8 17.5 38.6 31.6 100.0 Availability of mental health services and providers (N=58) 3.98 3.4 6.9 17.2 32.8 39.7 100.0 Coordination of care (N=58) 4.00 1.7 6.9 22.4 27.6 41.4 100.0

26 Appendix Table 13. Respondents' level of concern with statements about their community regarding PHYSICAL AND MENTAL HEALTH Percent of respondents Level of concern Statements regarding (1=not at all, 5=a great deal) physical and mental health Mean 1 2 3 4 5 Total Obesity (n=58) 4.36 0.0 1.7 12.1 34.5 51.7 100.0 Poor nutrition/eating habits N=58 4.28 0.0 0.0 20.7 31.0 48.3 100.0 Inactivity and/or lack of exercise N=58 4.28 0.0 5.2 10.3 36.2 48.3 100.0 Cancer (N=58) 3.86 0.0 5.2 27.6 43.1 24.1 100.0 Chronic disease (e.g., diabetes, heart disease, multiple sclerosis) N=58 4.24 0.0 1.7 15.5 39.7 43.1 100.0 Communicable disease (e.g., sexually transmitted diseases, AIDS (N=58) 3.31 0.0 15.5 46.6 29.3 8.6 100.0 Dementia/Alzheimer's disease N=57) 4.00 0.0 1.8 26.3 42.1 29.8 100.0 Depression (N=58) 4.16 0.0 1.7 20.7 37.9 39.7 100.0 Stress (N=57) 4.09 0.0 3.5 19.3 42.1 35.1 100.0 Suicide (N=58) 3.78 0.0 10.3 34.5 22.4 32.8 100.0

Appendix Table 14. Respondents' level of concern with statements about their community regarding SUBSTANCE USE AND ABUSE Percent of respondents Level of concern Statements regarding (1=not at all, 5=a great deal) substance use and abuse Mean 1 2 3 4 5 Total Alcohol use and abuse (N=58) 4.12 0.0 5.2 13.8 44.8 36.2 100.0 Drug use and abuse (N=58) 4.03 0.0 10.3 8.6 48.3 32.8 100.0 Smoking and tobacco use (N=57) 3.98 0.0 14.0 14.0 31.6 40.4 100.0 Exposure to second-hand smoke (N=58) 3.72 8.6 10.3 15.5 31.0 34.5 99.9

Appendix Table 15. Responses to other health and wellness concerns •'' ,'',, I I ', ( I i ''I·, (Other J,:1 I Iihealth 11:1 and( ,. wellness concerns; I ' / J I I, l Responses ' i ,I ,I Access: for low income/health care, dental care/urgent and preventive/primary care for children 5 Smoke-free: state-wide/communities where it's policy isn't enforced 2 Better quality of foods: for schools - local, wholesale, unprocessed/conditions that make it easier to make healthy choices 2 Protection of employee privacy in health care setting 1 Chronic disease 1 N=ll

27 Personal Health Care Information

Appendix Table 16. Respondents' primary healt h care provider Primary health care provider Percent of respondents* Essent ia Healt h 27.6 Family HealthCare Center 3.4 Independent Family Doctors 15.5 Sanford Healt h 62.1 Use emergency room/urgent care for primary care services 0.0 Did not access hea lth care in last 12 months 1.7 Other: 3.4 St. Alexius Medical Center in Bismarck (2) Trinity Medical Center in Minot (1) N=58 *Percentages do not equal 100.0 due to multiple responses.

Appendix Table 17. Respondents' rea sons for choosing their primary health care provider Reasons for choice of primary health care provider Percent of respondents* Location 27.6 Cost 5.2 Qua lity of services 39.7 Availability of services 25.9 Sense of being valued as a patient 25.9 Influenced by hea lth insura nce 29.3 Other: 15.5 Followed physician (2) Ref erral/recommendation (2) Keep medical records in one place (2) Provider relationships (2) Have been there many years (1) Employed there (1) N=58 * Percentages do not equal 100.0 due to multiple responses.

Appendix Table 18. Whether respondents have had a cancer screening or cancer care in the past year Percent of respondents Cancer screening/cancer care (N=58) Yes 82.8 No 17.2 Total 100.0

28 Appendix Table 19. Among respondents who have not had a cancer screening or cancer care in the past year, reasons for not having done so Reason for not having a cancer screening/care Percent of respondents* Not necessary 60.0 Fear 10.0 Cost 0.0 Unfamiliar with recommendations 10.0 Doctor hasn't suggested 0.0 Unable to access care 0.0 I don't know who to see 10.0 Other: 30.0 Time constraints: need after work hours (2) Personal reasons {1} N=l0 *Percentages do not equal 100.0 due to multiple responses.

Appendix Table 20. Methods used by respondents to pay for health care costs for themselves or family members over the past 12 months

I I I I I ' ' ( .. I I ,, I IPaying (, 1 !, for, 1,health .,,, careI l costs ( '< .I.~!••• ~ji,~ . h,.: I Percent' "'<;I, of respondents * I Health insurance through an employer 91.4 Medicare 1.7 Private health insurance 5.2 Personal income (e.g., cash, check, credit) 43.1 Medicaid 1.7 Did not access health care in last 12 months 0.0 Other 0.0 N=58 *Percentages do not equal 100.0 due to multiple responses.

Demographic Information

Appendix Table 21. Respondents' age ':,•, I . ' I I I\Percent 1' .. (of I !respondents I : I (1' Age (~ i .. ' • ' , \ j . ' (N=58)I ' 18 to 29 years 1.7 30 to 44 years 25.9 45 to 64 years 67.2 65 to 74 years 5.2 75 years or older 0.0 Prefer not to answer 0.0 Total 100.0

29 Appendix Tab le 22. Respondents' highest level of education Percent of respondents Highest level of education (N=58) Some high school 0.0 High school diploma or GED 3.4 Some college/no degree 3.4 Associate's degree 3.4 Bachelor's degree 31.0 Graduate or professional degree 58.6 Prefer not to answer 0.0 Total 99.8

Appendix Table 23. Respondents' gender Percent of respondents Gender (N=58) Male 34.5 Female 65.5 Prefer not to answer 0.0 Total 100.0

Appendix Table 24. Whether respondents work/volunteer outside the home Percent of respondents Work/volunteer (N=58) Yes 98.3 No 1.7 Prefer not to answer 0.0 Total 100.0

Appendix Table 25. Respondents' annual household income before taxes Percent of respondents Annual household income before taxes (N=57) Less than $20,000 0.0 $20,000 to $39,999 1.8 $40,000 to $69,999 19.3 $70,000 to $119,999 38.6 $120,000 or more 35.1 Do not know/prefer not to answer 5.3 Total 100.1

Appendix Table 26. Whether respondents own or rent their home ' . f . 1 l ~ • f I r ! , "i i l Percent I ~ ( of respondentsI I I l f d !f \ (I. Tenure ' (N=58)') .I Own 94.8 Rent 3.4 Prefer not to answer 1.7 Other 0.0 Total 99.9

30 Appendix Table 27. Respondents' race or ethnicity

I I I Ii • j; (1; I\ l 'I) J. 'I I I I\ Race/ethnicity, iPercent of respondents* I White 96.6 Black/African American 0.0 Native American/A laska Native 0.0 Asian/Pacific Islander 0.0 Hispanic 3.4 Other 0.0 N=58 *Percentages do not equal 100.0 due to multiple responses.

Appendix Table 28. Whether respondents are the parent or primary caregiver of a child or children 18 years of age or younger .. , , PercentI of respondents,, I " I .: , ) Parent or Iprimary caregiver ' . , I(N=58) • I Yes 34.5 No 65.5 Prefer not to answer 0.0 Total 100.0

Appendix Table 29. Respondents' area of employment Area of employment Percent of respondents*, Healt h ca re 37.9 Retail trade 1.7 Ed ucational services 25.9 Arts/entertainment 0.0 Agriculture 0.0 Construction 0.0 Government 29.3 Manufacturing 0.0 Not applicable 0.0 Other: 24.1 Social services (4) Non-profit {4} Financial services (2) Law (1) Retired (1) Higher education (1) Faith-based community (1) N=58 *Percentages do not equal 100.0 due to multiple responses.

31 Appendix Table 30. If respondents' area of employment is healt h care, respondents' health care position I ' '' ' I ( ''Health care' position I ' " Percent' of respondents* Clerical 4.5 Administrator 40.9 Nurse 4.5 Physician's Assistant/Nurse Practitioner 0.0 CNA/Other assistant 0.0 I work in Public Health 27.3 Other: 22.7 Medical doctor (2) Finance (1) Public education (1) Development and health promotion (1) N=22 * Percentages do not equal 100.0 due to multiple responses.

Appendix Table 31. Additional concerns and suggestions Comments Provide a noise and litter ordinance. [There is a] lack of available resources for the mentally ill. Sharing listserv or contact list of this group. We need to be a visibly "breast feeding friendly" community. Signs: BF welcome here. Make it easy for women to BF. Thank you for including me in this discussion. Great meeting. Look for increased cooperation between major clinics and health oriented non-profits (arthritis Foundation, Heart Assoc., etc.,) to avoid duplication of services, increase patient education.

32 United April 16, 2012 Way United Way ofCass-Clay To: Community Leaders

From: The Fargo Moorhead Community Health Needs Assessment Collaborative

RE: 2012-2013 Community Health Needs Assessment Key Stakeholders Meeting

You are receiving this invitation because you have been identified as a key community leader and stake holder. Please join us on May 3, 2012 at 7:00 a.m. at the Holiday Inn (3803 13th Avenue South, Fargo) for a discussion and survey of the community health needs. Breakfast will be served.

Part of the IRS 990 requirement for a not-for-profit health system is to address issues that have been assessed as an unmet need in the community. Conducting a Community Health Needs Assessment is a requirement of the 201 O Health Care Reform Act. Both Essentia Health and Sanford Health are required to complete this assessment and to secure input from the groups of key community leaders.

In May 2011, the Greater Fargo Moorhead Community Health Needs Assessment Collaborative was established, and has been busy developing standardized data reporting. This data will then be used by each organization to complete their individual assessments and IRS require ments. By developing a collaborative approach, we are better utilizing the financial and personnel resources available to create plans for improving the health of our communities.

The Fargo Moorhead Community Health Needs Assessment Collaborative includes: • Center for Rural Health • Clay County Public Health • Dakota Medical Foundation • Essentia Health • Family HealthCare Center • Fargo Cass Public Health • NDSU • Sanford Health • Southeast Human Service Center • United Way of Cass-Clay

Please RSVP by April 30 to Mary Lake at Sanford Health at [email protected] or 701.234.6951 Thank you.

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United Way of Cass-Clay 219 7th Street South I P.O. Box 16091 Fargo, ND 58107- 1609 I 70 1.237.5050 I www.unitedwaycassclay.org United Way of Cass-Clay brings people together to create lasting change that will improve lives. Fargo Moorhead CHNA-Stakeholder Survey ------~--- ' + ' - (< J'~~D"e" ,\:~1/; ,~-;;,} _y '~" 0 -,~%: ':\ :,;~~:";"::-::, 0 ~?;,~if--;jf~:~&~si2i~::i:;")E:,;:: c~"?t;i

The FM Community Health Needs Assessment Collaborative invites you to participate in the 2012 Community Health Needs Assessment. The information that we gather from you will be important for the future development of an action plan to address the identified unmet needs in the community. Your participation in this work ls important to the community health improvement for a!I of our communities.

Please take a moment to complete the survey. You may skip any questions that you do not wish to answer. Your answers will be combined with other responses and reported in aggregate form. If you have any questions about the survey, you may contact Kay Schwarzwa!ter at 701-231-1058 or by email at [email protected].

COMMUNITY ASSETS/BEST THINGS ABOUT YOUR COMMUNITY

Using a 1 to 5 scale, with 1 being "not at all" and 5 being "a great deal," please tell us your level of agreement with each of the following statements about your community regarding PEOPLE, SERVICES AND RESOURCES, and QUALITY OF LIFE.

Considering your community, what is your level of agreement wlth ..

1. PEOPLE 1=Not at al! 2 3 4 5=A great deal a. People are friendly, helpful, supportive. 0 0 0 0 0 b. There is a sense of community/feeling connected to people who live here. 0 0 0 0 0

c. People who live here are aware of/engaged in social, civic, or political issues. 0 0 0 0 0 d. The community is socially and culturally diverse. 0 0 0 0 0 e. There is an engaged government. 0 0 0 0 0 f. There is tolerance, inclusion, and open- 0 mindedness. 0 0 0 0 g. There is a sense that you can make a difference. 0 0 0 0 0 2. SERVICES AND RESOURCES 1=Not at all 2 3 4 5=A great deal a. There are quality school systems and programs for youth. 0 0 0 0 0

b. There are quality higher education opportunities and institutions. 0 0 0 0 0 c. There is quality health care. 0 0 0 0 0 d. There is effective transportation. 0 0 0 0 0 e, There is access to healthy food. 0 0 0 0 0 f. There is access to family services. 0 0 0 0 0 Fargo Moorhead CHNA-Stakeholder Survey • . ' . ,~ ~ ~ - ~ V ,C - ~ -a "" ~ ~ ~- ~-~~0 'S ~ sc- ~ ~ - = Yc ,:~ ~'j:~/ =~~ ~ ''" '1%~ ,; « v \ v ~\~ b (, ~,~ '~,,-,i,%f,, '::"if ~, -~ 0- i~o?.,'ic ~\J~'i, j"' \ Y~'( ~ ,';:, -- ',,,~:(,v ~--,ff

Using a 1 to 5 scale, with 1 being "not at all" and 5 being ~a great deal," please tell us your level of agreement with each of the following statements about your community.

3. QUALITY OF LIFE 1=Not at all 2 3 4 5=A great deal a. The community is a safe p!ace to live and has 0 0 0 0 0 little or no crime. b. The community is a good place to raise kids. 0 0 0 0 0 c. The community has a peaceful, calm, and quiet 0 0 0 0 0 environment. d. The community is a healthy place to live. 0 0 0 0 0 e. There are quality arts, cultural activities, events, 0 0 0 0 0 and festivals. f. There are many recreational, exercise, and sports 0 0 0 0 0 activities/opportunities.

4. What are other "best things" about your community that are not reflected in the questions above? -

GENERAL CONCERNS ABOUT YOUR COMMUNITY

Using a 1 to 5 scale, with one being "not at all" and 5 being "a great deal," please tell us the level of concern you have about your community in each of the following areas: ECONOMIC ISSUES, TRANSPORTATION, ENVIRONMENT, CHILDREN AND YOUTH, THE AGING POPULATION, and SAFETY.

Considering your community, what is your level of concern with ..

5. ECONOMIC ISSUES 1=Not at all 2 3 4 5=A great deal a. Availability of affordable housing 0 0 0 0 0 b. Availability of employment opportunities 0 0 0 0 0 c. Wage levels 0 0 0 0 0 d. Poverty 0 0 0 0 0 e. Homelessness 0 0 0 0 0 f. Cost of living 0 0 0 0 0 g. Economic disparities between higher and lower 0 0 0 0 0 classes h. Hunger 0 0 0 0 0 Fargo Moorhead CHNA-Stakeholder Survey

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Using a 1 to 5 scale, with one being "not at all" and 5 being "a great deal," please tell us the level of concern you have about your community in each of the following areas.

6. TRANSPORTATION

1=Not at all 2 3 4 5=A great deaf a. Traffic congestion 0 0 0 0 0 b. Availability and/or cost of public transportation 0 0 0 0 0 c. Road conditions 0 0 0 0 0 d. Driving habits (e.g., speeding, road rage) 0 0 0 0 0 e. Availability of good walking or biking options (as alternatives to driving) 0 0 0 0 0

f. Cost of automobile ownership (e.g., gas, maintenance, insurance) 0 0 0 0 0

7. ENVIRONMENT

1=Not at all 2 3 4 5=A great deal a. Water quality concerns 0 0 0 0 0 b. Noise level concerns 0 0 0 0 0 c. Air quality concerns 0 0 0 0 0 d. Garbage and litter concerns 0 0 0 0 0 8. CHILDREN AND YOUTH

1=Not at all 2 3 4 5=A great dea! a. Availability and/or cost of services for at-risk youth 0 0 0 0 0 b. Youth crime 0 0 0 0 0 c. School dropout rates/truancy 0 0 0 0 0 d. Teen pregnancy 0 0 0 0 0 e. Bullying 0 0 0 0 0 f. Availability and/or cost of activities for children and youth 0 0 0 0 0 h. Availability and/or cost of quality child care 0 0 0 0 0 Fargo Moorhead CHNA-Stakeholder Survey

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Using a 1 to 5 scale, with one being "not at all" and 5 being "a great deal," please tell us the level of concern you have about your community in each of the following areas.

9. THE AGING POPULATION 1 =Not at all 2 3 4 5=A great deal a. Availability and/or cost of activities for seniors 0 0 0 0 0 b. Availability and/or cost of long-term care 0 0 0 0 0 c. Availability of resources to help the elderly stay 0 0 0 0 0 in their homes d. Availability of resources for family and friends 0 0 0 0 0 caring for elders e. Availability of resources for grandparents caring 0 0 0 0 0 for grandchildren

10.SAFETY 1 =Not at all 2 3 4 S=A great deal a. Child abuse and neglect 0 0 0 0 0 b. Elder abuse 0 0 0 0 0 c. Domestic violence 0 0 0 0 0 d. Presence and influence of drug dealers in the 0 0 0 0 0 community e. Property crimes 0 0 0 0 0 f. Violent crimes 0 0 0 0 0 11. What other COMMUNITY CONCERNS do you have that are not reflected in the previous questions? - Fargo Moorhead CHNA-Stakeholder Survey ------' ' A ~ ~ - r - ~ ~ ~ - ? ~ ~ A - S ~'-' f,~ Y, , c, ~ C ; o,;) \ V )'. ) ) "- ~ ,o /4

HEALTH AND WELLNESS CONCERNS ABOUT YOUR COMMUNITY

Using a 1 to 5 scale, with 1 being "not at all" and 5 being "a great deal," please tell us your level of concern about health and wellness issues in your community within each of the following categories: ACCESS TO HEALTH CARE, PHYSICAL AND MENTAL HEAL TH, and SUBSTANCE USE AND ABUSE.

Considering your community, how concerned are you about..

12. ACCESS TO HEALTHCARE 1=Not at all 2 3 4 S=A great deal a. Cost of health care 0 0 0 0 0 b. Cost of prescription drugs 0 0 0 0 0 c. Cost of health insurance 0 0 0 0 0 d. Adequacy of health insurance (e.g., amount of 0 0 0 0 co-pays, deductibles) 0 e. Access to health insurance coverage {e.g., 0 0 0 0 preexisting conditions) 0

f. Availability and/or cost of dental and/or vision insurance coverage 0 0 0 0 0 g. Availability and/or cost of dental and/or vision 0 0 0 0 care 0 h. Availability of prevention programs or services 0 0 0 0 0 L Availability of doctors, nurses, and/or specialists 0 0 0 0 0 j. Availability of bilingual providers and/or translators 0 0 0 0 0 k. Distance to health care services 0 0 0 0 0 I. Availability of/access to transportation 0 0 0 0 0 m. Providers not taking new patients 0 0 0 0 0 n. Time it takes to get an appointment 0 0 0 0 0 o. Availability of non.traditional hours (e.g., 0 0 0 0 evenings, weekends) 0 p. Patient confidentiality 0 0 0 0 0 q. Use of emergency room services for primary 0 0 0 0 health care 0 r. Availability of mental health services and 0 0 0 0 providers 0 s. Coordination of care 0 0 0 0 0 Fargo Moorhead CHNA-Stakeholder Survey • 1 1/ ~ \ \ ( ) V 'h

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13. PHYSICAL AND MENTAL HEALTH 1=Not at all 2 3 4 5=A great dea! a. Obesity 0 0 0 0 0 b. Poor nutrition/eating habits 0 0 0 0 0 c. Inactivity and/or lack of exercise 0 0 0 0 0 d. Cancer 0 0 0 0 0 e. Chronic disease (e.g., diabetes, heart disease, 0 0 0 0 0 multiple sclerosis) f. Communicable disease (e.g., sexually 0 0 0 0 0 transmitted diseases, AIDS) g. Dementia/Alzheimer's disease 0 0 0 0 0 h. Depression 0 0 0 0 0 L Stress 0 0 0 0 0 j. Suicide 0 0 0 0 0 14. SUBSTANCE USE AND ABUSE 1=Not at al! 2 3 4 5=A great deal a. Alcohol use and abuse 0 0 0 0 0 b. Drug use and abuse 0 0 0 0 0 c. Smoking and tobacco use 0 0 0 0 0 d. Exposure to second~hand smoke 0 0 0 0 0 15. What other HEALTH AND WELLNESS CONCERNS do you have about your community that are not reflected in the previous questions? - Fargo Moorhead CHNA-Stakeholder Survey ------1 ' ~ - ~ ~ ~/ - "' - ~ ~ - - ~ ~~ ~ - ·-J -- - ~- - - - ~ '~ - ~- >, f / /!", X X ) ~ /! ~ " / "' ( ,t :, , ) ; '° c, ,c " v, )/')~ , ~ ;; , Jc * ~ , );,c ~ ;; ' ,c/

DEMOGRAPHIC INFORMATION

Please tell us about yourself.

16. What is your age?

Q 18 to 29 years

Q 30 to 44 years

Q 45 to 64 years

Q 65 to 74 years

Q 75 years or older

Q Prefer not to answer

17. What is your highest level of education?

Q Some high school

Q High school diploma or GED

Q Some college/no degree

Q Associate's degree

Q Bachelor's degree

Q Graduate or Professional degree

Q Prefer not to answer

18. What is your gender?

Q Male

Q Female

Q Prefer not to answer

19. What is your approximate annual household income before taxes?

Q Less than $20,000

Q $20,000 to $39,999

Q $40,000 to $69,999

Q $70,000 to $119,999

Q $120,000 or more

Q Do not know/prefer not to answer .Fargo Moorhead CHNA-Stakeholder Survey 1/ '

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20. Do you own or rent your home?

Q Own

Q Rent

Q Prefer not to answer

Q Other (please specify) -

21. What best describes your race/ethnicity? (choose all that apply)

□ White

D Black/African American

D Native American/Alaska Native

D Asian/Pacific Islander

D Hispanic

D Other (please specify)

22. Are you the parent or primary caregiver of a child/children 18 years of age or younger?

Q Yes

Q No

Q Prefer not to answer

23. What provider do you use for your primary health care? (choose all that apply)

D Essentia Health D Family HealthCare Center D Independent Family Doctors

D Sanford Health D Use emergency room/urgent care for primary care services D Did not access health care in last 12 months (skip to 025)

D Other (please specify) Fargo Moorhead CHNA-Stakeholder Survey ------' ' j

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24. Why did you choose this provider? (choose all that apply)

D Location

D Cost D Quality of services

D Availability of services D Sense of being valued as a patient

D Influenced by health insurance

D Other (please specify) j

25. Have you personally had a cancer screening (mammogram, Pap smear, breast exam, testicular exam, rectal exam, prostate blood test, colonoscopy, etc.) or cancer care in the past year?

Q Yes (skip to 027)

26. If you haven't had a cancer screening in the past year, why not? (choose all that apply)

D Not necessary

D Fear

D Cost D Doctor hasn't suggested

D Unable to access care

D I don't know who to see D Unfamiliar with recommendations

D Other (please specify} j Fargo Moorhead CHNA-Stakeholder Survey 27. Over the past 12 months, how have you paid for health care costs (for you or family members)? (choose all that apply)

D Health insurance through an employer

D Private health insurance

D Persona! income (e.g., cash, check, credit)

D Medicaid D Medicare D Did not access health care in last 12 months

D Other (please specify) J 28. Do you work/volunteer outside the home?

Q Yes

Q Prefer not to answer

29. What is/was your area of employment? (choose all that apply)

D Health care

D Retail trade D Educational services

D Arts/entertainment

D Agriculture

D Construction

D Government

D Manufacturing

D Not applicable

D Other (please specify) J Fargo Moorhead CHNA-Stakeholder Survey 30. For those with employment in HEAL TH CARE, what is/was your position? (choose all that apply)

D Clerical

D Administrator

D Nurse D Physician's Assistant/Nurse Practitioner

D CNA/Other assistant

D I work in Public Health

D Other (please specify) Fargo Moorhead CHNA-Stakeholder Survey

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~~31. PLEASE PROVIDE THE FOLLOWING INFORMATION. We are compiling the name, area of expertise, affiliation, and location of respondents in order to acknowledge them for contributing to our project.~~

This information will appear separately in a special acknowledgements section. No personal information will be attributed to your responses, which will be reported in aggregate form only. We greatly appreciate your assistance in this matter.

~~Please provide us with the following information: name, title, affiliation, area of expertise, city, state~~

~~Example: John Smith Pastor Calvary Lutheran Church Health ministry, part of hospital advisory group Fargo North Dakota~~

~~Name:~~

~~Title:~~

~~Affiliation:~~

~~Area of expertise:~~

~~City/Town:~~

~~State:~~

~~32. Please share any additional concerns and suggestions you may have.~~