2021 CMC CHA Report FINAL.Pdf

Contents Executive Summary ...... 4 Current Environment ...... 4 2021 RVCHA Key Findings ...... 5 Mental Health ...... 5 Socioeconomic Factors ...... 6 Primary Care ...... 6 COVID-19 ...... 7 Board Adoption ...... 8 Disclaimer ...... 8 Acknowledgements ...... 8 Project Management Team ...... 8 Project Support Team ...... 8 Healthy Roanoke Valley ...... 8 Roanoke City and Alleghany Health Districts ...... 9 Community Health Assessment Team (CHAT) ...... 9 CHAT Members and Area of Expertise ...... 9 Community Served ...... 12 Carilion Medical Center Principal Functions ...... 12 Geographic Area ...... 12 Target Population ...... 13 Service Area Demographics ...... 13 Community Health Assessment Process ...... 15 Identification of Significant Health Needs ...... 15 Prioritization of Significant Health Needs ...... 15 Identification of Resources to Address Needs ...... 16 Community Input ...... 17 Community Impact ...... 18 Impact of Actions Taken in Response to 2018 RVCHA ...... 18 Data Collection and Analysis Methods ...... 20 Community Health Survey ...... 20 Stakeholder (CHAT) Focus Group ...... 21 Stakeholder Survey ...... 21

Secondary Data ...... 22 Collaboration ...... 23 Data Review ...... 24 Clinical Data ...... 24 Vital Conditions for Well-Being ...... 29 Vital Condition: Basic Needs for Health & Safety ...... 29 Vital Condition: Lifelong Learning ...... 35 Vital Condition: Meaningful Work & Wealth ...... 37 Vital Condition: Humane Housing ...... 39 Vital Condition: Thriving Natural World ...... 41 Vital Condition: Reliable Transportation ...... 43 Vital Condition: Belonging & Civic Muscle ...... 44 Self-Reported Data ...... 45 Equity ...... 49 Appendices ...... 50 Appendix 1: Gantt Chart ...... 50 Appendix 2: Community Health Survey ...... 51 Appendix 3: Stakeholder Survey and Data Summary ...... 55 Appendix 4: Prioritization Worksheet ...... 61 Appendix 5: Resource List ...... 63 Appendix 6: Community Health Survey Results ...... 70 Appendix 7: Secondary Data from University of Missouri CARES SparkMap ...... 101 Appendix 8: Links to Other Assessments ...... 178 Appendix 9: Cancer Community Health Survey Results ...... 179

Executive Summary Carilion Clinic is committed to joining with our partners to pursue the essential work of improving and maintaining the health of the Roanoke Valley. To ensure that current needs are being addressed, we assess the health concerns of each community every three years to uncover issues, indicate where improvement is needed, and track and promote progress. Carilion Medical Center’s (CMC) 2021 Roanoke Valley Community Health Assessment (RVCHA) is complete with the adoption and dissemination of this report. The Community Health Assessment (CHA) process and the public availability of its findings enables our community to effectively maintain and improve health1. Current Environment Since the 2018 RVCHA, significant changes have impacted our community’s health. There is no doubt that the COVID-19 pandemic has greatly disrupted all aspects of life. In Virginia, a state of emergency was declared on March 13, 2020, leading to temporary business closures, halting of routine health care services, and closures of schools—among a host of other challenges. Cases peaked in January of 2021, which also marked the end of the Community Health Survey period.

The COVID-19 pandemic has led to an increase in substance use and mental health issues, with the Virginia Department of Health (VDH) reporting a 22% increase in drug overdoses from 2019 to 2020 for Southwest Virginia2. Social isolation increased due to stay at home orders. Health care access was temporarily halted for a wide range of preventative and maintenance needs and, together with required protocols to prevent exposures in health care settings, has created more demand and lower patient throughput. Unemployment rates skyrocketed, going as high as 13% in Roanoke City in April of 2020— and the economic impact is still being felt3. Finally, the additional mortality from COVID-19 led to a projected decrease nationwide in life expectancy of greater than one year, with a larger impact on Black and Latino populations4.

Virginia’s Medicaid program also expanded since the 2018 RVCHA, leading to an increase in Medicaid enrollees across the Commonwealth. Over 27,000 adults in the RVCHA service area enrolled in Medicaid thanks to the expansion5. Medicaid coverage will also include adult dental care beginning July 1, 2021. This expansion is a step in the right direction to ensure health care access for the entire community, but challenges will continue to arise on how to best meet health care needs.

Awareness of health disparities, inequities and racial injustices continues to grow throughout the community and the United States. Health status, access and outcomes can be widely impacted by

1 Carilion Clinic began conducting Community Health Assessments prior to the IRS adoption of the 501(r)(3) which requires not-for-profit hospitals to conduct a Community Health Needs Assessment (CHNA) every three years. While meeting the CHNA requirement, Carilion maintains the longstanding formal name, Community Health Assessment, for our process and reports. 2 Virginia Department of Health, Emergency Department Visits for Unintentional Drug Overdose among Virginia Residents, accessed via https://www.vdh.virginia.gov/content/uploads/sites/13/2021/01/Emergency-Department- Visits-for-Unintentional-Drug-Overdose-2020-COVID-19-report_Final.pdf. 3 US Department of Labor, Bureau of Labor Statistics. Accessed via SparkMap. 4 https://www.pnas.org/content/pnas/118/5/e2014746118.full.pdf 5 https://www.dmas.virginia.gov/open-data/medicaid-expansion-enrollment/

individual experiences. We are committed to improving equity in care—both within and outside of the hospital walls. 2021 RVCHA Key Findings Carilion, Healthy Roanoke Valley (HRV) and the Roanoke City and Alleghany Health Districts (RCAHD) collaborated to conduct the 2021 RVCHA. The findings revealed 10 priority health-related issues in the community, identified by the Community Health Assessment Team (CHAT) after review of the data collected. Like-issues were grouped into categories to promote upstream and out-of-the-box thinking to address the top needs.

Top Needs Access to mental/behavioral health services Mental Health Access to substance use services Alcohol and drug use Mental health problems (general)

Poverty/low average household income Socioeconomic Affordable/safe housing Factors Transportation/transit system Lack of family/social support systems Primary Care Access to primary care COVID-19 COVID-19 impact

Mental Health Mental health continues to be a top health issue in the Roanoke Valley according to the community, stakeholders and as seen through additional data points.

• The Community Health Survey results indicate mental health as the top issue impacting the health of the community. Mental health services are the second most difficult health care service to access6. • Mental health and substance use are top issues according to the CHAT stakeholders7. • Drug overdose rates increased 22% in the Southwest Virginia from 2019 to 20208. • 49% of households surveyed by the United Way of Roanoke Valley reported mental health issues as a top concern during the pandemic9.

6 2021 Roanoke Valley Community Health Survey 7 2021 Stakeholder Survey 8 Virginia Department of Health, Emergency Department Visits for Unintentional Drug Overdose among Virginia Residents, accessed via https://www.vdh.virginia.gov/content/uploads/sites/13/2021/01/Emergency-Department- Visits-for-Unintentional-Drug-Overdose-2020-COVID-19-report_Final.pdf. 9 United Way of Roanoke Valley ALICE COVID-19 Report, accessed via https://www.uwrv.org/alice-covid-19-survey- results/.

• The Roanoke Valley has a mental health provider deficit, with 42.4% of the population considered underserved10. Socioeconomic Factors Socioeconomic factors and their contribution to poor health status and outcomes continue to be of concern for the Roanoke Valley. According to United Way, prior to COVID-19, 45% of households within the Roanoke Valley were already struggling to get by on their household income11. Across the assessment service area:

• 12.05% of the population live below the Federal Poverty Level. When looking at only Roanoke City, the rate jumps to over 20%12. • 25.17% of households are cost-burdened, with household expenses totaling more than 30% of household income. The highest individual locality rates are in Roanoke City (36.61%), Salem (25.45%) and Franklin County (22.59%)13. • 6.54% of households are without a motor vehicle. The highest individual locality rates are in Roanoke City (13.06%), Craig County (7.84%) and Salem (7.04%)14.

In addition to the needs presented above, broadband internet access was a topic of discussion in the final CHAT meeting. CHAT members agreed that to improve access to all resources mentioned— including health care, social services and education—affordable and reliable internet is a basic need.

• Significant pockets across Bedford, Craig and Franklin Counties are considered unserved areas based on slow (or no) download and upload speeds15. • Citizen surveys also indicate pockets across Roanoke County with low or no access to broadband16. Primary Care Access to primary care remains a top concern in the Roanoke Valley. Routine checkups with primary care providers can greatly improve health status and a variety of health outcomes through prompt identification of problems and treatment or lifestyle modifications.

• Roughly 80% of adults in the service area had a primary care checkup in the last year, according to 2018 data from the Centers for Disease Control and Prevention (CDC)17. • 79% of Community Health Survey respondents report that they have had a routine checkup in the last year.

10 Health Resources & Services Administration, 2019. Accessed via IP3 Assess, courtesy of ReThink Health. 11 United Way of Roanoke Valley ALICE COVID-19 Report, accessed via https://www.uwrv.org/alice-covid-19- survey-results/. 12 US Census Bureau, American Community Survey. 2015-19. Accessed via SparkMap. 13 US Census Bureau, American Community Survey. 2015-19. Accessed via SparkMap. 14 US Census Bureau, American Community Survey. 2015-19. Accessed via SparkMap. 15 Virginia Broadband Availability Map and Integrated Broadband Planning and Analysis Toolbox, Virginia Tech. Accessed via https://broadband.cgit.vt.edu/IntegratedToolbox/. 16 Roanoke County Broadband Availability Study, accessed via https://www.roanokecountyva.gov/2583/Broadband-Availability-Study. 17 Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System. Accessed via the 500 Cities Data Portal. 2018. Accessed via SparkMap.

• The expansion of Medicaid has created an increase in the population insured; however, provider availability has not increased to match the number of newly covered individuals. COVID-19 The impact of COVID-19 will persist for years to come. In addition to the statistics discussed previously:

• COVID-19 has been a considerable cause of morbidity and mortality, contributing to 630 deaths, 32,992 infections and 1,055 hospitalizations as of July 1, 202118. • 76% of households surveyed by United Way reported contracting COVID-19 as a top concern during the pandemic19.

This report contains the findings of the 2021 RVCHA, including primary and secondary health and social determinant data on the service area and specific populations.

18 Virginia Department of Health, https://www.vdh.virginia.gov/coronavirus/covid-19-in-virginia-locality/ 19 United Way of Roanoke Valley ALICE COVID-19 Report, accessed via https://www.uwrv.org/alice-covid-19- survey-results/.

Board Adoption This document was approved by the CMC Board of Directors on July 20, 2021, and formally adopted as the 2021 Roanoke Valley Community Health Assessment.

Disclaimer This document has been produced to benefit the community. Carilion Clinic encourages use of this report for planning purposes and is interested in learning of its utilization. Comments and questions are welcome and can be submitted to Carilion Clinic Community Health & Outreach at [email protected].

Members of the Project Management Team reviewed all documents prior to publication and provided critical edits. Every effort has been made to ensure the accuracy of the information presented in this report; however, accuracy cannot be guaranteed. Members of the Roanoke Valley Community Health Assessment Team cannot accept responsibility for any consequences that result from the use of any information presented in this report.

Acknowledgements Success of the 2021 RVCHA was due to the strong leadership and participation of its Project Management Team, the Project Support Team, members of Healthy Roanoke Valley, the Roanoke City and Alleghany Health Districts and the Community Health Assessment Team. Thank you to all the community members who participated in the Community Health Survey.

Members of these teams included: Project Management Team Project Director: Shirley Holland, Carilion Clinic – Vice President, Planning and Community Development Project Manager: Aaron Boush, Carilion Clinic – Community Health & Outreach Director Project Manager: Molly Roberts, Carilion Clinic – Community Benefit Manager

Project Support Team Carilion Clinic: Amy Michals, Kenya Thompson, Mandi Shoemaker, Carilion Direct Staff Roanoke City and Alleghany Health Districts: Kristin Adkins, Samara Lott United Way of Roanoke Valley: Hannah Adkins, David Nova (interim)

Healthy Roanoke Valley In 2012, using the Strive Collective Impact model, Carilion and United Way of Roanoke Valley brought together strategic community partners to create HRV. An initiative supported by United Way, HRV is now a partnership of more than 50 organizations striving to enhance health equity and create a “culture of wellness” across our region.

For years, HRV has served as a valuable partner with Carilion Clinic. The collaborative updates HRV’s strategic framework to align with the triennial CHA, a community-driven process and a significant component of Carilion’s Health Improvement Implementation Strategy for the Roanoke Valley. Through strategic planning in response to the 2018 RVCHA priorities, HRV identified four goals:

1. Reduce barriers to resources that address the social determinants of health 2. Expand access to quality care and support a culture of health 3. Encourage and support lifestyle behaviors that result in improved health and well-being 4. Support and advocate for natural and built environments that cultivate vibrant neighborhoods

Carilion provides in-kind support to HRV, with representatives active on the HRV steering committee and action teams focused on wellness, mental health, primary care, oral health and coordination of care.

Roanoke City and Alleghany Health Districts The RCAHD, under the VDH, serve the majority of the RVCHA service area. RCAHD has nine office locations across the service area, serving over 278,400 people. The district promotes and encourages healthy behavior, protects the public against environmental hazards, works to prevent epidemics and the spread of disease, responds to disasters, assists communities in recovery, and assures the quality and accessibility of health services for all community members20.

Through its population health management department, RCAHD focuses on the health of the entire population served by the health district and aims to reduce health inequities among specific groups. As a partner in the RVCHA, RCAHD works to identify health needs and the socioeconomic factors impacting the health of the community. In response to the CHA’s findings, RCAHD develops Community Health Improvement Plans to support health improvement across the service area21. Community Health Assessment Team (CHAT) Carilion Clinic’s CHAs are community-driven projects. Their success is highly dependent on the involvement of citizens, health and human service agencies, businesses, and community leaders. Stakeholder collaborations known as CHATs lead the CHAs. The CHATs are dynamic groups that include health and human service agency leaders, persons with special knowledge of, or expertise in, public health, the local health department officials. The CHATs obtain input from leaders, representatives or members of medically underserved populations who report low-income, are minorities and suffer from chronic disease. In the Roanoke Valley, the HRV Steering Committee serves as the CHAT along with additional key community leaders. CHAT Members and Area of Expertise This list includes members that attended at least half of the CHAT meetings.

Name Organization Area of Expertise Aaron Boush Carilion Clinic Hospitals, Healthy Food

Abby Hamilton United Way of Roanoke Collective Impact, Social Valley Determinants of Health Aisha Johnson City of Roanoke- Economic Economic Development Development

20 https://www.vdh.virginia.gov/roanoke/about-us/ 21 https://www.vdh.virginia.gov/roanoke/population-health/

Name Organization Area of Expertise Anne Marie Green Council of Community Community Development, Services Homelessness Ashley Trainque Craig County Health Center Federally Qualified Health Center

Bill Jones American National Bank Financial Well-Being Brandon Meginley City of Roanoke, Financial Financial Well-Being Empowerment Center

Brooke Crouch New Horizons Healthcare Primary Care Access/Healthy Communities Development Chance Welfare New Horizons Healthcare Primary Care Access/Healthy Communities Development Dave Prosser FreedomFirst Financial Well-Being

David Nova Blue Blaze Consulting Community Development

Debbie Bonniwell Blue Ridge Behavioral Mental Health, Substance Use, ID Healthcare Eileen Lepro New Horizons Healthcare Primary Care Access/Healthy Communities Development

Elizabeth (Beth) Leffel Leffel Consulting Group, LLC Medical Research

F.L. Slough Roanoke City Public Schools Schools

Hannah Adkins United Way of Roanoke Community Development, Public Valley Health

Isabel Thornton Restoration Housing Housing

Jeremy Holmes Roanoke Valley Alleghany Transportation Regional Commission Joanna Spar Roanoke County DSS Social Services Jojo Friday Sisters of Change Community and Business Development, Diversity, Inclusion Julie Phillips Botetourt County Libraries Library

Kim Roe Carilion Clinic Ambulatory Care Kristin Adkins Roanoke City & Alleghany Public Health Health Districts / VDH Lee Clark Rescue Mission Ministries, Health and Human Services for the Inc. Homeless Leslie Clark United Way of Roanoke Community Arm of CHA Valley, Healthy Roanoke Valley Leslie Loving Carilion Oncology Oncology

Name Organization Area of Expertise Linda Hentschel Family Service of Roanoke Mental Health Valley Lisa Denney Children's Trust Children Marilyn Herbert-Ashton Virginia Western Community Higher Education College Mary Ann Gilmer Goodwill Industries of the Community Development, Valleys Employment

Molly Roberts Carilion Clinic Public Health

Morgan Romeo Virginia Blue Ridge Works Workforce (Western VA Workforce Development/Community Planning Development Board) N.L. Bishop Carilion Clinic Equity, Diversity, Inclusion

Pam Chitwood United Way of Roanoke Community Impact, Food Insecurity Valley, Healthy Franklin County Pamela Irvine Feeding Southwest Virginia Food Insecurity Paula Prince Radford University Carilion Human Services/ Research/ Homelessness Rebecca Stackhouse VAMC Hospital Based Care

Robin Haldiman CHIP of Roanoke Valley Children and Families

Samara Lott Roanoke City & Alleghany Public Health Health Districts / VDH

Shirley Holland Carilion Clinic Hospitals, Community Development Steven Martin City of Roanoke - DSS Social Services Timothy Hahn Roanoke City Public Schools Schools Vivien McMahon United Way of Roanoke Community Impact Valley

Community Served Carilion Medical Center Principal Functions CMC, located in Roanoke, Virginia, includes Carilion’s flagship facility, Carilion Roanoke Memorial Hospital (CRMH), and Carilion Roanoke Community Hospital. CRMH includes a Level 1 Trauma Center, a Neonatal Intensive Care Unit, Carilion Children’s Hospital and 703 patient beds. Offering a wide range of inpatient and outpatient care, specialty care, medical education and fellowships, CRMH has gained recognition as Virginia’s top four hospital by U.S. News and World Report22. Additionally, Carilion Roanoke Community Hospital houses a highly skilled inpatient rehabilitation unit. Geographic Area The service areas for Carilion Clinic’s CHAs are determined by 70-80% of unique patient origin of the hospital in each respective market. Focus is placed on areas that are considered Medically Underserved Areas (MUAs) and Health Professional Shortage Areas (HPSAs).

In fiscal year 2020, CMC served 121,095 unique patients. Patient origin data revealed that during this year, 74% of patients served by CMC lived in the following localities:

• Roanoke City (27.5%) • Roanoke County (19%) • Franklin County (8.8%) • Botetourt County (7.4%) • Salem (5.6%) • Bedford County (5.1%) • Craig County (0.7%)

22 https://www.carilionclinic.org/locations/carilion-roanoke-memorial-hospital

The service area for the 2021 RVCHA includes the cities of Roanoke and Salem and the counties of Bedford, Botetourt, Craig and Roanoke, with secondary data included for Franklin County. Franklin County is partly served by Carilion Franklin Memorial Hospital (CFMH) located in Rocky Mount, Virginia. CFMH also conducted its own CHA of Franklin and Henry counties concurrently, so Franklin County is not included as part of the service area for the 2021 RVCHA. Franklin County data are included in secondary data so complete data for the Metropolitan Statistical Area (MSA) will be available in this report. Please note that while Bedford County is included in the service area, it is not part of the Roanoke MSA. Carilion participates in the Bedford Region Community Health Needs Assessment with neighboring Centra Health System. Target Population The target population for Carilion Clinic’s CHA projects consists of underserved/vulnerable populations disproportionately impacted by the social determinants of health, including poverty, race/ethnicity, education, access and/or lack of insurance. Populations are examined across the different life cycles, including parents of children and adolescents, women of child-bearing age, adults, and the elderly. They are also studied across various race and ethnic groups and income levels. All patients are included in this assessment regardless of insurance payments or financial assistance eligibility. Service Area Demographics The Roanoke MSA, home to Carilion Clinic’s flagship hospital CRMH, is commonly known as the Roanoke Valley. It is composed of the independent cities of Roanoke and Salem and the counties of Botetourt, Craig, Franklin and Roanoke. The Valley is nestled among the Blue Ridge Mountains with the City of Roanoke at its heart. Roanoke is a destination place, rich in cultural diversity, the arts, shopping, recreational opportunities, natural beauty and services not available in more rural areas of the region.

In addition to Carilion, key safety net providers in the region include Veterans Administrations, a federally qualified health center, free clinics, local offices of the VDH and other service organizations. Despite these entities’ presence, however, thousands of low-income, uninsured and underinsured residents do not have access to affordable health care services.

The Roanoke Valley is comprised of distinct communities with significant disparities in size, population and social determinants of health. The 2015-2019 American Community Survey (ACS) found the Roanoke MSA’s total population to be 313,009. The cities of Roanoke and Salem had 99,229 residents and 25,317 people, respectively. The counties of Botetourt, Craig, Franklin and Roanoke had 33,343, 5,110, 56,187 and 93,823 residents, respectively. The median age in the MSA localities ranges from 37.8 in the City of Roanoke to 47.2 in Craig and Franklin Counties, all above the state median of 38.223. The Weldon Cooper Center for Public Service predicts positive population change by 2040 for all communities except Craig County, which may have very slight population loss 24. The ACS finds that for most of the Roanoke MSA, a more significant percentage of the population is White than in the Commonwealth of Virginia as a whole, with rates ranging up to 98.6% in Craig County25.

23 U.S. Census Bureau, 2015-2019 5-year American Community Survey, Table S0101, https://data.census.gov/cedsci/table?q=S0101&tid=ACSST5Y2019.S0101&hidePreview=true. 24 Weldon Cooper Center for Public Service, https://demographics.coopercenter.org/virginia-population-projections. 25 U.S. Census Bureau, 2015-2019 5-year estimates, American Community Survey, Table DP05, https://data.census.gov/cedsci/table?tid=ACSDP5Y2019.DP05&hidePreview=true.

The Roanoke Valley’s urban hub, the City of Roanoke, is more racially and ethnically diverse than the rest of the MSA. Roanoke’s population is 62.4% White, 29.0% Black and 3.0% Asian, with 4.4% representing more than one race. The remainder represents small minorities of American Indian/Alaskan Native, Native Hawaiian/Pacific Islander or some other race. Of the population, 6.3% are Hispanic or Latino26.

The city is divided into quadrants (Northwest, Northeast, Southwest and Southeast) separated geographically by railroad tracks, the Roanoke River and Interstate 581. These quadrants vary significantly in the demographic and economic make-up of their residents. Specifically, two of the quadrants—Northwest and Southeast—have federal designations as MUAs. The quadrants are home to a large proportion of the low-income individuals and families in the city who may be uninsured, underinsured or are Medicaid recipients facing additional barriers due to cultural differences.

26 U.S. Census Bureau, 2015-2019 5-year estimates, American Community Survey, Table DP05, https://data.census.gov/cedsci/table?tid=ACSDP5Y2019.DP05&hidePreview=true.

Community Health Assessment Process Identification of Significant Health Needs Carilion Clinic, HRV and the RCAHD led the efforts to conduct the 2021 RVCHA. A 43-member CHAT oversaw the planning activities.

The CHAT meets four times throughout the process, with each meeting serving a distinct purpose. See Appendix 1, Gantt Chart, for specific meeting dates.

• Meeting 1: Introduction and Overview of the Process • Meeting 2: Stakeholder Focus Group • Meeting 3: Data Review and Discussion • Meeting 4: Prioritized Needs Discussion

Each meeting builds on the one prior and fosters interactive dialogue amongst CHAT members. Due to the impact of COVID-19, all CHAT meetings were held virtually via WebEx.

Significant community health needs were identified utilizing the following:

• Community Health Survey (Appendix 2) • Stakeholder Survey and CHAT Focus Group (Appendix 3) • Data Review

Further details are provided in the Data Collection and Analysis section. The main criteria for determining the significance of a need were its presence as a top need through a high percentage of Community Health Survey respondents, high percentage of stakeholder survey respondents, and/or notable worsening trends in either primary or secondary data.

To better understand the specific needs of those with cancer, the Community Health Survey was also filtered to show results from respondents who self-identified as having cancer or once having cancer. Their results can be found in Appendix 9.

To identify significant health needs in particular parts of the community, additional detail was provided where feasible to make comparisons by county, gender, race and age. In the third CHAT meeting (Data Review), Roanoke City data was compared to the overall service area data to identify needs that may be an issue in the City but did not affect the service area at large. Prioritization of Significant Health Needs After all primary and secondary data collection is complete, the CHAT reviews all data and participates in a prioritization activity. Each CHAT member selects and ranks the ten most pertinent community needs. The data are combined, and priorities are selected based on the highest weighted score of each need. Please see Appendix 4 to view the prioritization worksheet.

Through this process, needs are prioritized by the CHAT members according to:

• The perceived burden, scope, severity or urgency of the health need • The importance the community places on addressing the need through survey responses and other interactions

• Their own unique perspective on the health-related needs of the community

Identification of Resources to Address Needs The CHAT members were integral in identifying resources to address needs. During the Stakeholder Focus Group and subsequent survey, the CHAT was asked to provide feedback on what health resources exist in the service area. The list was compiled from their responses, and additional resource lists that have since been identified have also been included. Please see Appendix 5 for the full resource list.

Community Input Hearing voices from across our service area is crucial to the success of a CHA. Broad-interest community reach is a main qualification when inviting individuals to join the CHAT. In addition to the HRV Steering Committee, we also invite representatives from the RCAHD, local governments, the local school system, social service organizations, and other community organizers and nonprofit leaders.

The RCAHD was engaged from the beginning of the planning process (late spring of 2020) all throughout the assessment period and fourth CHAT meeting—despite navigating the pandemic of a lifetime. RCAHD’s involvement helped shape all aspects of this assessment. Its team identified community partners to serve on the CHAT, provided discussion points during the first CHAT meeting and offered feedback on the prioritized needs. Additionally, RCAHD representatives were active on the CHAT, participating in the Stakeholder Survey, CHAT focus group and prioritization activity.

In addition to RCAHD, the CHAT included other individuals or organizations serving or representing the community’s medically underserved, low-income and minority populations. Examples include:

• Free clinics (e.g., Bradley Free Clinic, Fralin Free Clinic) • Federally Qualified Health Centers (e.g., New Horizons Healthcare) • Social service agencies (e.g., Roanoke County Department of Social Services) • The United Way of Roanoke Valley • Hospitals, physicians

These organizations and individuals helped gather community input by distributing the Community Health Survey. CHAT member input was solicited through the Stakeholder Survey and Focus Group. Combined, these efforts led to the identification and prioritization of community health needs.

Target population focus groups are typically a significant way in which we collect community input, especially for those who are medically underserved, under-resourced or have disadvantages related to health needs. The COVID-19 pandemic impacted our ability to gather in groups and created logistical barriers for these focus groups. The CHAT decided that these focus groups would not be possible for the 2021 assessment due to resource and logistical strains.

The 2018 RVCHA and the subsequent Implementation Strategy were posted publicly though multiple electronic channels and shared widely by community partners. An email address was provided for submission of written comments, but none were received.

Community Impact Impact of Actions Taken in Response to 2018 RVCHA Carilion Clinic responds to community health needs in innovative ways. Our initiatives include:

• Having a robust primary care physician practice network of medical homes • Making sure our regions have access to state-of-the-art health care close to home • Providing community grants and sponsorships to extend our mission and support other organizations that address health need • Creating and implementing community-wide strategies to reduce barriers, coordinate resources and enhance community strengths • Providing community-based health and wellness programming

In our commitment to improving the health of the communities we serve, Carilion has focused on projects to improve health in the MUAs of Southeast and Northwest Roanoke City. Southeast neighborhoods border our flagship hospital, CRMH. Much of Carilion’s health programming and grant giving has focused on Southeast in recent years. In Northwest, Carilion now has a Community Health Worker (CHW) at the Roanoke EnVision Center, a one-stop hub that helps low-income residents access important community resources. The CHW helps connect individuals with services like transportation, mental health and substance abuse treatment, housing, clothing, food and more. We continue to explore opportunities to invest in these neighborhoods in ways that will impact health and social determinants.

With the onset of COVID-19, Carilion immediately recognized the prominent role we would play in both prevention and treatment for our region. The pandemic demanded a shift in operations and priorities during Virginia’s stay-at-home order. While some of our Implementation Strategies were delayed or altered, Carilion quickly responded to the new and unique social health needs arising from COVID-19.

Community response efforts included establishing a community hotline and recovery support phone line, expanding flu shot distribution, and broad community health education and guidance. We also made it our mission to ensure the safety and well-being of patients at higher risk of severe infection from COVID-19 through targeted outreach programs. The Home Alone project, for example, connected senior patients who were living alone with resources such as food, masks, medications and toiletries. Patients with more complex social needs were escalated to CHWs and those with more complex health needs were escalated to a nurse. Care kits and information were also provided to Housing Authority sites that specifically housed older adult populations. Home Alone reached a total of 1,651 high-risk patients across Carilion’s footprint, allowing seniors to stay home safely, avoid the hospital and reduce their exposure to COVID-19.

As COVID-19 vaccinations became available, Carilion once again shifted operations to convene regular mass vaccination clinics in Roanoke City, Franklin County and surrounding parts of the Carilion service area. Since December 2020, we've partnered with local health departments and authorities across our region to aid in the fight against COVID-19. From our very first mass vaccination clinic at the Berglund Center to assisting with smaller clinics at churches, parks and community centers, Carilion staff and volunteers have administered hundreds of thousands of COVID-19 vaccine doses to our communities. Each dose moves us one step closer to getting the pandemic under control.

To improve health behaviors, over 960 health education events, programs, screenings or immunizations have nearly 16,000 people in response to the 2018 RVCHA identified needs. CMC also awarded more than 40 community grants to support organizations across the Roanoke Valley working to address those needs.

The Pathways Community HUB, a program in partnership with the United Way that connects uninsured patients to social services through CHWs, has grown. CHWs are now housed in three Roanoke-area medical offices and can receive referrals from the CRMH Emergency Department. Carilion is also planning to expand CHW work across the Roanoke area.

Medicaid expansion continues to increase access to health services across the region. With commitment to continued enrollment in Medicaid and other applicable public programs, Carilion has partnered with MedAssist, a contractor dedicated to determining eligibility and assisting with all aspects of enrollment for eligible patients and community members. Enrollment not only allows access to Carilion services, but to additional dental and mental health services across the community as well.

The #ALLin program and Peer Recovery Services were launched to provide mental health awareness and education helping those with addiction and mental health conditions move towards recovery. Through these programs, CMC operates an ED Bridge to Treatment program connecting patients to substance use treatment, has established a mental health collaborative in the Roanoke Valley, and trains community members to utilize Narcan. The Peer Recovery Center, established in 2019, has become a trusted space for individuals struggling with addiction, mental health issues or in need of support.

Data Collection and Analysis Methods Primary and secondary data were collected for the 2021 RVCHA. Additionally, billing data from Carilion Clinic on hospital admissions and emergency department visits for residents within the service area helped corroborate perceived community needs with the clinical conditions being seen at the hospital. Primary data collection included the Community Health Survey, the Stakeholder Focus Group and the Stakeholder Survey. Both primary and secondary data were shared for review with the CHAT in advance of the third CHAT meeting. Community Health Survey A Community Health Survey was conducted as part of the RVCHA. This survey was used to evaluate the health of the community and identify potential geographic areas to target improvements. Input and oversight of survey development was provided by the CHAT and a planning group consisting of representatives from Carilion, HRV and the RCAHD.

A 38-question survey instrument was initially developed in 2011 and updated in 2020 that asked questions about socioeconomic factors, healthy behaviors, physical environment, health outcomes, demographics and access to medical, dental and mental health care (Appendix 2: Community Health Survey). The survey instrument included commonly used questions and metrics from the following established community surveys:

• Community Themes and Strengths Assessments, National Association of County and City Health Officials (NACCHO), Mobilizing for Action through Planning and Partnerships (MAPP) • Community Healthy Living Index, YMCA • Behavioral Risk Factor Surveillance System, CDC • National Health Interview Survey, CDC • Youth Risk Behavior Surveillance System, CDC • Martin County Community Health Assessment, Martin County, North Carolina • Previous Roanoke Valley Community Health Surveys

The population of interest for the survey was Roanoke Valley residents 18 years of age and older. The Roanoke Valley includes the RVCHA service area of Bedford County, Botetourt County, Craig County, Roanoke County, Roanoke City and Salem City. Surveys were distributed from October 2020 through January 2021. A drawing for two $100 grocery store gift cards was offered as an incentive for those completing the survey.

The following subpopulations were especially targeted for sampling:

• Underserved/vulnerable populations disproportionately impacted by the social determinants of health, including: o Poverty o Race/ethnicity o Education o Lack of insurance A non-probability sample method was used, where respondents were not randomly selected. Although the survey was available to all residents living in the Roanoke Valley, oversampling of the targeted

subpopulations was attempted through specific outreach efforts through community partners. Despite oversampling efforts to ensure that needs and assets specific to this subpopulation of interest were captured, survey demographic results indicate a lower-than-expected response from these groups.

The survey instrument was available in both English and Spanish via the following methods:

• Survey Monkey link (www.surveymonkey.com/r/2018CHA) • Phone line (888-964-6620) • Paper surveys (collected by volunteers and/or staff of partner agencies)

Outreach strategies for survey distribution included:

• Media coverage by the local television and newspaper announcing the URL for the survey • Facebook, including geographically targeted advertisements • Flyers and posters distributed throughout the community with survey URL and phone line information • Survey URL posted on partner agency websites

Due to the impact of COVID-19 on face-to-face interactions, electronic survey completion was emphasized. Although paper surveys were distributed, they represented a lesser share of responses than in prior assessment periods.

In total, 1,560 surveys were collected.

• 183 paper surveys • 1,376 online surveys • 1 phone survey

All responses were entered into Survey Monkey by survey respondents or by Carilion Direct representatives, who entered responses from paper or phone surveys. Surveys were analyzed and reported using Survey Monkey and Microsoft Excel.

Survey results for respondents who have self-identified as having cancer or once having cancer can be found in Appendix 9. Stakeholder (CHAT) Focus Group The second CHAT meeting consisted of a Stakeholder Focus Group with the CHAT members. The questions discussed were identical to those included in the Stakeholder Survey (Appendix 7: Stakeholder Survey). Carilion Clinic staff from across the organization aided in facilitating small group discussions. In order to quantify focus group data, CHAT members were asked to complete the Stakeholder Survey.

An additional Stakeholder Focus Group was held with CMC’s Clinical Advancement and Patient Safety Committee as a representative of the CMC Board of Directors. These participants were also asked to complete a Stakeholder Survey to quantify data from the discussion. Stakeholder Survey Throughout the RVCHA process, community stakeholders, leaders and providers were encouraged to complete the Stakeholder Survey (Appendix 3: Stakeholder Survey). This survey provided an additional perspective to the needs and barriers to health facing our community. The survey was available online

and was shared at the CHAT meetings and via email. Surveys were analyzed and reported using Survey Monkey and Microsoft Excel. Secondary Data Secondary data was collected through SparkMap, a University of Missouri product that quickly and accurately aggregates data across geographies for 80+ indicators from publicly available sources such as the ACS, County Health Rankings and the VDH. Secondary data analysis was provided through SparkMap’s tables, maps and visual diagrams depicting indicators that are better or worse than the state average, trends over time, and comparisons across different population segments such as race and life cycle. See Appendix 7 for full secondary data report from SparkMap.

While SparkMap was the main source of secondary data, additional sources were utilized. The VDH’s Equity Dashboard was utilized for an overview and analysis of equity in the Roanoke Valley.

Collaboration

Forming a true community collaborative with lasting impact is no small feat. In response to the 2012 RVCHA, HRV was formed to foster cohesive community development between partners using the Strive Collective Impact Model27. This evidence-based model focuses on “the commitment of a group of important players from different sectors to a common agenda for solving a specific social problem” and has been proven to lead to large-scale change.

Collective impact focuses on four conditions for collective success:

1. A Shared Community Vision: a broad set of cross-sector community partners come together in an accountable way to implement a vision for a healthier community and communicate that vision effectively.

2. Evidence-based Decision-Making: The integration of professional expertise and data to make decisions about how to prioritize a community's efforts to improve health outcomes.

3. Collaborative Action: the process by which networks of appropriate cross-sector services/providers use data to continually identify, adopt and scale practices that improve health outcomes.

4. Investment & Sustainability: There is broad community ownership for building civic infrastructure and resources are committed to sustain the work of the partnership to improve health outcomes. Collective Impact also suggests having a neutral anchor institution to serve as the convening body for community collaborative.

To ensure long-term impact of the health assessment and resulting community health improvement process implementation, Carilion funds and plays a key role in HRV and supports United Way serving as the anchor institution in the Roanoke Valley. This collaboration earned national attention as a recipient of the 2020 American Hospital Association’s Dick Davidson NOVA Award, an honor awarded annually to five hospital-led collaborations improving community health.

The 2021 RVCHA would not have been possible without collaboration with HRV and the RCAHD. In addition, teamwork across all CHAT members was critical to the success of this project.

27 Kania, J., & Kramer, M. (2011). Collective Impact. Stanford Social Innovation Review. https://ssir.org/images/articles/2011_WI_Feature_Kania.pdf

Data Review In the following sections, data will be presented in a variety of formats to illustrate some of the relevant issues impacting the community’s health. Higher rates of chronic diseases, cancers and many socioeconomic factors exist across the service area to varying degrees when compared with the Commonwealth of Virginia as a whole. Where tables exist, red text indicates a value worse than the Virginia average. Clinical Data Chronic Diseases in Residents of the Roanoke Valley from Secondary Data Sources In review of secondary data for chronic disease, most Roanoke Valley localities have higher rates of chronic diseases than Virginia overall. Notably, the percentage of adults with asthma in Roanoke City is the highest across the service area at 10.1%, compared to Virginia’s 8.9%. Table C1 shows the percentage of adults with a subset of chronic diseases across the service area according to the CDC’s Behavioral Risk Factor Surveillance System.

Diabetes and obesity are variable across the service area. Botetourt and Craig Counties have the lowest rates of diabetes at 4.3% and 5.5%, respectively. This compares to Virginia’s overall rate of 9.7% and the highest rate in the service area of 14.5% in Salem. Adult obesity, defined by a Body Mass Index greater than 30, ranges from a low of 27.6% in Craig County to a high of 39.8% in Franklin County. Virginia’s overall rate is 30.4%. See Table C2 for details.

Table C1. Chronic Diseases Across Roanoke Valley Service Area

Locality Percentage of Adults Percentage of Adults Ever Percentage of Adults Ever Percentage of Adults Percentage of Adults with Asthma Diagnosed with Chronic Diagnosed with Coronary Ever Having a Stroke with High Blood Lower Respiratory Disease Heart Disease Pressure

Roanoke Valley 9.26% 8.33% 7.99% 3.85% 36.88% Service Area Bedford County 9.0% 8.2% 7.8% 3.7% 37.3% Botetourt County 8.8% 8.1% 8.0% 3.6% 35.5% Craig County 9.0% 8.8% 8.4% 3.8% 37.3% Franklin County 9.6% 9.9% 9.5% 4.4% 39.6% Roanoke County 8.6% 7.3% 7.5% 3.4% 33.9% Roanoke City 10.1% 8.8% 8.0% 4.3% 39.4% Salem City 9.1% 7.4% 7.0% 3.3% 32.5% Virginia 8.9% 6.6% 6.4% 3.2% 32.2% United States 9.5% 7.2% 6.9% 3.4% 32.9%

Data Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System. Accessed via the 500 Cities Data Portal. 2018. Accessed via SparkMap

Table C2. Diabetes and Obesity for Roanoke Valley Service Area Adults with Diagnosed Diabetes, Age- Adjusted Adults with BMI > 30.0 (Obese), Percent Report Area Rate Roanoke Valley Service Area 10.8% 33.4% Bedford County 11.9% 33.4% Botetourt County 4.3% 28.5% Craig County 5.5% 27.6% Franklin County 12.5% 39.8% Roanoke County 11.1% 29.7% Roanoke City 11.0% 35.9% Salem City 14.5% 31.3% Virginia 9.7% 30.4% United States 9.5% 29.5% Data Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2017. Source geography: County. Accessed via SparkMap.

Chronic Diseases in Patients Seeking Care at Carilion Medical Center by Zip Code The Virginia Hospital and Healthcare Association (VHHA) analyzes hospital discharge data for patients with specific chronic diseases (diabetes, kidney disease, hypertension, heart disease, stroke, hyperlipidemia and heart failure). Diseases selected are based on VHHA funding requirements. In review of this data, a trend of zip codes with high shares of chronic disease was determined. Across the Roanoke Valley, the following zip codes continued to rise to the top: 24012, 24017, 24179, 24014, 24019, 24153, 24018, 24151, 24016 and 24013. Overall, these 10 zip codes account for roughly 50% of all admissions flagged with the included chronic disease.

Zip code 24012 has the largest percentage of all chronic diseases examined by VHHA at CMC, despite not being the largest share of the population within the service area. Zip codes 24016 and 24013 were also consistently in the top 10 despite their small share of the population, each with populations below 10% of the total Roanoke Valley service area size. These statistics shed light on zip codes that may be experiencing disproportionate health-related challenges in the Valley. See Table C3 for details.

Table C3. Chronic Disease Discharges, Carilion Medical Center data via Virginia Hospital and Healthcare Association Kidney Heart Heart Diabetes Hypertension Stroke Hyperlipidemia Disease Disease Failure Total Discharges (2016-2020) 32,327 35,451 66,953 27,482 4,925 46,818 22,657 Zip Code Percent of t ot al 24012 8% 9% 8% 8% 8% 8% 9% 24017 7% 6% 6% 5% 5% 5% 6% 24179 6% 6% 5% 6% 5% 6% 6% 24014 5% 5% 5% 5% 5% 5% 5% 24019 5% 5% 5% 5% 5% 5% 5% 24153 5% 5% 5% 5% 4% 5% 5% 24018 5% 5% 6% 5% 5% 6% 6% 24151 4% 4% 4% 4% 3% 4% 4% 24016 3% 3% 3% 2% 3% 2% 3% 24013 3% 3% 3% 3% 2% 3% 3% Data Source: Virginia Hospital and Healthcare Association

Chronic Diseases in Carilion Patients Residing in the Roanoke Valley, Medical Billing Data As the primary source of medical care in the Roanoke Valley, Carilion leverages internal data for insights on the health of the community. Data on inpatient admissions point to some service lines with preventable aspects as top reasons for seeking care. Cardiology, for example, includes heart attacks and heart failure, conditions which can be largely impacted through behaviors and lifestyle. Other Medical, the top service line for admissions, includes systemic issues such as sepsis, urinary tract or kidney issues, ear, diseases of the ear, nose and throat, blood and immune disorders, and diseases of the subcutaneous tissue. Data on emergency department visits for Roanoke Valley residents shows the top category is injuries (broadly). Here we see an opportunity for decreased emergency department visits through education. Table C4 and Table C5 provide further detail on admissions and emergency department visits.

When considering only patients identified through the medical record as Hispanic, Mother Baby/GYN accounted for well over 55% of all admissions each year from FY2017-FY2020 ranging from a low of 55% in FY19 to 58% in FY20. This includes admissions for delivery, newborn stays and neonatal admissions. The large percentage of admissions in this service line indicate that Hispanic patients are admitted for other service lines less frequently than the overall patient population, indicating potential gaps in care.

Table C4. Top 10 Inpatient Admission Service Lines for Roanoke Valley Patients Service Line FY2017 FY2018 FY2019 FY2020 IP Mother Baby/GYN 16.72% 16.80% 17.08% 19.02% IP Other Medical 17.39% 18.69% 18.13% 17.53% IP Cardiology 10.41% 10.47% 11.25% 11.51% IP Neurology 7.51% 7.83% 7.71% 7.77% IP Behavioral Health 9.63% 8.79% 8.53% 7.55% IP Pulmonary 6.92% 7.24% 7.33% 7.55% IP Orthopedics 8.00% 7.53% 7.66% 6.73% IP GI 6.30% 6.33% 6.28% 5.92% IP Other Surgery 5.17% 4.79% 4.57% 5.10% IP Pediatrics 3.92% 3.39% 3.37% 2.65% Data Source: Strata

Table C5. Top 10 Emergency Department Visits for Roanoke Valley Patients ICD-10 Category FY2017 FY2018 FY2019 FY2020 Injury, poisoning, and certain other consequences of external causes 17.45% 16.78% 16.49% 16.74% Diseases of the respiratory system 9.11% 9.86% 9.35% 9.13% Symptoms, signs, and abnormal clinical laboratory findings, not elsewhere classified 8.37% 7.98% 7.95% 8.17% Diseases of the digestive system 7.12% 7.04% 7.09% 7.25% Diseases of the circulatory system 6.52% 6.51% 6.82% 7.23% Diseases of the musculoskeletal system and connective tissue 7.96% 8.04% 7.80% 7.19% Symptoms, signs, circulatory and respiratory 7.22% 7.14% 6.91% 6.90% Mental, behavioral and neurodevelopmental disorders 5.22% 5.41% 5.74% 6.09% Symptoms, signs, digestive and abdomen 6.94% 6.83% 6.24% 5.88% Diseases of the genitourinary system 5.04% 5.19% 5.22% 5.09% Data Source: Strata

Cancer While most Roanoke Valley localities have a breast cancer rate similar to Virginia’s rate of 127.4 cases per 100,000 people, Roanoke County and Salem stand out as having higher rates of 138.8 and 144.3 cases per 100,000 people, respectively28. When analyzing rates by race, Black residents in Franklin County have a higher incidence of breast cancer at 152.9 per 100,000 people compared to 118.3 per 100,000 people reporting white race. Black residents in Roanoke County have a lower incidence of breast cancer at 117.6 per 100,000 people compared to 138.3 per 100,000 people reporting white race.

Colorectal cancer rates across the Roanoke Valley are higher in comparison to Virginia’s incidence rate, with the exception of Roanoke County. Franklin and Craig Counties have the highest colorectal cancer rates across the service area at 45.7 and 52.3 cases per 100,000 people, respectively. When analyzing

28 State Cancer Profiles. 2013-17. Source geography: County. Accessed through SparkMap.

rates by race, Black residents in Franklin County have a higher incidence of colorectal cancer at 61.9 per 100,000 people compared to 43.9 per 100,000 people reporting white race29.

Lung cancer rates are variable across the Roanoke Valley. Rates range from a low of 52.7 cases per 100,000 in Roanoke County to 74.3 cases per 100,000 people in Roanoke City, with Virginia’s overall rate of 56.4. When analyzing rates by race, Black residents in Roanoke County have a higher incidence of lung cancer at 67.9 per 100,000 people compared to 52.1 per 100,000 people reporting white race30. See Table C6 for breast, colorectal and lung cancer incidence rates by locality.

Table C6. Cancer Incidence Rates by Locality, 2013-2017 Cancer Incidence Rate Breast Cancer Incidence Colorectal Cancer Lung Cancer Incidence Rate Locality (Per 100,000 Population) Rate (Per 100,000 Incidence Rate (Per (Per 100,000 Population) Population) 100,000 Population) Roanoke Valley Service 444.3 129.7 40.5 61.5 Area Bedford County 434.9 126.0 38.9 59.8 Botetourt County 427.2 127.6 40.5 57.7 Craig County 425.4 120.4 52.3 55.1 Franklin County 412.5 120.3 45.7 58.2 Roanoke County 441.5 138.8 33.4 52.7 Roanoke City 466.1 123.5 44.2 74.3 Salem City 485.7 144.3 40.6 67.6 Virginia 416.1 127.4 35.2 56.4 United States 448.7 125.9 38.4 58.3 Data Source: State Cancer Profiles. 2013-17. Source geography: County. Accessed via SparkMap.

29 State Cancer Profiles. 2013-17. Source geography: County. Accessed through SparkMap. 30 State Cancer Profiles. 2013-17. Source geography: County. Accessed through SparkMap.

Vital Conditions for Well-Being In addition to addressing the social determinants of health, we are utilizing a framework for viewing health and well-being through seven vital conditions. The WIN Network’s Vital Conditions for Well-Being emphasize the health and well-being of people and places as a necessary component to thrive31. Below we describe each vital condition and present a subset of related data.

Vital Condition: Basic Needs for Health & Safety Basic needs for health and safety include factors like access to physical and mental health care services, nutritious foods, and freedom from addiction, trauma and crime32. The subset of indicators provided below paints a picture of some of the potential barriers across the Roanoke Valley in meeting these basic needs. Additionally, we can pinpoint specific areas within the region that are likely to have more gaps in basic needs based on lower life expectancy.

Life Expectancy Disparities in life expectancy are widespread across the Roanoke Valley, ranging from 71.3 years in Franklin County’s census tract 203 to over 81 years in census tracts throughout Bedford, Botetourt and Roanoke Counties. With the exception of census tract 29 (South Roanoke), Roanoke City has some of the lowest life expectancy values across the Valley. Census tract 26 in Southeast Roanoke City has the lowest life expectancy at 68.4 years.

Map V1. Life Expectancy by Census Tract, Roanoke Valley Service Area

Data Source: Centers for Disease Control and Prevention and the National Center for Health Statistics, U.S. Small-Area Life Expectancy Estimates Project. 2010-15. Source geography: Tract. Accessed via SparkMap.

31 https://winnetwork.org/vital-conditions 32 https://thriving.us/wp-content/uploads/2020/07/Springboard-Main-Narrative-For-Print-.pdf

Map V2. Life Expectancy Detail, Urban Hub of Roanoke Valley Service Area

Health Professional Shortage Areas A shortage of health professionals is a barrier to care that contributes to poor outcomes. In the Roanoke Valley service area, HPSAs exist for primary care, dental and mental health services. Primary care HPSAs exists in the counties of Bedford, Craig and Franklin, Northern Botetourt County, and Northwest Roanoke City. Dental HPSAs exist in Bedford County and Craig County, and specifically related to low- income populations in Franklin County, Northern Botetourt County, Roanoke County, Roanoke City and Salem. Mental health HPSAs exist in Craig and Botetourt Counties, and for the low-income populations in Bedford, Franklin, and Roanoke Counties and the Cities of Roanoke and Salem33. This supports the need for expanded access to providers, with specific emphasis on the low-income population.

Drug Overdose Higher rates of drug overdoses exist in much of the Roanoke Valley than in Virginia overall, seen through both opioid overdose mortality and drug poisoning (all drugs) mortality.

Chart V1. Posioning and Drug Overdose Mortality, Roanoke Valley Service Area

33 https://data.hrsa.gov/tools/shortage-area/hpsa-find

Table V1. Posioning and Drug Overdose Mortality, Roanoke Valley Service Area

Poisoning Age-Adjusted Death Rate (Per Opioid Overdose Age-Adjusted Death

Report Area 100,000 Pop.), 2015-2019 Rate (Per 100,000 Pop.), 2015-2019

Roanoke Valley Service Area 25.4 19.0

Bedford County 16.9 10.4

Botetourt County 15.3 No data

Craig County No data No data

Franklin County 25.5 18.0

Roanoke County 22.1 15.6

Roanoke City 38.0 29.1

Salem City 27.9 20.4

Virginia 17.6 13.4

United States 21.6 13.7

Data Source: Centers for Disease Control and Prevention, National Vital Statistics System. Accessed via CDC WONDER. 2015-2019. Source geography: County. Accessed via SparkMap.

Binge Drinking Binge drinking across the service area is higher in areas of Franklin and Roanoke Counties than other areas of the Valley. Rates tend to be higher in areas with higher income and lower poverty.

Map V3. Adults (age 18+) Binge Drinking by Census Tract, Roanoke Valley Service Area

Data Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System. Accessed via the 500 Cities Data Portal. 2018. Accessed via SparkMap.

Food Insecurity Prior to the pandemic, food insecurity had been at its lowest level in 20 years according to statistics provided by Feeding America. Due to income losses during this time, food insecurity is projected to increase for 2020 and 202134. Additionally, while COVID-19 relief funding has been available to nonprofit organizations addressing food insecurity, it is an unreliable funding stream. It is reasonable to expect that insecurity will persist long after the funding ends.

Table V2. Food Insecurity Rate, Roanoke Valley Service Area Food Insecurity Rate (Overall) Food Insecurity Rate (Children) Bedford 9.1% 10.7% Botetourt 7.7% 8.4% Craig 10.6% 10.8% Franklin 10.8% 15.2% Roanoke City 13.4% 19.3% Roanoke County 8.2% 8.3% Salem 10.1% 11.0% Virginia 9.4% 11.5% Data source: Feeding America Map the Meal Gap 2019

Resource Requests to Virginia 211 Virginia 211 is a free service that helps connect people to resources they need. An initiative of the Department of Social Services and partners, Virginia 211 is available online, by phone call or by text message. The data dashboard is a useful tool to see what basic needs are not being met in individuals across the commonwealth.

Of all requests in the last year for the Roanoke Valley service area, over 30% have been related to housing. Within that category, over half of requests have been related to rent assistance. This overlaps with humane housing vital condition and is a great example of how these conditions are interrelated.

Figure V1. Resource Requests to Virginia 211, June 2020-June 2021, Roanoke Valley Service Area

Data Source: https://va.211counts.org/

34 https://feedingamericaaction.org/resources/state-by-state-resource-the-impact-of-coronavirus-on-food- insecurity/

Broadband Access Access to the internet is an increasingly important requisite for accessing information and health and social services. Many areas across Virginia suffer from inadequate access. According to the Integrated Broadband Planning and Analysis Toolbox by Virginia Tech’s Center for Geospatial Information Technology, there are pockets within the Roanoke Valley that are considered unserved—a definition based on low or no upload and download speeds35. Roanoke City, Roanoke County and Salem are not considered unserved, but many unserved areas exist across the counties of Craig, Bedford, Botetourt and Franklin, indicated by the dark red sections on the following maps.

35 Virginia Tech Virginia Broadband Availability Map and Integrated Broadband Planning and Analysis Toolbox, accessed via https://broadband.cgit.vt.edu/IntegratedToolbox/#about

Map V4. Areas Unserved by Broadband, Roanoke Valley Service Area by Locality Craig County Bedford County

Botetourt County Franklin County

Data Source: https://broadband.cgit.vt.edu/IntegratedToolbox/#about

Vital Condition: Lifelong Learning Lifelong learning is defined as continued education, learning and literacy36. Higher levels of education tend to be reflective of better health status and health outcomes, emphasizing the importance of the data presented below and its impact on health and well-being.

Educational Attainment Education is a predictor of health outcomes and economic stability. Understanding the educational attainment for an area is key to developing a strong labor force and economic development. The table below shows educational attainment across the service area. Roanoke City stands out with a higher percentage of the population without a high school diploma compared with Virginia, while the entire area has higher percentages of the population with a high school diploma only and no post-secondary education.

Table V3. Educational Attainment, Roanoke Valley Service Area No High High Graduate or Some Associates Bachelors Report Area School School Professional College Degree Degree Diploma Only Degree

Roanoke Valley Service Area 10.5% 30.8% 20.5% 10.2% 17.4% 10.6%

Bedford County 9.98% 30.2% 21.8% 8.8% 17.4% 11.8%

Botetourt Count 7.24% 32.3% 20.7% 11.4% 17.2% 11.2%

Craig County 9.17% 37.5% 17.7% 12.0% 16.2% 7.4%

Franklin County 11.88% 34.9% 21.2% 10.1% 13.5% 8.3%

Roanoke County 7.67% 25.0% 19.7% 12.1% 22.8% 12.8%

Roanoke City 13.81% 34.1% 19.7% 9.0% 14.4% 9.0%

Salem 10.85% 29.0% 20.9% 11.4% 17.3% 10.6%

Virginia 10.31% 24.0% 19.2% 7.8% 22.0% 16.8%

United States 12.00% 27.0% 20.4% 8.5% 19.8% 12.4% Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: County. Accessed via SparkMap.

36 https://thriving.us/wp-content/uploads/2020/07/Springboard-Main-Narrative-For-Screen-2.pdf

Preschool Enrollment Preschool enrollment is an important indicator for early childhood education and opportunities where programming needs may exist. The map below shows high variability across Roanoke Valley census tracts, ranging from below 35.1% of 3- to 4-year-old children enrolled to over 55% of 3- to 4-year-old children enrolled.

Map V5. Preschool Enrollment by Census Tract, Roanoke Valley Service Area

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract. Accessed via SparkMap.

Vital Condition: Meaningful Work & Wealth Meaningful work and wealth refer to rewarding work, careers and standards of living. It can be measured through indicators such as job training, well-paying jobs, income and poverty37. Low economic status is often associated with poor health, as cost and affordability can be barriers to accessing health care and healthy foods. Income and poverty as presented below highlight pockets across the service area that have low income and high poverty.

Map V6. Median Household Income by Census Tract, Roanoke Valley Service Area

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract. Accessed via SparkMap.

37 https://thriving.us/wp-content/uploads/2020/07/Springboard-Main-Narrative-For-Screen-2.pdf

Map V7. Percent Population below 200% Federal Poverty Level by Census Tract, Roanoke Valley Service Area

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract. Accessed Via SparkMap.

Vital Condition: Humane Housing Humane housing includes indicators related to safety and security at home, a key need for thriving people and communities. Housing is often the highest expense for a household and can easily set the trajectory for all aspects of health—for better or worse38. Data on cost-burdened households and substandard housing show large variability across census tracts and point to geographic disparities in humane housing.

Map V8. Cost Burdened Households (Housing Costs Exceed 30% of Household Income) by Census Tract, Roanoke Valley Service Area

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract. Accessed Via SparkMap. Map V9. Cost Burdened Households (Housing Costs Exceed 30% of Household Income) by Census Tract, Urban Hub of Roanoke Valley Service Area

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract. Accessed Via SparkMap.

38 https://www.communitycommons.org/collections/Humane-Housing-as-a-Vital-Condition

Substandard housing (At Least 1 Substandard Condition Present) Substandard conditions include: 1) lacking complete plumbing facilities, 2) lacking complete kitchen facilities, 3) with 1 or more occupants per room, 4) selected monthly owner costs as a percentage of household income greater than 30%, and 5) gross rent as a percentage of household income greater than 30%.

Map V10. Substandard Housing by Census Tract, Roanoke Valley Service Area

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract. Accessed Via SparkMap.

Vital Condition: Thriving Natural World A thriving natural world includes indicators related to clean air, clean water and clean places to live, work and play39. The physical environment plays a large role in health outcomes. It contributes to a wide range of factors, including healthy behaviors like physical activity, and health conditions such as asthma. Although secondary data related to environmental health is largely uneventful for the Roanoke Valley— including generally high air quality and low or no drinking water violations—we know concerns exist in specific neighborhoods in closer proximity to industrial facilities and that have lower walkability and safety concerns impacting the potential to thrive.

Social Vulnerability Index The CDC created a measure—the Social Vulnerability Index—to determine how vulnerable a community may be to human suffering and financial loss in a disaster, including environmental issues such as chemical spills or natural disasters, as well as disease outbreaks. By analyzing various social determinant issues, the vulnerability of each census tract is determined and allows for more efficient preparation and response40.

Ranging from 0-1, a higher score indicates higher vulnerability. The Roanoke Valley service area and Virginia both have a social vulnerability index score of 0.34, indicating the same level of vulnerability in the Valley overall compared to the Commonwealth. Map V11 shows details by census tract and Table V3 shows overall scores by locality.

Map V11. Social Vulnerability Index by Census Tract, Roanoke Valley Service Area

Data Source: Centers for Disease Control and Prevention and the National Center for Health Statistics, CDC - GRASP. 2018. Source geography: Tract. Accessed via SparkMap.

39 https://www.communitycommons.org/collections/Thriving-Natural-World-as-a-Vital-Condition 40 https://www.atsdr.cdc.gov/placeandhealth/svi/fact_sheet/fact_sheet.html

Table V3. Social Vulnerability Index, Roanoke Valley Service Area

Report Area Social Vulnerability Index Score

Roanoke Valley Service Area 0.34

Bedford County 0.10

Botetourt County 0.04

Craig County 0.07

Franklin County 0.40

Roanoke County 0.13

Roanoke City 0.80

Salem City 0.31

Virginia 0.34

United States 0.40

Data Source: Centers for Disease Control and Prevention and the National Center for Health Statistics, CDC - GRASP. 2018. Source geography: Tract. Accessed via SparkMap.

Vital Condition: Reliable Transportation Reliable transportation refers to access to transportation that is yes, reliable, but also safe, accessible and close to places for food, work and play41. According to the ACS, Roanoke City residents are more likely to rely on public transportation for their commute, with 3.59% of workers relying on public transportation. All other Roanoke Valley localities show 0.5% or less of workers utilizing public transportation for commuting. The statistics below show a sharp increase in the percentage of households with no motor vehicle for Roanoke City compared to other service area localities.

Table V4. Households with No Motor Vehicle, Roanoke Valley Service Area

Report Area Households with No Motor Vehicle, Percent

Roanoke Valley Service Area 6.54%

Bedford County 3.21%

Botetourt County 3.89%

Craig County 7.84%

Franklin County 4.72%

Roanoke County 3.97%

Roanoke City 13.06%

Salem City 7.04%

Virginia 6.10%

United States 8.61%

Data Source: US Census Bureau, American Community Survey. 2015-19. Source geography: Tract Show more details. Accessed via SparkMap.

41 https://thriving.us/wp-content/uploads/2020/07/Springboard-Main-Narrative-For-Screen-2.pdf

Vital Condition: Belonging & Civic Muscle Belonging and civic muscle refers to a sense of belonging and power to shape the world. It includes indicators such as civic engagement and social associations42. Fulfilling relationships and social supports are key to thriving, engaging and investing in the community.

Social Associations

This indicator reports the number of social associations per 10,000 population. Associations include membership organizations such as civic organizations, bowling centers, golf clubs, fitness centers, sports organizations, political organizations, labor organizations, business organizations and professional organizations43. Communities with fewer social associations may be more likely to have individuals with a lower sense of belonging.

Map V12. Social Associations, Roanoke Valley Service Area

Data Source: US Census Bureau, County Business Patterns. Additional data analysis by CARES. 2018. Accessed via SparkMap.

42 https://thriving.us/wp-content/uploads/2020/07/Springboard-Main-Narrative-For-Screen-2.pdf 43 US Census Bureau, County Business Patterns. Accessed through SparkMap,

Self-Reported Data The Community Health Survey, the primary method of identifying significant needs based on community input, showed distinct issues regarding health-related needs, health services and social/support resources in the community. Full survey responses can be found in Appendix 6. Figure SR1 shows the demographics of survey respondents.

Figure SR1. Roanoke Valley Survey Respondent Demographics

When asked “What do you think are the most important issues impacting health in our community?”, the community indicated overweight/obesity a top issue, as well as issues surrounding access, mental health and substance use such as drugs, alcohol and tobacco. While many of these issues have come out as top needs in previous assessments, the stories behind them are uniquely impacted by COVID-19 for the 2021 RVCHA. Major changes in nearly every aspect of life shook the world starting in 2020 and upended things like economics, lifestyle, health and safety. Figure SR2 shows the top 10 issues impacting health in the community according to the survey.

When analyzing responses based on income level, distinct differences were revealed between respondents with lower income ($20,000 or below) and respondents with higher income (above $70,000). Environmental health and housing problems were indicated as health concerns among a significantly higher proportion of the lower income respondents. Homicide, gang activity and neighborhood safety were also significant concerns among lower income respondents.

In comparing responses from male and female survey respondents, females chose bullying and domestic violence as top issues impacting health at a significantly higher rate than males.

Figure SR2. Survey Responses: What do you think are the most important issues impacting health in our community?

When asked “Which health care services are hard to get in our community?”, the top responses also included services related to mental health and substance abuse. Figure SR3 shows the top 10 health care services hard to get in the community according to the survey.

Adult dental care, while indicated as a difficult health service to access across all income levels, was significantly higher in low-income groups. Similarly, mental health services were indicated as hard to get across all incomes, but significantly higher in high-income groups. Domestic violence services were indicated as a hard-to-get resource for female respondents significantly more than for male respondents.

Figure SR3. Survey Responses: Which health care services are hard to get in our community?

When asked “Which social/support resources are hard to get in our community?”, affordable/safe housing was by far the top response. Additional resources in the top 10 included childcare, transportation and those related to the cost/affordability of health care and other social determinants of health. Figure SR4 shows the top 10 social/support resources hard to get in the community according to the survey.

Across income levels, banking and financial assistance, rent/utilities assistance, food benefits and unemployment benefits were significantly more difficult to access for lower income respondents. Childcare and domestic violence assistance were indicated as issues significantly more often for females than males, while males indicated health insurance as hard to get significantly more than females.

Figure SR4. Survey Responses: Which social/support resources are hard to get in our community?

The survey also included questions as indicators of connectedness. Across the Roanoke Valley, 25% of survey respondents report feeling not connected with the community and those around them, an indicator significantly higher for low-income respondents than those with higher incomes. Higher income respondents also reported eating meals together with their household on a regular basis over the seven days prior to taking the survey.

Self-reported data from stakeholders supported similar concerns as those of the community. The most important issues were access to care or services and mental health and substance use. Stakeholders also identified two areas of Roanoke City as having the greatest unmet needs: Northwest and Southeast Roanoke City, which are both MUAs. Stakeholders also reported the elderly as a population with greatest unmet needs. See Appendix 3 for full stakeholder data summary.

Equity Equity is an increasingly important lens through which to view health issues. The VDH’s Equity at a Glance Dashboard provides a scorecard that highlights income and poverty, educational attainment, food access, unemployment, broadband access and housing insecurity by locality in comparison to Virginia44. See Figure E1 for the scorecards for each locality included in this assessment.

Figure E1. Data from Virginia Department of Health Equity at a Glance Locality Scorecards

Indicators Virginia Bedford Botetourt Craig Franklin Roanoke Roanoke Salem County County County County City County Living in Poverty 10.6% 8.9% 6.5% 8.9% 14.5% 20.8% 6.9% 9.1% Adults with High School 89.7% 90.1% 92.2% 91.6% 88.2% 86.0% 91.7% 90.3% Diploma Low Access to Food 18.1% 9.8% 35.0% 11.2% 14.9% 18.4% 20.2% 42.1% Labor Force that is 5.1% 5.1% 4.2% 4.5% 5.4% 7.0% 4.6% 5.0% Unemployed Households with 83.9% 76.1% 80.2% 73.5% 73.5% 74.9% 84.1% 79.3% Internet Access Households with 12.5% 7.6% 9.0% 4.3% 11.2% 16.7% 9.5% 10.5% Severe Cost Burden Data Source: Virginia Department of Health Equity at a Glance Locality Scorecard

Roanoke City stands out from the rest of the service area as worse than the Virginia average in all six categories on the scorecard. Notably, Roanoke City has a high percent of population living in poverty— nearly twice that of Virginia. The average annual income per person for those identifying as Black or African American and Hispanic or Latino are 60% and 50%, respectively, of the income per person of white Roanoke City residents45.

Across the Roanoke Valley, most localities have a lower percentage of households with broadband access than the statewide rate of 83.9%, with Craig County and Franklin County having the lowest access at 74.9%. Additionally, Black or African American households reported the lowest percentages of computer access and broadband across almost all Roanoke Valley localities. These numbers are self- reported by household through the ACS and do not consider reliability or affordability of service46.

44 https://www.vdh.virginia.gov/equity-at-a-glance/locality-scorecard/ 45 https://www.vdh.virginia.gov/equity-at-a-glance/locality/income-and-poverty/ 46 https://www.vdh.virginia.gov/equity-at-a-glance/locality/broadband/

Appendices Appendix 1: Gantt Chart

Tasks: Assigned To: Start Date End Date 2021 Roanoke Valley CHA 06-01 Mon 01-01 Sat Amy & Molly (Aaron & CHA Planning 06-01 Mon 10-01 Thu Shirley) CHA Process Molly & CHO Staff 09-01 Tue 08-01 Sun CHA Data Collection Molly & CHO Staff 10-01 Thu 01-31 Sun CHAT Meeting #1 (9/28/20) Molly & Aaron & Partners 09-01 Tue 09-28 Mon CHAT Meeting #2 (11/16/20) Molly & Aaron & Partners 11-01 Sun 11-16 Mon Data Coding, Organization, Prep. and Molly 11-01 Sun 03-01 Mon Visualization CHAT Meeting #3 (2/15/21) Molly & Aaron & Partners 02-01 Mon 02-15 Mon CHA Reports Molly & CHO Staff 04-01 Thu 07-01 Thu CHAT Meeting #4 (5/17/21) Molly & Aaron & Partners 05-01 Sat 05-17 Mon CHA Hospital Board Approvals Molly (Shirley, Aaron) 07-01 Thu 08-30 Mon Molly & Aaron & CHO Staff CHA Results Community Communications 08-01 Sun 01-30 Sun and Community Recommendations & Partners (PR) Shirley with White Paper Carilion Clinic-wide CHIP Planning 07-01 Wed 08-01 Sun Team Molly & CHO Staff (Shirley 10-01 Thu 08-01 Sun Implementation Strategy Planning & White Paper Team) Implementation Strategy Reports (6) Molly & Aaron & CHO Staff 05-01 Sat 09-01 Wed Implementation Strategy Report Hospital Administrator Approval (on behalf of Molly (Shirley, Aaron) 09-01 Wed 10-01 Fri Boards) Hospital Boards Ratify Implementation Molly (Shirley, Aaron) 10-01 Fri 11-30 Tue Strategy Approval Community Coalitions Planning (as a result Carilion Clinic / HRV 07-01 Thu 07-01 Fri of CHAs) Molly & Amy & CHO Staff CB Teams (or hospitals operations teams) & CB Teams (Hospital and CHO Action Planning (resulting from 08-01 Sun 10-01 Fri Administrators, Shirley, Implementation Strategies) Aaron) First Hospital Board Implementation Molly & Aaron & CHO Staff 01-01 Sat 01-31 Mon Strategy Update

Appendix 2: Community Health Survey

Appendix 3: Stakeholder Survey and Data Summary 2021 Community Health Assessment Stakeholder Survey

Survey available in online format only via: https://www.surveymonkey.com/r/2021Stakeholder

1. Please select the community you and/or your organization represent: a. The Roanoke Valley b. The Rockbridge Area c. Giles County/Monroe County d. New River Valley e. Franklin County/Henry County f. Tazewell County 2. Your name, organization, and title:

NAME: ______

ORGANIZATION:______

TITLE: ______

3. What are the most important issues (needs) that impact health in the service area? ______

4. What are the barriers to health for the populations you serve? ______

5. Is there one locality / neighborhood with the greatest unmet need? If so, why? ______

6. Is there one population group with the greatest unmet need? If so, why? ______

7. What are the resources for health for the populations you serve? ______

8. If we could make one change as a community to meet the needs and reduce the barriers to health in the service area, what would that be? ______

Thank you for your input!

Roanoke Valley Community Health Assessment Team (CHAT) members completed a stakeholder survey following discussion of needs, barriers, resources, and initiatives impacting health of the community. Additionally, a focus group was held with the Carilion Medical Center Clinical Advancement and Patient Safety Committee (CAPS) representing CMC broadly. The results below include the CHAT survey results and responses discussed with the CAPS committee.

What are the most important issues (needs) that impact health in your community? Top themes Responses: 30

Access to Care / Services 33% Mental Health / Substance Use 30% Food Access 13% Chronic Diseases (obesity, diabetes) 13% Dental Health 13% COVID-19 13% Housing 13% Affordability of Care 10% Education 10% Child Safety / Support 10% Poverty 10% Transportation 10%

0% 5% 10% 15% 20% 25% 30% 35%

What are the barriers to health for the populations you serve? Top themes Responses: 25

Transportation 64%

Financial Barriers 56%

Accessibility of Care 36%

Health Literacy / Education 20%

Access to Affordable/Healthy Food 16%

0% 10% 20% 30% 40% 50% 60% 70%

Is there one locality/neighborhood with the greatest unmet need? Top themes Responses: 22

Northwest Roanoke City 55%

Southeast Roanoke City 55%

Craig County / New Castle 27%

Low Income Areas 14%

North Botetourt County 9%

0% 10% 20% 30% 40% 50% 60%

Reasons why: Low income, low access, transportation, lack of resources

Is there one population group with the greatest unmet need? Top themes Responses: 26

Elderly 35%

The Working Poor 19%

Immigrants 15%

People in Poverty 15%

Hispanic Community 12%

Homeless 8%

Non-English Speakers 8%

Black / African American Community 8%

Single Parent Families 8%

0% 5% 10% 15% 20% 25% 30% 35% 40%

What are the resources for health for the populations you serve?

Responses: 24

• Acute care • PCC • ARCH Services • Physicians to Children • Blue Ridge Behavioral Health • RAM House • Botetourt Free Clinic • Roanoke Redevelopment and Housing • Botetourt Resource Center Authority • Bradley Free Clinic • Recreational/fitness opportunities • Carilion Clinic • Rescue Mission • Carilion Clinic Pediatrics • Safe walking and biking paths • Carilion Community Health and • Urgent Care Outreach • Valley Metro • CHIP • VAMC • Churches / Faith Community • VDH • Craig County Medical Center • Well-child visits / children's preventive • Department of Social Services care • Drive through Flu clinics • West End Center • Education through community service • WIC organizations. • Emergency Care • Expanded Medicaid • Family practice care • Family Service of Roanoke Valley • Farmers Markets • Fralin Clinic • Free clinics • Government resources • Health care clinics for medical home • Health Departments • Immunizations • LEAP • Lewis Gale • Libraries • Mckinney-Vento program at RCPS • Meals on Wheels • Medicaid • Medicare • New Horizons • Non-profit organizations that serve vulnerable clients

If we could make one change as a community to meet the needs and reduce the barriers to health, what would that be? Top themes Responses: 34

Access 41%

Health Literacy / Education 15%

Transportation 15%

Strengthen Partnerships / Community 12% Relationships

Income / Employment 6%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Appendix 4: Prioritization Worksheet Community Health Assessment Prioritization

Please rank from 1-10 the top 10 most pertinent community needs with 1 being the most pertinent. Rank Community Issue Health Behavior Factors Alcohol and drug use Culture: healthy behaviors not a priority Lack of exercise Lack of health literacy / lack of knowledge of healthy behaviors Lack of knowledge of community resources Poor diet / poor eating habits Risky sexual activity Tobacco use Access to healthy foods Stress Clinical Care Factors Access to primary care Access to dental care Access to mental / behavioral health services Access to specialty care (general) Access to substance use services Communication barriers with providers Coordination of care High cost of care High uninsured / underinsured population Quality of care Social and Economic Health Factors Child abuse / neglect Community safety / violence Domestic violence Educational attainment Lack of family / social support systems Poverty / low average household income Unemployment

Physical Environment Factors Air quality Affordable / safe housing Injury prevention / safety of environment Outdoor recreation Transportation / transit system Water quality Health Conditions / Outcomes COVID-19 Overweight / Obesity Mental health problems Cancers Diabetes High Blood Pressure Heart Disease and Stroke High prevalence of chronic disease (general) Write-in section

Appendix 5: Resource List Community Resources listed by Stakeholders in the spring of 2021 are listed below. Please note that information may have changed since the collection date.

A more in-depth resource list organized by type of resource is also included courtesy of Carilion’s quarterly Easy Health publication.

Community members can also learn more about available resources by calling 2-1-1 or going online to https://www.211virginia.org/consumer/index.php. 2-1-1 is a free service available to help callers find appropriate resources in their local area.

Community Resources Listed by Stakeholders

• Acute care • Immunizations • ARCH Services • LEAP • Blue Ridge Behavioral Health • Lewis Gale • Botetourt Free Clinic • Libraries • Botetourt Resource Center • Mckinney-Vento program at RCPS • Bradley Free Clinic • Meals on Wheels • Carilion Clinic • Medicaid • Carilion Clinic Pediatrics • Medicare • Carilion Community Health and • New Horizons Outreach • Non-profit organizations that serve • CHIP vulnerable clients • Churches / Faith Community • PCC • Craig County Medical Center • Physicians to Children • Department of Social Services • RAM House • Drive through Flu clinics • Roanoke Redevelopment and Housing • Education through community service Authority organizations. • Recreational/fitness opportunities • Emergency Care • Rescue Mission • Expanded Medicaid • Safe walking and biking paths • Family practice care • Urgent Care • Family Service of Roanoke Valley • Valley Metro • Farmers Markets • VAMC • Fralin Clinic • VDH • Free clinics • Well-child visits / children's preventive • Government resources care • Health care clinics for medical home • West End Center • Health Departments • WIC

Resources from Carilion Clinic’s Easy Health Summer 2021 Publication

Hotlines: • Al-Anon for Families of Alcoholics 800-344-2666 • Alcohol Abuse Hotline 800-331-2900 • Alcohol & Drug Abuse Helpline 800-821-4357 • Poison Control 800-222-1222 • National Domestic Violence Hotline 800-799-7233 • National Hopeline Network (for Crisis and Suicide) 800-784-2433 • National Suicide Prevention Lifeline 800-273-8255 • National U.S. Child Abuse Hotline 800-422-4453 • National Youth Crisis Hotline 800-442-4673 • SARA (Sexual Assault/Rape) Crisis Hotline 540-981-9352

2-1-1 Virginia Services: referral for food banks, shelters, utility assistance, job training, physical/ mental health resources, support for seniors, ESOL classes, child care and disaster support. Contact: 2-1-1 or 211virginia.org

Bernard Healthcare Center Services: medical, pharmaceutical and preventive health care services for uninsured adults. 1171 Franklin St., Rocky Mount, Va. Contact: 540-489-7500

Blue Ridge Behavioral Health Services: counseling, substance abuse recovery and a walk-in clinic. The Burrell Center 611 McDowell Ave., Roanoke, Va. Contact: 540-343-3007

Botetourt Resource Center Services: social and human services, including Department of Social Services programming and assistance. 33 Bedford St., Buchanan, Va. Contact: 540-254-1468 or botetourtva.gov

Bradley Free Clinic Services: medical, dental, pharmaceutical and preventive health care services. 1240 3rd St., S.W., Roanoke, Va. Contact: 540-344-5156

Carilion Clinic Community Care Services: primary care services for minor health concerns. 101 Elm Ave., Roanoke, Va. Contact: 540-985-8044 or CarilionClinic.org/locations/carilion-clinic-community-care

Carilion Clinic Community Health and Outreach Services: wellness workshops, healthier lifestyle educational programs, community recovery groups and peer support, injury prevention and community health screenings.

1202 Third St., SW, Roanoke, Va. Contact: 540-266-6000 / 800-422-8482 or CarilionClinic.org/community-health-outreach

Carilion Diabetes Management Program Services: endocrinology, diabetes and metabolism clinical services, and a support group for diabetes management. 1030 S. Jefferson St., Ste. G101, Roanoke, Va. Contact: 540-266-6000

Commonwealth Catholic Charities Services: pregnancy counseling, foster care and adoption services; interpreter services, refugee resettlement and employment support; immigration services and citizenship instruction; and food pantry, housing and financial counseling. 541 Luck Ave, Ste. 118, Roanoke, Va. Contact: 540-342-0411 or cccofva.org 802 Campbell Ave., S.W., Roanoke, Va. Contact: 540-342-7561 or cccofva.org St. Francis House (food pantry) Contact: 540-342-7561 ext. 319 or cccofva.org Pregnancy Counseling Hotline Contact: 800-296-2367 or cccofva.org

Central Intake – One Door Services: homeless services, housing stability and a shelter system. 339 Salem Ave., S.W., Roanoke, Va. Contact: 540-853-1163

Child Health Investment Partnership (CHIP) of Roanoke Valley Services: pairs pregnant moms, low-income children (birth to first-grade entry) and their guardians with medical services, assists with managing chronic conditions and provides developmental education, kindergarten preparation and regular child assessment and monitoring. Contact: 540-857-6993 or chiprv.org or [email protected]

Common Help website (for Virginia citizens) Services: access to applications for TANF, child care services, energy assistance (fuel, crisis and cooling), food assistance (SNAP) and medical assistance for Virginia citizens. Eligibility requirements. Contact: 855-242-8282 or commonhelp.virginia.gov

Community Housing Resource Center Services: homeless services, housing stability and a shelter system. 339 Salem Ave., S.W., Roanoke, Va. Contact: 540-266-7551

Council of Community Services A central information and referral organization for homelessness prevention, HIV/ HCV prevention and care, and community building. 502 Campbell Ave., S.W., Roanoke, Va. Contact: 540-985-0131 / 800-354-3388 or councilofcommunityservices.org

Cover Virginia

Services: health insurance, Medicaid, Medicare and FAMIS enrollment. Contact: 855-242-8282 (toll-free) or coverva.org

Department of Social Services, Botetourt County 220 Commons Parkway, Daleville, Va. Contact: 540-591-5960 or botetourtva.gov

Department of Social Services, Franklin County Services: adult protective services, child protective services, foster care and prevention, TANF and child care. 120 East Court St., Rocky Mount, Va. Services: SNAP, Medicaid and energy assistance 11161 Virgil H Goode Hwy., Rocky Mount, Va. Contact: 540-483-9247 or franklincountyva.gov

Department of Social Services, Roanoke City 1510 Williamson Road, N.E., 3rd floor, Roanoke, Va. Contact: 540-853-2591 or roanokeva.gov

Department of Social Services, Roanoke County 220 E. Main St., Salem, Va. Contact: 540-387-6087 or roanokecountyva.gov

Department of Social Services, Salem 220 E. Main St., Salem, Va. Contact: 540-375-3039 or roanokecountyva.gov

Family Services of Roanoke Valley Services: counseling, therapy and outreach for children, youth and adults; life skills training; personal affairs management; domestic violence survivor programs. 360 Campbell Ave., S.W., Roanoke, Va. Contact: 540-563-5316 or fsrv.org

Feeding America Southwest Virginia (FASWVA) Services: food pantries, elderly and youth nutrition, shelter and emergency meal programs, and culinary arts training. Contact: 540-342-3011 or faswva.org

F.R.E.E. Foundation Services: providing mobility rehabilitation equipment. 1489 East Main St., Salem, Va. Contact: 540-777-4929 or free-foundation.org

G. Wayne Fralin Free Clinic for the Homeless Services: primary and preventive care for uninsured and homeless individuals. 321 Tazewell Ave., S.E., Roanoke, Va. Contact: 540-777-7671

Goodwill Industries of the Valleys Services: employment training for youth, adult and older citizens, computer training and education programs. Goodwill Roanoke Job Campus

2502 Melrose Ave., N.W., Ste. B, Roanoke, Va. Contact: 540-581-0620, option 1 or goodwillvalleys.com

Habitat for Humanity in Roanoke Valley Services: assistance with construction or restoration of housing, housing placement, construction supplies and home furnishings. 3435 Melrose Ave., N.W., Roanoke, Va. Contact: 540-344-0747 or habitat-roanoke.org

InnovAge PACE Services: provides medical services including personal care, transportation, medicines, adult day center, therapy, medical supplies, dental and vision for adults ages 55+. InnovAge PACE – Roanoke Valley 1606 Lynchburg Turnpike, Salem, Va. Contact: 540-682-3851 or [email protected]

Local Office on Aging (LOA) Services: care coordination and outreach, care transitions, Meals on Wheels, adult daycare, homemaker services, transportation, emergency services, options counseling, long term care ombudsman, Elder Justice Alliance and VICAP (to assist with insurance questions and needs). 4932 Frontage Road, N.W., Roanoke, Va. Contact: 540-345-0451 / 888-355-6222

Mental Health America of Roanoke Valley Services: mental illness first aid training, workshops for families and individuals, counseling, advocacy and crisis intervention for individuals with mental illness. 10 Church Ave., S.E., Ste. 300, Roanoke, Va. Contact: 540-344-0931 or mharv.org

NAMI - Roanoke Valley Services: emotional support, fellowship and informational programs for parents, relatives and friends, as well as individuals with mental illness. Contact: 540-977-3470 or [email protected]

New Horizons Healthcare Services: adult and pediatric medical, behavioral health, dental and pharmacy services, and assistance enrolling in health care coverage. 3716 Melrose Ave., N.W., Roanoke, Va. Contact: 540-362-0360

Peer Recovery Center Specialists can help you apply for resources, including Medicaid, a cell phone, transportation and much more. Call for an appointment. Carilion Clinic Rehabilitation Building/Peer Recovery Center 2017 S. Jefferson St., First Floor, Roanoke, Va. Contact: 540-853-9152

Piedmont Community Services Services: daily continuum of behavioral health services, including prevention, treatment, education and support. Same-day and emergency access available.

24 Clay St., Martinsville, Va. Contact: 540-483-0582 / (888) 819-1331

Presbyterian Community Center Services: after-school program, food pantry, emergency services and utility assistance. 1228 Jamison Ave., S.E., Roanoke, Va. Contact: 540-982-2911

RADAR Transit Services: Valley Metro STAR service, CORTRAN program, the Mountain Express, Maury Express, PART and College Express. P.O. Box 13825, Roanoke, Va. Contact: 540-343-1721 / 800-964-5707 or radartransit.org

RAM House Services: day shelter for homeless individuals, noon-day meals, emergency financial assistance, laundry services, employment training and job placement, clothes closet. 824 Campbell Ave., S.W., Roanoke, Va. Contact: 540-345-8850

Rescue Mission Services: emergency shelter for homeless individuals, including meals, spiritual guidance, self-sufficiency and life-stabilizing programs, substance abuse recovery programs. 402 4th St., S.E., Roanoke, Va. Contact: 540-343-7227

Roanoke City Parks and Recreation 215 Church Ave., Room 303, Roanoke, Va. Contact: 540-853-2236 or playroanoke.com

Roanoke Financial Empowerment Center Services: No-cost, professional one-on-one financial counseling. Contact: 540-427-6811 or RoanokeFEC.org

Roanoke Redevelopment and Housing Authority Services: housing placement, homeownership programs, employment training and job placement. 2624 Salem Turnpike N.W., Roanoke, Va. Contact: 540-983-9281 or rkehousing.org

Roanoke Valley-Alleghany Region 5 Adult Education Services: adult education, GED courses and testing, ESL courses and testing. Contact: 540-853-2151 or regionfiveadulted.com

Roanoke Valley Libraries Botetourt County 540-928-2900 Roanoke City 540-853-2473 Roanoke County 540-772-7507 Salem 540-375-3089

Salem City Parks and Recreation 620 Florida St., Salem, Va. Contact: 540-375-3057 or salemva.gov/departments/parks-and-recreation

Salvation Army Services: New Day Center for youth ages 18-24, Pathway of Hope life-stabilizing program for families, domestic violence and human trafficking survivor programs, disaster relief, short-term family emergency/utility relief, youth fellowship and senior fellowship. 724 Dale Ave., S.E., Roanoke, Va. Contact: 540-343-5335

SARA Roanoke Services: crisis counseling, individual/group/family counseling and advocacy for sexual assault survivors. 3034 Brambleton Ave., S.W., Roanoke, Va. Contact: 540-345-7273 24-Hour Crisis Hotline 540-981-9352

Tap Into Hope/Total Action for Progress (TAP) Services: housing, employment and education for early learning, youth and adults; financial basics; support for veterans; domestic violence services; and child-parent relationship support. 302 2nd St., S.W., Roanoke, Va. Contact: 540-777-HOPE (4673) or tapintohope.org

United Way of Roanoke Valley Services: early learning and childcare programs for ages 0-12, housing and life-stabilizing services for families, family health strategies, financial basics and prescription medication program. 325 Campbell Ave., S.W., Roanoke, Va. Contact: 540-777-4200

Virginia Career Works Services: job searching, training, education, career planning and unemployment. 3601 Thirlane Road, N.W., Ste. 2, Roanoke, Va. Contact: 540-613-8220

Virginia Cooperative Extension - Roanoke Services: Nutrition education, food safety, water and soil testing, agricultural support, positive youth development (4-H) and health/wellness classes. Contact: 540-772-7524 or ext.vt.edu/Roanoke

Virginia Department of Health Services: clinical, community outreach, emergency preparedness and response, environmental health, family services and WIC 1502 Williamson Road, N.E., 2nd floor, Roanoke, Va. Contact: 540-283-5050 or vdh.virginia.gov/Roanoke

Virginia Health Care Foundation (VHCF) Services: SignUpNow program for Medicaid and FAMIS. Contact: vhcf.org/workshops

Appendix 6: Community Health Survey Results 1. County of Residence

# % Roanoke City 648 41.54% Roanoke County 435 27.88% Botetourt County 215 13.78% Craig County 90 5.77% Bedford County 84 5.38% Answered 1560 Skipped 0

County of Residence

6% 6% Roanoke City

15% 44% Roanoke County Botetourt County Craig County Bedford County 29%

2. What do you think are the most important issues that affect health in our community? (Check all that apply)

# % Overweight / obesity 808 60.12% Mental health problems 781 58.11% COVID-19 / Coronavirus 761 56.62% Alcohol and illegal drug use 738 54.91% Poor eating habits 708 52.68% Access to affordable housing 658 48.96% Access to healthy foods 632 47.02% Stress 628 46.73% Lack of exercise 593 44.12% Tobacco use / smoking / vaping 472 35.12% High blood pressure 464 34.52% Prescription drug abuse 455 33.85% Child abuse / neglect 444 33.04% Diabetes 444 33.04% Domestic violence 442 32.89% Cell phone use / texting and driving / distracted driving 441 32.81% Heart disease and stroke 436 32.44% Social isolation 415 30.88% Aging problems 379 28.20% Cancers 366 27.23% Dental problems 336 25.00% Gang activity 335 24.93% Transportation problems 326 24.26% Housing problems (e.g. mold, bed bugs, lead paint) 325 24.18% Bullying 276 20.54% Neighborhood safety 275 20.46% Suicide 271 20.16% Environmental health (e.g. water quality, air quality, pesticides, etc.) 234 17.41% Homicide 221 16.44% Not getting “shots” to prevent disease 214 15.92% Unsafe sex 207 15.40% Grief 202 15.03% Sexual assault 188 13.99% Not using seat belts / child safety seats / helmets 176 13.10% Teenage pregnancy 169 12.57% Accidents in the home (ex. falls, burns, cuts) 140 10.42% Lung disease 135 10.04% HIV / AIDS 107 7.96% Injuries 89 6.62% Other (please specify) 86 6.40% Infant death 54 4.02% Answered 1344 Skipped 216

3. Which health care services are hard to get in our community? (Check all that apply)

# % Mental health / counseling 520 40.28% Adult dental care 467 36.17% Alternative therapy (ex. herbal, acupuncture, massage) 370 28.66% Substance abuse services –drug and alcohol 346 26.80% Eldercare 306 23.70% Dermatology 252 19.52% Domestic violence services 219 16.96% Medication / medical supplies 213 16.50% Specialty care (ex. heart doctor) 209 16.19% Family doctor 208 16.11% Programs to stop using tobacco products 206 15.96% Vision care 201 15.57% Emergency room care 187 14.48% Women’s health services 173 13.40% Child dental care 160 12.39% Preventive care (ex. yearly check-ups) 155 12.01% Cancer care 133 10.30% None 129 9.99% Urgent care / walk in clinic 128 9.91% X-rays / mammograms 123 9.53% Chiropractic care 122 9.45% Other (please specify) 121 9.37% End of life / hospice / palliative care 111 8.60% Family planning / birth control 96 7.44% Physical therapy 96 7.44% Inpatient hospital 86 6.66% Lab work 69 5.34% Ambulance services 63 4.88% Immunizations 53 4.11% Answered 1291 Skipped 269

4. What social / support resources are hard to get in our community?

# % Affordable / safe housing 654 51.05% Childcare 453 35.36% Transportation 425 33.18% Medical debt assistance 415 32.40% Health insurance 384 29.98% Employment / jobs assistance 378 29.51% Rent / utilities assistance 374 29.20% Healthy food 365 28.49% Medication assistance 336 26.23% Domestic violence assistance 280 21.86% Legal services 270 21.08% Banking / financial assistance 221 17.25% Food benefits (SNAP, WIC) 194 15.14% Education and literacy 191 14.91% Unemployment benefits 191 14.91% Veterans services 175 13.66% Translation assistance / language services 171 13.35% TANF (Temporary Assistance for Needy Families) 153 11.94% None 91 7.10% Other (please specify) 64 5.00% Answered 1281 Skipped 279

5. What keeps you from being healthy? (Check all that apply)

# % Nothing keeps me from being healthy 453 35.75% Cost 433 34.18% Long waits for appointments 329 25.97% Lack of evening and weekend services 319 25.18% High co-pay 277 21.86% Don’t know what types of services are available 136 10.73% Other (please specify) 112 8.84% No health Insurance 103 8.13% Afraid to have check-ups 90 7.10% Don’t trust doctors / clinics 83 6.55% Location of offices 82 6.47% Childcare 76 6.00% No transportation 75 5.92% Have no regular source of healthcare 58 4.58% Can’t find providers that accept my Medicaid insurance 54 4.26% Don’t like accepting government assistance 36 2.84% Can’t find providers that accept my Medicare insurance 28 2.21% Language services 15 1.18% Answered 1267 Skipped 293

6. Do you use medical care services?

# % Yes 1082 82.91% No 223 17.09% Answered 1305 Skipped 255

Do you use medical care services?

17%

Yes No

83%

Where do you go for medical care? (Check all that apply)

# % Doctor’s Office 976 91.13% Urgent Care / Walk in Clinic 457 42.67% Emergency Room 198 18.49% Online / Telehealth / Virtual Visits 191 17.83% Free Clinic (e.g. Bradley Free Clinic, Fralin Free Clinic - Rescue Mission, Botetourt Christian Free Clinic) 69 6.44% Health Department 44 4.11% Federally Qualified Health Center (e.g. New Horizons Healthcare) 41 3.83% Other (please specify) 25 2.33% Salem VA Medical Center 20 1.87% Answered 1071 Skipped 489

7. How long has it been since you last visited a doctor for a routine checkup? (Please check one)

# % Within the past year (1 to 12 months ago) 1025 78.97% Within the past 2 years (1 to 2 years ago) 183 14.10% Within the past 5 years (2 to 5 years ago) 48 3.70% 5 or more years ago 34 2.62% I have never visited a doctor or other healthcare provider for a routine checkup. 8 0.62% Answered 1298 Skipped 262

How long has it been since you last visited a doctor for a routine checkup? 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Within the past year Within the past 2 Within the past 5 5 or more years ago I have never visited a (1 to 12 months ago) years (1 to 2 years years (2 to 5 years doctor or other ago) ago) healthcare provider for a routine checkup.

8. Do you use dental care services?

# % Yes 1004 77.53% No 291 22.47% Answered 1295 Skipped 265

Do you use dental care services?

22%

Yes No

78%

Where do you go for dental care? (Check all that apply)

# % Dentist’s office 955 95.21% Free Clinic (e.g. Bradley Free Clinic, Fralin Free Clinic - Rescue Mission, Botetourt Christian Free Clinic) 40 3.99% Other (please specify) 26 2.59% VWCC Dental Hygiene Program 8 0.80% Urgent Care / Walk in Clinic 7 0.70% Emergency Room 3 0.30% Salem VA Medical Center 2 0.20% Answered 1003 Skipped 557

9. How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists. (Please check one)

# % Within the past year (1 to 12 months ago) 866 67.34% Within the past 2 years (1 to 2 years ago) 154 11.98% 5 or more years ago 154 11.98% Within the past 5 years (2 to 5 years ago) 105 8.16% I have never visited a dentist or a dental clinic for any reason. 7 0.54% Answered 1286 Skipped 274

How long has it been since you last visited a dentist or a dental clinic for any reason? 80% 70% 60% 50% 40% 30% 20% 10% 0% Within the past Within the past 2 Within the past 5 5 or more years I have never year (1 to 12 years (1 to 2 years years (2 to 5 years ago visited a dentist or months ago) ago) ago) a dental clinic for any reason.

10. Do you use mental health, alcohol abuse, or drug abuse services?

# % Yes 261 20.20% No 1031 79.80% Answered 1292 Skipped 268

Do you use mental health, alcohol abuse, or drug abuse services?

20% Yes No

80%

Where do you go for mental health alcohol abuse, or drug abuse services? (Check all that apply)

# % Doctor/Counselor’s Office 171 67.06% Online / Telehealth / Virtual Visits 82 32.16% Other (please specify) 39 15.29% Free Clinic (e.g. Bradley Free Clinic, Fralin Free Clinic - Rescue Mission, Botetourt Christian Free Clinic) 22 8.63% Federally Qualified Health Center (e.g. New Horizons Healthcare) 16 6.27% Emergency Room 5 1.96% Salem VA Medical Center 3 1.18% Urgent Care / Walk in Clinic 1 0.39% Answered 255 Skipped 1305

11. How long has it been since you used mental health, alcohol abuse, or drug abuse services for any reason? (Please check one)

# % I have never used mental health, alcohol abuse, or drug abuse services for any reason. 737 57.94% Within the past year (1 to 12 months ago) 264 20.75% 5 or more years ago 143 11.24% Within the past 5 years (2 to 5 years ago) 74 5.82% Within the past 2 years (1 to 2 years ago) 54 4.25% Answered 1272 Skipped 288

How long has it been since you used mental health, alcohol abuse, or drug abuse services for any reason? 70%

60%

50%

40%

30%

20%

10%

0% Within the past year Within the past 2 Within the past 5 5 or more years ago I have never used (1 to 12 months ago) years (1 to 2 years years (2 to 5 years mental health, alcohol ago) ago) abuse, or drug abuse services for any reason.

12. Have you been told by a doctor that you have… (Check all that apply)

# % Depression or anxiety 475 39.68% Obesity / overweight 438 36.59% High blood pressure 419 35.00% High cholesterol 260 21.72% I have no health problems 214 17.88% Asthma 181 15.12% Other (please specify) 163 13.62% High blood sugar or diabetes 148 12.36% Mental health problems 147 12.28% Cancer 61 5.10% Heart disease 55 4.59% COPD / chronic bronchitis / Emphysema 52 4.34% Drug or alcohol problems 40 3.34% Stroke / Cerebrovascular disease 29 2.42% HIV / AIDS 2 0.17% Cerebral palsy 1 0.08% Answered 1197 Skipped 363

13. Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

Median: 5.4 Answered 1037 Skipped 523

14. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

Median: 8.3 Answered 1051 Skipped 509

15. During the past 30 days: (Check all that apply)

# % I have had 5 or more alcoholic drinks (if male) or 4 or more alcoholic drinks (if female) during one occasion. 205 17.31% I have used tobacco products (cigarettes, smokeless tobacco, e-cigarettes, etc.) 186 15.71% I have taken prescription drugs to get high 4 0.34% I have used marijuana 61 5.15% I have used other illegal drugs (e.g. cocaine, heroin, ecstasy, crack, LSD, etc.) 8 0.68% None of these 836 70.61% Answered 1184 Skipped 376

During the past 30 days: 80% 70% 60% 50% 40% 30% 20% 10% 0% I have had 5 or I have used tobacco I have taken I have used I have used other None of these more alcoholic products prescription drugs marijuana illegal drugs (e.g. drinks (if male) or 4 (cigarettes, to get high cocaine, heroin, or more alcoholic smokeless tobacco, ecstasy, crack, drinks (if female) e-cigarettes, etc.) LSD, etc.) during one occasion.

16. Please check one of the following for each statement

Yes No Not applicable # % # % # % I have been to the emergency room in the past 12 months. 222 18.18% 957 78.38% 42 3.44% I have been to the emergency room for an injury in the past 12 months (e.g. motor vehicle crash, fall, poisoning, burn, cut, etc.). 76 6.26% 1082 89.05% 57 4.69% I have been a victim of domestic violence or abuse in the past 12 months. 39 3.22% 1108 91.49% 64 5.28% I take the medicine my doctor tells me to take to control my chronic illness. 641 52.71% 236 19.41% 339 27.88% I can afford medicine needed for my health conditions. 837 69.17% 189 15.62% 184 15.21% Does your community support physical activity? (e.g. parks, sidewalks, bike lanes, etc.) 919 76.01% 253 20.93% 37 3.06% In the area that you live, is it easy to get affordable fresh fruits and vegetables? 893 73.74% 308 25.43% 10 0.83% Have there been times in the past 12 months when you did not have enough money to buy the food that you or your family needed? 301 24.79% 886 72.98% 27 2.22% Have there been times in the past 12 months when you did not have enough money to pay your rent or mortgage? 306 25.19% 866 71.28% 43 3.54% Do you feel safe where you live? 1115 92.00% 93 7.67% 4 0.33% Answered 1228 Skipped 332

17. Where do you get the food that you eat at home? (Check all that apply)

# % Grocery store 1194 97.55% Take-out / fast food / restaurant 525 42.89% Farmers’ market 273 22.30% Home garden 257 21.00% Dollar store 196 16.01% Corner store / convenience store / gas station 116 9.48% Food bank / food kitchen / food pantry 112 9.15% Other (please specify) 52 4.25% Back-pack or summer food programs 50 4.08% I regularly receive food from family, friends, neighbors, or my church 50 4.08% Community garden 18 1.47% Meals on Wheels 5 0.41% I do not eat at home 3 0.25% Answered 1224 Skipped 336

18. During the past 7 days, how many times did you eat fruit or vegetables? Do not count fruit juice. (Please check one)

# % 1 – 3 times during the past 7 days 325 26.60% 4 – 6 times during the past 7 days 290 23.73% 2 times per day 256 20.95% 1 time per day 138 11.29% 3 times per day 117 9.57% 4 or more times per day 61 4.99% I did not eat fruits or vegetables during the past 7 days 35 2.86% Answered 1222 Skipped 338

During the past 7 days, how many times did you eat fruit or vegetables? 30%

25%

20%

15%

10%

0% I did not eat 1 – 3 times 4 – 6 times 1 time per day 2 times per day 3 times per day 4 or more fruits or during the past during the past times per day vegetables 7 days 7 days during the past 7 days

19. How connected do you feel with the community and those around you?

# % Very connected 237 19.44% Somewhat connected 681 55.87% Not connected 301 24.69% Answered 1219 Skipped 341

How connected do you feel with the community and those around you? 60%

50%

40%

30%

20%

10%

0% Very connected Somewhat connected Not connected

# % 0 days 194 15.93% 1 day 127 10.43% 2 days 177 14.53% 3 days 213 17.49% 4 days 148 12.15% 5 days 143 11.74% 6 days 51 4.19% 7 days 165 13.55% Answered 1218 Skipped 342

In the past 7 days, on how many days were you physically active for a total of at least 30 minutes? 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

21. During the past 7 days, how many times did all, or most, of your family living in your house eat a meal together?

# % Never 61 4.98% 1-2 times 154 12.58% 3-4 times 206 16.83% 5-6 times 192 15.69% 7 times 163 13.32% More than 7 times 266 21.73% Not applicable / I live alone 182 14.87% Answered 1224 Skipped 336

During the past 7 days, how many times did all, or most, of your family living in your house eat a meal together? 25%

20%

15%

10%

0% Never 1-2 times 3-4 times 5-6 times 7 times More than 7 Not times applicable / I live alone

22. Do you have reliable transportation?

# % Yes 1147 94.48% No 67 5.52% Answered 1214 Skipped 346

Do you have reliable transportation?

Yes No

94%

23. What type of transportation do you use typically use?

# % I drive 1118 91.12% Bike or walk 113 9.21% Friends / Family drive me 100 8.15% Public transit (i.e. bus, shuttle, similar) 54 4.40% Other (please specify) 28 2.28% Taxi (including Uber/LYFT) 23 1.87% RADAR / CORTRAN 9 0.73% Ridesharing / Carpooling 8 0.65% Answered 1227 Skipped 333

What type of transportation do you use typically use? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% I drive Bike or walk Friends / Public transit RADAR / Ridesharing / Taxi Other (please Family drive (i.e. bus, CORTRAN Carpooling (including specify) me shuttle, Uber/LYFT) similar)

24. Which of the following describes your current type of health insurance? (Check all that apply)

# % Employer Provided Insurance 701 58.32% Dental Insurance 461 38.35% Medicaid 183 15.22% Medicare 171 14.23% Health Savings / Spending Account 158 13.14% Individual / Private Insurance / Market Place / Obamacare 110 9.15% No Dental Insurance 95 7.90% Medicare Supplement 94 7.82% No Health Insurance 70 5.82% Government (VA, Champus) 38 3.16% COBRA 10 0.83% Answered 1202 Skipped 358

25. If you have no health insurance, why don’t you have insurance? (Check all that apply)

# % Not applicable- I have health insurance 666 87.29% Too expensive / cost 72 9.44% Unemployed / no job 21 2.75% Other (please specify) 21 2.75% I don’t understand Marketplace / Obamacare Options 9 1.18% Not available at my job 5 0.66% Student 1 0.13% Answered 763 Skipped 797

26. What is your ZIP code?

Zip Code # % 24012 104 8.50% 24013 64 5.20% 24014 93 7.60% 24015 106 8.67% 24016 60 4.90% 24017 94 7.70% 24018 159 13.00% 24019 105 8.60% 24066 29 2.40% 24085 24 2% 24090 26 2.10% 24127 47 3.80% 24153 96 7.90% 24175 33 2.70% 24179 62 5.10% Other 120 9.80% Answered 1222 Skipped 338

27. What is your age?

Average: 47.8 Answered 1190 Skipped 370

28. What is your gender identity?

# % Male 223 18.52% Female 976 81.06% Other 0 0.00% In your own words: 5 0.42% Answered 1204 Skipped 356

What is your gender identity? 90%

80%

70%

60%

50%

40%

30%

20%

10%

0% Male Female Other In your own words:

29. What is your height, in inches?

Median: 72.0 Answered 1182 Skipped 378

30. What is your weight, in pounds?

Median: 191.3 Answered 1157 Skipped 403

Weight Status Based on Self-Reported Height and Weight

1.75%

24.08% 27.93%

46.23%

Normal Obese Overweight Underweight

31. How many people live in your home (including yourself)?

Median: Number of children (0 – 17 years of age): 1.1 Number of adults age 18 – 64: 1.8 Number of adults age 65 or older: 0.5 Answered 1180 Skipped 380

32. What us your highest education level completed?

# % High school diploma/GED 353 29.20% Bachelors 322 26.63% Masters / PhD 272 22.50% Associates 222 18.36% Some high school 25 2.07% Less than high school 15 1.24% Answered 1209 Skipped 351

Education Level 35%

30%

25%

20%

15%

10%

0% Less than high Some high High school Associates Bachelors Masters / PhD school school diploma/GED

33. What is your primary language?

# % English 1175 97.59% Spanish 16 1.33% Other (please specify) 13 1.08% Answered 1204 Skipped 356

Primary Language 120%

100%

80%

60%

40%

20%

0% English Spanish Other (please specify)

34. With what ethnicity do you identify? (Check all that apply)

# % White 944 78.60% Black / African American 178 14.82% Latino 32 2.66% Decline to answer 32 2.66% More than one race 20 1.67% Asian 17 1.42% American Indian / Alaskan Native 13 1.08% Other (please specify) 12 1.00% Native Hawaiian / Pacific Islander 4 0.33% Answered 1201 Skipped 359

35. What is your marital status?

# % Married 618 51.85% Single 281 23.57% Divorced 181 15.18% Widowed 65 5.45% Domestic Partnership 47 3.94% Answered 1192 Skipped 368

Marital Status 60%

50%

40%

30%

20%

10%

0% Married Single Divorced Widowed Domestic Partnership

36. What is your yearly household income?

# % $100,001 and above 233 20.33% $70,001 – $100,000 187 16.32% $20,001 – $30,000 127 11.08% $30,001 – $40,000 127 11.08% $50,001 – $60,000 101 8.81% $0 – $10,000 99 8.64% $40,001 – $50,000 96 8.38% $10,001 – $20,000 95 8.29% $60,001 – $70,000 81 7.07% Answered 1146 Skipped 414

Yearly Household Income 25%

20%

15%

10%

0% $0 – $10,001 – $20,001 – $30,001 – $40,001 – $50,001 – $60,001 – $70,001 – $100,001 $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $100,000 and above

37. What is your current employment status?

# % Full-time 763 63.58% Part-time 130 10.83% Retired 129 10.75% Unemployed 114 9.50% Homemaker 33 2.75% Self-employed 21 1.75% Student 10 0.83% Answered 1200 Skipped 360

Employment Status 70%

60%

50%

40%

30%

20%

10%

0% Full-time Part-time Unemployed Self-employed Retired Homemaker Student

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Appendix 7: Secondary Data from University of Missouri CARES SparkMap

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Appendix 8: Links to Other Assessments • 2019 Roanoke Valley Community Healthy Living Index, Roanoke College Center for Community Health Innovation o https://www.roanoke.edu/documents/CommunityHealthInnovation/2019RVCHLIFinalR eport.pdf • COVID-19 Impact Survey, 2021 Roanoke Valley, Virginia Results Report, United Way of Roanoke Valley o https://www.uwrv.org/alice-covid-19-survey-results/ • Regional Housing Market Analysis Study, Roanoke Valley-Alleghany Regional Commission o https://rvarc.org/wp-content/uploads/2021/02/RVA-Regional-Housing-Study-FINAL- 121520.pdf • Roanoke City Plan 2040 Community Response Report (2018), City of Roanoke o https://www.roanokeva.gov/DocumentCenter/View/11666/Community-Response- Report • Roanoke Valley Local Food Plan 2020, Roanoke Valley-Alleghany Regional Commission o https://rvarc.org/wp-content/uploads/2020/09/Local-Food-Plan-2020-FINAL- 9.16.20.pdf

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Appendix 9: Cancer Community Health Survey Results To better understand the specific needs of those with cancer, the Community Health Survey was filtered to show results from respondents who self-identified as having cancer.

1. County of Residence # % Roanoke City 19 31.15% Roanoke County 18 29.51% Botetourt County 10 16.39% Salem City 6 9.84% Bedford County 5 8.20% Craig County 3 4.92% Answered 61 Skipped 0

179

2. What do you think are the most important issues that affect health in our community? (Check all that apply) # % Overweight / obesity 43 70.49% COVID-19 / Coronavirus 39 63.93% Alcohol and illegal drug use 36 59.02% Poor eating habits 33 54.10% Access to healthy foods 32 52.46% Access to affordable housing 31 50.82% Lack of exercise 30 49.18% Stress 30 49.18% Mental health problems 29 47.54% Cell phone use / texting and driving / distracted driving 28 45.90% Aging problems 27 44.26% Social isolation 27 44.26% Cancers 26 42.62% Tobacco use / smoking / vaping 26 42.62% Heart disease and stroke 24 39.34% Diabetes 23 37.70% Domestic violence 23 37.70% High blood pressure 23 37.70% Dental problems 22 36.07% Prescription drug abuse 22 36.07% Not getting “shots” to prevent disease 20 32.79% Child abuse / neglect 19 31.15% Bullying 18 29.51% Housing problems (e.g. mold, bed bugs, lead paint) 18 29.51% Gang activity 17 27.87% Environmental health (e.g. water quality, air quality, pesticides, etc.) 16 26.23% Transportation problems 16 26.23% Sexual assault 13 21.31% Unsafe sex 13 21.31% Grief 12 19.67% Neighborhood safety 12 19.67% Suicide 11 18.03% Lung disease 10 16.39% Teenage pregnancy 10 16.39% Homicide 9 14.75% Not using seat belts / child safety seats / helmets 9 14.75% Accidents in the home (ex. falls, burns, cuts) 8 13.11% HIV / AIDS 7 11.48% Infant death 6 9.84% Injuries 5 8.20%

180

Other (please specify) 4 6.56% Answered 61 Skipped 0

3. Which health care services are hard to get in our community? (Check all that apply) # % Mental health / counseling 25 44.64% Adult dental care 19 33.93% Substance abuse services –drug and alcohol 18 32.14% Alternative therapy (ex. herbal, acupuncture, massage) 13 23.21% Eldercare 13 23.21% Programs to stop using tobacco products 13 23.21% Cancer care 11 19.64% Family doctor 11 19.64% Domestic violence services 10 17.86% Vision care 10 17.86% Emergency room care 9 16.07% Family planning / birth control 9 16.07% Medication / medical supplies 9 16.07% Urgent care / walk in clinic 9 16.07% Child dental care 8 14.29% None 8 14.29% Specialty care (ex. heart doctor) 7 12.50% Women’s health services 7 12.50% Other (please specify) 7 12.50% End of life / hospice / palliative care 6 10.71% Immunizations 6 10.71% Preventive care (ex. yearly check-ups) 6 10.71% Dermatology 5 8.93% X-rays / mammograms 5 8.93% Inpatient hospital 4 7.14% Chiropractic care 3 5.36% Lab work 2 3.57% Physical therapy 2 3.57% Ambulance services 0 0.00% Answered 56 Skipped 5

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4. What social / support resources are hard to get in our community? # % Affordable / safe housing 27 47.37% Childcare 19 33.33% Healthy food 18 31.58% Medication assistance 18 31.58% Transportation 17 29.82% Health insurance 16 28.07% Medical debt assistance 16 28.07% Domestic violence assistance 15 26.32% Employment / jobs assistance 13 22.81% Food benefits (SNAP, WIC) 12 21.05% Rent / utilities assistance 12 21.05% Veterans services 12 21.05% Banking / financial assistance 11 19.30% Unemployment benefits 11 19.30% Legal services 10 17.54% Education and literacy 9 15.79% TANF (Temporary Assistance for Needy Families) 9 15.79% None 8 14.04% Translation assistance / language services 6 10.53% Other (please specify) 3 5.26% Answered 57 Skipped 4

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5. What keeps you from being healthy? (Check all that apply) # % Nothing keeps me from being healthy 23 41.07% Long waits for appointments 13 23.21% Lack of evening and weekend services 12 21.43% High co-pay 11 19.64% Cost 9 16.07% Don’t know what types of services are available 6 10.71% No transportation 6 10.71% Other (please specify) 6 10.71% No health Insurance 5 8.93% Childcare 4 7.14% Location of offices 4 7.14% Can’t find providers that accept my Medicaid insurance 3 5.36% Don’t trust doctors / clinics 3 5.36% Have no regular source of healthcare 3 5.36% Can’t find providers that accept my Medicare insurance 2 3.57% Don’t like accepting government assistance 2 3.57% Afraid to have check-ups 1 1.79% Language services 1 1.79% Answered 56 Skipped 5

183

6. Do you use medical care services? # % Yes 51 86.44% No 8 13.56% Answered 59 Skipped 2

Where do you go for medical care? (Check all that apply)

# % Doctor’s Office 50 94.34% Urgent Care / Walk in Clinic 21 39.62% Emergency Room 9 16.98% Online / Telehealth / Virtual Visits 9 16.98% Federally Qualified Health Center (e.g. New Horizons Healthcare) 2 3.77% Free Clinic (e.g. Bradley Free Clinic, Fralin Free Clinic - Rescue Mission, Botetourt Christian Free Clinic) 1 1.89% Health Department 1 1.89% Salem VA Medical Center 1 1.89% Other (please specify) 1 1.89% Answered 53 Skipped 8

184

7. How long has it been since you last visited a doctor for a routine checkup? (Please check one) # % Within the past year (1 to 12 months ago) 52 85.25% Within the past 2 years (1 to 2 years ago) 7 11.48% Within the past 5 years (2 to 5 years ago) 1 1.64% 5 or more years ago 1 1.64% I have never visited a doctor or other healthcare provider for a routine checkup. 0 0.00% Answered 61 Skipped 0

185

8. Do you use dental care services? # % Yes 48 78.69% No 13 21.31% Answered 61 Skipped 0

Where do you go for dental care? (Check all that apply) # % Dentist’s office 44 91.67% Other (please specify) 2 4.17% Free Clinic (e.g. Bradley Free Clinic, Fralin Free Clinic - Rescue Mission, Botetourt Christian Free Clinic) 1 2.08% Salem VA Medical Center 1 2.08% Emergency Room 0 0.00% Urgent Care / Walk in Clinic 0 0.00% VWCC Dental Hygiene Program 0 0.00% Answered 48 Skipped 13

186

9. How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists. (Please check one) # % Within the past year (1 to 12 months ago) 42 68.85% Within the past 2 years (1 to 2 years ago) 6 9.84% Within the past 5 years (2 to 5 years ago) 7 11.48% 5 or more years ago 6 9.84% I have never visited a dentist or a dental clinic for any reason. 0 0.00% Answered 61 Skipped 0

187

10. Do you use mental health, alcohol abuse, or drug abuse services? # % Yes 6 9.84% No 55 90.16% Answered 61 Skipped 0

Where do you go for mental health alcohol abuse, or drug abuse services? (Check all that apply) # % Doctor/Counselor’s Office 4 66.67% Other (please specify) 2 33.33% Federally Qualified Health Center (e.g. New Horizons Healthcare) 1 16.67% Online / Telehealth / Virtual Visits 1 16.67% Emergency Room 0 0.00% Free Clinic (e.g. Bradley Free Clinic, Fralin Free Clinic - Rescue Mission, Botetourt Christian Free Clinic) 0 0.00% Salem VA Medical Center 0 0.00% Urgent Care / Walk in Clinic 0 0.00% Answered 6 Skipped 55

188

11. How long has it been since you used mental health, alcohol abuse, or drug abuse services for any reason? (Please check one) # % I have never used mental health, alcohol abuse, or drug abuse services for any reason. 41 67.21% Within the past year (1 to 12 months ago) 8 13.11% 5 or more years ago 7 11.48% Within the past 5 years (2 to 5 years ago) 3 4.92% Within the past 2 years (1 to 2 years ago) 2 3.28% Answered 61 Skipped 0

189

12. Have you been told by a doctor that you have… (Check all that apply) # % Cancer 61 100.00% High blood pressure 33 54.10% Obesity / overweight 21 34.43% Depression or anxiety 20 32.79% High cholesterol 19 31.15% COPD / chronic bronchitis / Emphysema 13 21.31% High blood sugar or diabetes 13 21.31% Asthma 11 18.03% Heart disease 7 11.48% Mental health problems 5 8.20% Stroke / Cerebrovascular disease 5 8.20% Other (please specify) 4 6.56% Drug or alcohol problems 2 3.28% Cerebral palsy 0 0.00% HIV / AIDS 0 0.00% I have no health problems 0 0.00% Answered 61 Skipped 0

190

13. Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

Median: 6.4 Answered 52 Skipped 9

14. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

Median: 7.0 Answered 55 Skipped 6

15. During the past 30 days: (Check all that apply) # % None of these 45 75.00% I have used tobacco products (cigarettes, smokeless tobacco, e-cigarettes, etc.) 7 11.67% I have had 5 or more alcoholic drinks (if male) or 4 or more alcoholic drinks (if female) during one occasion. 6 10.00% I have used marijuana 3 5.00% I have taken prescription drugs to get high 2 3.33% I have used other illegal drugs (e.g. cocaine, heroin, ecstasy, crack, LSD, etc.) 1 1.67% Answered 60 Skipped 1

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16. Please check one of the following for each statement

Yes No # Not applicable # % # % % I have been to the emergency room in the past 12 months. 10 16.39% 47 77.05% 4 6.56% I have been to the emergency room for an injury in the past 12 months (e.g. motor vehicle crash, fall, poisoning, burn, cut, etc.). 6 9.84% 51 83.61% 4 6.56% I have been a victim of domestic violence or abuse in the past 12 months. 1 1.64% 53 86.89% 7 11.48% I take the medicine my doctor tells me to take to control my chronic illness. 45 73.77% 8 13.11% 8 13.11% I can afford medicine needed for my health conditions. 46 77.97% 8 13.56% 5 8.47% Does your community support physical activity? (e.g. parks, sidewalks, bike lanes, etc.) 49 80.33% 10 16.39% 2 3.28% In the area that you live, is it easy to get affordable fresh fruits and vegetables? 42 70.00% 17 28.33% 1 1.67% Have there been times in the past 12 months when you did not have enough money to buy the food that you or your family needed? 14 22.95% 46 75.41% 1 1.64% Have there been times in the past 12 months when you did not have enough money to pay your rent or mortgage? 12 19.67% 48 78.69% 1 1.64% Do you feel safe where you live? 55 90.16% 6 9.84% 0 0.00% Answered 61 Skipped 0

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17. Where do you get the food that you eat at home? (Check all that apply) # % Grocery store 60 98.36% Take-out / fast food / restaurant 22 36.07% Farmers’ market 20 32.79% Home garden 16 26.23% Dollar store 12 19.67% Corner store / convenience store / gas station 8 13.11% Food bank / food kitchen / food pantry 4 6.56% Other (please specify) 3 4.92% Back-pack or summer food programs 2 3.28% I regularly receive food from family, friends, neighbors, or my church 2 3.28% Community garden 1 1.64% I do not eat at home 0 0.00% Meals on Wheels 0 0.00% Answered 61 Skipped 0

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18. During the past 7 days, how many times did you eat fruit or vegetables? Do not count fruit juice. (Please check one) # % 1 – 3 times during the past 7 days 18 29.51% 4 – 6 times during the past 7 days 13 21.31% 2 times per day 10 16.39% 1 time per day 8 13.11% 3 times per day 7 11.48% 4 or more times per day 3 4.92% I did not eat fruits or vegetables during the past 7 days 2 3.28% Answered 61 Skipped 0

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19. How connected do you feel with the community and those around you? # % Very connected 16 26.23% Somewhat connected 35 57.38% Not connected 10 16.39% Answered 61 Skipped 0

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20. In the past 7 days, on how many days were you physically active for a total of at least 30 minutes? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard for some of the time.) # % 0 days 7 11.48% 1 day 4 6.56% 2 days 11 18.03% 3 days 5 8.20% 4 days 8 13.11% 5 days 9 14.75% 6 days 1 1.64% 7 days 16 26.23% Answered 61 Skipped 0

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21. During the past 7 days, how many times did all, or most, of your family living in your house eat a meal together? # % Never 5 8.20% 1-2 times 7 11.48% 3-4 times 7 11.48% 5-6 times 8 13.11% 7 times 11 18.03% More than 7 times 10 16.39% Not applicable / I live alone 13 21.31% Answered 61 Skipped 0

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22. Do you have reliable transportation?

# % Yes 57 95.00% No 3 5.00% Answered 60 Skipped 1

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23. What type of transportation do you use typically use?

# % I drive 55 90.16% Friends / Family drive me 4 6.56% Public transit (i.e. bus, shuttle, similar) 4 6.56% Bike or walk 3 4.92% Taxi (including Uber/LYFT) 1 1.64% Other (please specify) 1 1.64% RADAR / CORTRAN 0 0.00% Ridesharing / Carpooling 0 0.00% Answered 61 Skipped 0

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24. Which of the following describes your current type of health insurance? (Check all that apply)

# % Dental Insurance 27 45.76% Employer Provided Insurance 25 42.37% Medicare 21 35.59% Medicaid 11 18.64% Medicare Supplement 9 15.25% Health Savings / Spending Account 8 13.56% Individual / Private Insurance / Market Place / Obamacare 7 11.86% No Dental Insurance 4 6.78% Government (VA, Champus) 3 5.08% No Health Insurance 3 5.08% COBRA 0 0.00% Answered 59 Skipped 2

25. If you have no health insurance, why don’t you have insurance? (Check all that apply)

# % Not applicable- I have health insurance 31 88.57% Unemployed / no job 2 5.71% Too expensive / cost 1 2.86% Other (please specify) 1 2.86% I don’t understand Marketplace / Obamacare Options 0 0.00% Not available at my job 0 0.00% Student 0 0.00% Answered 35 Skipped 26

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26. What is your ZIP code?

Zip Code # % 24014 4 6.8% 24015 4 6.8% 24016 3 5.1% 24017 7 11.9% 24018 6 10.2% 24019 3 5.1% 24064 3 5.1% 24153 8 13.6% Other 21 35.6% Answered 59 Skipped 2

27. What is your age?

Median: 58 Answered 59 Skipped 2

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28. What is your gender identity?

# % Male 11 18.64% Female 48 81.36% Other 0 0.00% In your own words: 0 0.00% Answered 59 Skipped 2

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29. What is your height, in inches?

Average: 65 Answered 58 Skipped 3

30. What is your weight, in pounds?

Average: 182.3 Answered 58 Skipped 3

31. How many people live in your home (including yourself)? Average Number of children (0 – 17 years of age): 0.725490196 Number of adults age 18 – 64: 1.471698113 Number of adults age 65 or older: 0.645833333 Answered 57 Skipped 4

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32. What is your highest education level completed?

# % Associates 18 30.51% High school diploma/GED 15 25.42% Bachelors 12 20.34% Masters / PhD 12 20.34% Less than high school 2 3.39% Some high school 0 0.00% Answered 59 Skipped 2

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33. What is your primary language?

# % English 59 100.00% Spanish 0 0.00% Other (please specify) 0 0.00% Answered 59 Skipped 2

34. With what ethnicity do you identify? (Check all that apply)

# % White 48 81.36% Black / African American 8 13.56% More than one race 1 1.69% Decline to answer 1 1.69% Other (please specify) 1 1.69% American Indian / Alaskan Native 0 0.00% Asian 0 0.00% Latino 0 0.00% Native Hawaiian / Pacific Islander 0 0.00% Answered 59 Skipped 2

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35. What is your marital status?

# % Married 33 55.93% Divorced 14 23.73% Single 7 11.86% Widowed 4 6.78% Domestic Partnership 1 1.69% Answered 59 Skipped 2

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36. What is your yearly household income?

# % $100,001 and above 12 23.08% $10,001 – $20,000 10 19.23% $70,001 – $100,000 6 11.54% $0 – $10,000 4 7.69% $20,001 – $30,000 4 7.69% $30,001 – $40,000 4 7.69% $40,001 – $50,000 4 7.69% $50,001 – $60,000 4 7.69% $60,001 – $70,000 4 7.69% Answered 52 Skipped 9

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37. What is your current employment status?

# % Full-time 29 49.15% Retired 16 27.12% Part-time 7 11.86% Unemployed 4 6.78% Homemaker 2 3.39% Self-employed 1 1.69% Student 0 0.00% Answered 59 Skipped 2

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